Treatment of established RA

Abstract

The treatment of established Rheumatoid Arthritis (RA) is a multistep process and includes prognostic features for classification into a disease that may have a poorer outcome, versus a disease that may be gentler on the patient.This algorithm borrows from and refers to the ACR-2012 modification of the 2008 guidelines for management of RA (Biologic & Non Biologic Management)1 as also referring to the Indian Rheumatology Association consensus statement for the medical management of RA.2 Individual opinion and unpublished expert consensus for the Indian setting is also incorporated in this algorithm (example more liberal use of corticosteroids, longer waits (6 months) before initiating biologics). Also, the treatment of RA with comorbidities; use of NSAIDs, osteoporosis medication, etc. have been excluded from this algorithm. The use of Biologics for patients with severe disease is generally continued indefinitely at least in the developed countries. In India and other developing countries, there are experts in the field of rheumatology who will use biologics intermittently and also at lower doses; this is a deviation from standard of care. This current algorithm also makes a case for short term use of biologics (example 6 months of Anti-TNF use) and if the patient achieves LDA/CR, then the biologics may be discontinued while continuing with conventional DMARDs. This practice is based on expert opinion only and there are no formal trials endorsing such a practice from the Indian subcontinent. While such therapy may “debulk” the swollen and active joints in patients with RA, there is no confirmation that radiological progression will be inhibited.In the context of Rituximab use in Rheumatoid arthritis patients, please note that in parallel with the greater acceptance of this molecule earlier in the RA disease process (rather than for Anti-TNF failures alone), a case is made for use in Biologic-naive patients who have longstanding, seropositive RA. This is again based on personal and expert opinion (unpublished), as also on the wider and cheaper availability of Rituximab in India and other developing countries.