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The Stages of Rheumatoid Arthritis Treatment


Amy Bernstein

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Rheumatoid arthritis (RA) treatment has drastically improved in recent years, as medical advances have given doctors better drugs to treat the disease. What hasn’t changed is that the drugs doctors choose and the approach they take varies based on the stage of the disease.

Treatment Goals

No matter what stage RA is in, the goals of treatment are to:

  • Improve physical function and overall well-being

  • Prevent damage to joints and organs

  • Reduce long-term complications

  • Relieve symptoms

  • Stop inflammation

The ultimate goal is remission, which doctors define as little or no signs of active inflammation. But when remission isn’t achieved, doctors want to get inflammation to a low level and keep it there, which they call having tight control of RA. Research shows that tight control can prevent or slow the damage RA causes.

Early, Aggressive Treatment

RA is in its early stage when it has been diagnosed less than three years earlier. Doctors have known for decades that treating RA as early as possible provides the best results. Now remission is more achievable than ever with aggressive, early treatment.

Treatment often begins with methotrexate, a medication from a class called disease-modifying antirheumatic drugs (DMARDs). Some people respond well to methotrexate alone, but to be more aggressive, doctors can combine drugs.

One common approach is to combine methotrexate with another DMARD, such as hydroxychloroquine (Plaquenil), leflunomide (Arava), or sulfasalazine (Azulfidine). A recent study found that triple therapy—combining methotrexate, hydroxychloroquine (Plaquenil), and sulfasalazine (Azulfidine)—helped people with RA improve more quickly than treatment with methotrexate alone.

Doctors also have the option of combining methotrexate with biologics, a new subset of DMARDs that work by blocking a step in the inflammation process. In one study of early treatment with methotrexate and the biologic adalimumab (Humira), 50% of participants achieved remission within two years.

Two other early treatment studies compared the combination of methotrexate and a biologic with triple therapy and found similar rates of success between the two approaches.

New Hope for Longstanding RA

While early treatment is best, experts say that with the new drugs available, even longstanding RA can be controlled or go into remission.

For many people with RA, the first treatment they try may not work, or a successful treatment may stop working over time. Current guidelines state that treatment should be adjusted if there is no improvement after three months, or if treatment goals are not met after six months. For example, if you take adalimumab (Humira), a type of biologic called a TNF-inhibitor, for three months without seeing improvements in your disease, your doctor might try another TNF-inhibitor, such as etanercept (Enbrel). All TNF-inhibitors work by blocking a specific protein that promotes inflammation, but some people respond to one better than another.

If a TNF-inhibitor doesn’t work, doctors may try other biologics, which target different sources of inflammation. For example, rituximab (Rituxan) blocks B cells that normally fight germs but mistakenly attack joints in RA. Other biologics block certain proteins associated with inflammation.

Another new subcategory of DMARDs is called JAK-inhibitors. These drugs, including tofacitinib (Xeljanz), work by blocking a pathway of the body’s immune system response.

The challenge is that so many drugs and combinations of drugs exist, and each person responds to them differently. No matter what stage your RA is in, working with your doctor and being persistent may be the key to finding the right treatment.

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Medical Reviewers: William C. Lloyd III, MD, FACS Last Review Date: Sep 1, 2017

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Medical References

  1. De Jong PH, et al. Randomized comparison of initial triple DMARD therapy with methotrexate monotherapy in combination with low-dose glucocorticoid bridging therapy; 1-year data of the t-REACH trial. Annals of the Rheumatic Diseases. 2014;0:1-9.
  2. Combination therapy often best for RA. Arthritis Foundation.
  3. Rheumatoid arthritis treatment. Arthritis Foundation.
  4. Arthritis treatment: early is best. Arthritis Foundation.
  5. Combating high disease Activity in Early RA. Arthritis Foundation.

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