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Deformity can occur early if RA is untreated

Arthritis

7

Rheumatoid Arthritis (RA) is the most common inflammatory

arthritis and causes severe damage to joints. RA also causes

overwhelming fatigue, early coronary artery disease and a

shortened lifespan. However, new approaches to treatment

have increased the chances of success.

Features of poor prognosis Rheumatoid Arthritis

• High titre RF

• Anti-CCP antibodies

• High ESR and CRP

• Multiple joints involved

• Female sex

Rheumatoid Arthritis causes damage in many

different ways

RA damages joints due to inflammation in the joint lining

(synovial membrane).The process is controlled by a variety

of protein messengers sent between cells called cytokines.The

most important of these is thought to be Tumour Necrosis

Factor (TNF).The effect of activated immune cells releasing

inflammatory cytokines leads to joint damage and disability.

Chronic inflammation can also have negative effects in many

other areas of the body. Individuals with RA may have a shortened

lifespan by up to 20 years. Premature death is often due to early

ischaemic heart disease. Constant inflammation also causes

decreased bone mineral density, increasing the likelihood of

osteoporosis, and produces overwhelming fatigue.

Early diagnosis

Recent research has shown that better outcomes are achieved

when RA is diagnosed and treated as early as possible.There

also appears to be an opportunity in early disease, to divert

RA to a more benign course, if treatment can be started soon

enough. Individuals of any age with joint pain associated with

early morning joint stiffness lasting more than 30 minutes

should be considered for assessment.

Predicting severity; matching treatment to individual

patients

The best possible treatment of RA requires an attempt to be

made at predicting the likely prognosis of each patient. A number

of features are associated with a poor prognosis in RA.These

include female sex, younger age, multiple joint involvement,

presence of RF and anti-CCP antibodies, high ESR and CRP.

The best use of traditional DMARDs

There have been major changes in how traditional DMARDs

(Disease Modifying Anti-Rheumatic Drugs) are used. Methotrexate

is now the treatment of first choice for most patients and is

generally well tolerated in doses of 7.5-25mg per week. For

resistant disease, methotrexate may be used in combination with

other DMARDs. Intensive monitoring, using validated scoring systems

and frequent review, improves outcomes.

Biological therapies

There are currently three TNF inhibitors available to treat individuals

with RA. Infliximab, Etanercept and Adalimumab are all effective at

treating the inflammation and joint damage associated with severe

RA. Severe RA may also be treated with the anti-B cell therapy,

Rituximab or T cell co-stimulation inhibitor, Abatacept. A number

of new agents are in development including, other TNF inhibitors,

an IL-6 inhibitor and new B cell inhibitors.

Conclusion

RA damages joints and, because it has widespread effects on many

other organs, can lead to a shortened lifespan.The best treatment

requires early diagnosis and assessment of prognosis.Traditional

DMARDs, such as methotrexate, should be instituted early and

corticosteriods can be used until they become effective. Combinations

of DMARDs may be effective if monotherapy fails. Knowing when

to increase or change therapy requires careful monitoring for side-

effects and a regular record of a disease activity.When DMARDs

are not effective, new biological therapies can be used.

Key messages

• Assess prognostic markers

• Early therapy with DMARDs

• Methotrexate

• Consider collateral damage

• Monitor disease activity score closely

• Consider biological therapies

Dr Christopher Edwards, Consultant Rheumatologist

and Honorary Senior Lecturer Southampton University

Hospitals and The London Lupus Centre.

For more information on the treatment of Rheumatoid Arthritis please contact Dr Christopher Edwards.

Address:The

London Lupus Centre, 1st Floor, St Olaf House, London Bridge Hospital, 27 Tooley Street, London SE1 2PR

Tel:

020 7234 2155

Lead to major changes in management

of Rheumatoid Arthritis

New Treatments