Time is critical when diagnosing rheumatoid arthritis

Time is critical when diagnosing rheumatoid arthritis

A. Arthur Steele

This week's column continues the discussion of rheumatoid arthritis (RA). Treatment for RA has totally changed from 15 or so years ago. Modern management is best accomplished by the team of your primary physician, a rheumatologist and physical therapist, with occasional extra help from a nutritionist and, sometimes, a surgeon.

Treatment must be as aggressive as the individual case of RA. Bone erosion can begin within the first three months of the onset. The initial evaluation has two purposes: to be sure the arthritis is RA, and to assess how severe and progressive it is. Time is critical.

Only if there are no serious signs can doctors be content with the traditional drugs. Aspirin, ibuprofen and all the other NSAIDS may be fine if they give adequate relief and if there are no signs of early destruction. NSAIDS can be subtle in injuring the stomach, so the doctor and the patient must be very sensitive to that possibility.

Immediate use of "disease modifying anti-rheumatic drugs" (DMARDs) is the current standard of practice. These drugs work by different mechanisms. Often your doctor will use two or more simultaneously. For example, prednisone (Deltasone, and other brand names), works right away to reduce the inflammatory process. Since other DMARDs can take weeks to modify the inflammatory reaction, prednisone can stop the disease quickly, and the doctor can taper it away later.

What are the DMARDs? There are several and they often work together. They fall into groups. The first group is those drugs that interfere with the metabolism of cells. These are "immunosuppressants." They work by slowing the immune system response that is destroying the joint. First, methotrexate is the single most effective drug. Forty percent of patients will have adequate control of their RA with this. Used correctly, methotrexate has very little toxic side effects. There are several other drugs in this group.

The second group of drugs block a protein that calls more inflammatory cells into the joint. These are known as "cytokines." This group of drugs are known as "ILK blockers." ILK stands for "interleukin-1." The first of these is anakinra (Kineret). This is taken as an injection beneath the skin, twice a day.

The third group of DMARDs block "tumor necrosis factor." TNF blockers include eternacept, infliximab and adalimumab. These drugs, like the immunosuppressants, and the ILK blockers, all cause immune suppression and therefore make people more vulnerable to infections.

As you can see, the modern treatment of rheumatoid arthritis has become so complex, that a rheumatologist should be involved early in the management. Ask your primary doctor for his/her recommendation.

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