| iagnosis of rheumatoid arthritis (RA) starts with a | | | | increase in cardiovascular events such as heart attack |
| careful history and physical examination. Answers to | | | | and stroke. These drugs require careful monitoring. |
| questions such as: | | | | Corticosteroids suppress inflammation but also have |
| •How did the symptoms begin? | | | | no effect on the underlying disease. Examples include |
| •When did they begin? | | | | prednisone, methylprednisolone, and prednisolone. They |
| •What joints are involved? | | | | have potential side effects including ulcers, cataracts, |
| •How long does the stiffness in the morning | | | | osteoporosis, adrenal gland suppression, thinning of the |
| last? | | | | skin, and diabetes. |
| •How has your level of fatigue changed? | | | | Disease-modifying anti-rheumatic drugs (DMARDS |
| •What do you have difficulty doing that you | | | | slow down the progression of rheumatoid arthritis. |
| could do without trouble before your symptoms | | | | Examples would be medicines such as methotrexate, |
| began? | | | | sulfasalazine (Azulfidine), leflunomide (Arava), and |
| … are very helpful. | | | | hydroxychloroquine (Plaquenil). |
| Valuable diagnostic laboratory tests include the | | | | DMARDS act slowly. They may also not stop the |
| rheumatoid factor, anti-CCP, erythrocyte sedimentation | | | | progression of RA. |
| test (ESR), and C-reactive protein (CRP). | | | | All DMARDS have potential side-effects and must be |
| Imaging tests such as magnetic resonance imaging | | | | monitored slowly. |
| and ultrasound are helpful. X-rays are of limited use | | | | Most recently, biologic therapies such as etanercept |
| because significant damage can occur before it | | | | (Enbrel), adalimumab (Humira), infliximab (Remicade), |
| shows up on x-ray. | | | | and anakinra (Kineret) have helped tremendously. |
| It's important to realize that progression of RA is | | | | These drugs target the cells and cytokines that are |
| closely associated with the development of disability. It | | | | the primary cause of rheumatoid arthritis. Etanercept, |
| is also associated with the development of other | | | | adalimumab, and infliximab block tumor necrosis factor- |
| potential problems such as early cardiovascular events | | | | the primary cytokine responsible for the damage in RA |
| such as heart attacks and strokes. | | | | Potential side-effects of anti-TNF therapy include an |
| Before discussing treatment, let’s look at the | | | | increased susceptibility to infection, the reactivation of |
| goals of treatment. These include: control of signs and | | | | latent tuberculosis, and the development of lupus-like or |
| symptoms, prevention of deformity, maintenance of | | | | MS-like syndromes. |
| joint function, control of co-morbidities (other | | | | A second wave of biologic therapies are available and |
| associated disease such as hypertension, diabetes, | | | | offers hope for patients who fail anti-TNF treatment. |
| etc.), and restoration of normal activities of daily living. | | | | The two newest drugs are abatacept (Orencia) and |
| Current treatment options involving medications include: | | | | rituximab (Rituxan). |
| Non-steroidal anti inflammatory drugs help reduce pain | | | | Abatacept is a co-stimulatory blocker. It prevents T |
| and improve function. They do not have an effect on | | | | cells from being activated to produce cytokines. |
| slowing the underlying disease. Examples include | | | | Rituximab is a B-cell depleter. It removes B cells from a |
| ibuprofen (Motrin), naproxyn (Naprosyn), sulindac | | | | patient’s system. B-cells are felt to play a big |
| (Clinoril), etodolac (Lodine), nabumatone (Relafen), | | | | role in the development of RA by some experts. |
| ketoprofen (Orudis), meloxicam (Mobic), and celecoxib | | | | Both drugs are given by intravenous infusion. Side |
| (Celebrex). | | | | effects include infusion reactions and rashes. |
| These drugs are effective but they have potential side | | | | Potentially helpful new drugs such as Actemra and |
| effects including peptic ulcer disease, kidney and liver | | | | Cimzia are on the horizon as this article is written. |
| damage, rashes, and fluid retention, and possibly a slight | | | | |