Treating Rheumatoid Arthritis
Readers may find the National Rheumatoid Arthritis Society (NRAS) website informative and helpful
Historically, there has been no “gold standard” or correct way to treat RA and clinicians have followed their best judgement against a background of generally conservative use of anti-arthritis drugs (drugs which suppress the disease process, rather than treat symptoms are called Disease Modifying Anti-Arthritis Drugs or DMARDs). All of this has to suit the individual; I am expert in treating the disease – you are expert in treating you so partnership and education are always essential.
For my part, I have always read the research evidence to support a more intensive treatment approach and have used combinations of DMARDs and where appropriate suppressive high dose steroids for many years. Over recent years modern consensus has evolved supporting this more assertive treatment of RA and this is now recognised in recent guidelines from NICE (UK) and EULAR (Europe). Recent studies suggest that possibly the most effective conventional management would be to use Methotrexate by injection from the start of treatment.
The principles underpinning modern management are:
- the treatment of RA is with DMARDs not symptomatic remedies
- Treat early: DMARDs should be started at the earliest moment, within weeks of of the onset of disease not months
- Treat to target: establish a goal or target in collaboration with the patient (remission or complete relief), take a measure of disease activity (usually the DAS score) and keep working regularly and frequently with the drugs and treatments to achieve that goal. In this approach patients with new disease should be seen monthly and those with established active disease seen as often as 2-monthly to adjust treatment
- Use combinations of DMARDs: either start with combinations (more severe cases) or build up (less severe). My routine is to use Methotrexate and Hydroxychloroquine (Plaquenil) together from the outset (see NRAS/about RA/treatments) for a patient-friendly description of these treatments.
- Use steroids appropriately. In severe cases, I believe in commencing treatment with a high dose of oral steroid, tapering quickly to induce a rapid remission (often within a few days) and improved long term control.
- Steroids should be used as an addition to DMARDs, not as the mainstay or sole treatment. Injections should be used to control individual joints where needed.
DMARDS in current use are Methotrexate, Sulphasalazine, Hydroxychloroquine and Leflunomide. Infomation on DMARDS, arthritis and patients support can be found at the Arthritis UK and The National Rheumatoid Arthritis Society (NRAS) websites.
DMARDs are conventional chemical drugs. In the last 20 years the marriage of detailed understanding of the biology of RA immunology and the techniques bioengineering have allowed the development of a range of treatments called “biologics”. These biological molecules such as antibodies or cell surface receptors which are targeted very specifically at the detailed processes of the disease and are able to treat active RA where DMARDs have failed.
I first used Infliximab (see below) in 1999 (to dramatic effect) and have been strongly involved in the clinical use and also research with biologics including representing Schering-Plough in public hearings with NICE and starting, then chairing the Kent and Medway Rheumatology Steering Committee which has had success collaborating with PCTs to ensure equitable access to biologic therapies across Kent.
We now have several types of biologic available:
TNF alpha blockers. These were the first class of biologic and there are now several agents including:
- Infliximab (Remicade: the word in brackets is the trade name)
- Etanercept (Enbrel)
- Adalimumab (Humira)
- Certolizumab (Cimzia)
- Golimumab (Simponi)
Recently, biosimilar (off patent equivalents) have been introduced and you are likely to be offered one of these.
B-Cell depleting Agents. These treatments are borrowed from the cancer doctors who use them to treat blood and lymphatic disorders. hey work by removing certain tyoes of B-Cells (one of the major cell-types in the immune system) which are responsible for producing Rheumatoid factors, one of the hallmarks of RA.
- Rituximab (mabthera). Given in two 6-hours infusions (by IV drip), two weeks apart then repeated when arthritis flairs up to maximum 6-monthly treatments
T-Cell Co-stimulatory Blockers. This gets a bit complex, suffice it to say that this agent is a sophisticated way of blocking the activation of T-Cells (the other major immune cell type with B-Cells) and so stopping arthritis inflammation
- Abatacept (Orencia). Given monthly by IV injection/mini infusion over 30 mins
- Tocilizimab (RoActemra). Given monthly by IV infusion (drip).
New oral agents:
- there a re several new agents working on intra-cellular pathways such as JAK inhibitors (Tofacitinib) and others. These will be available through 2017 and 2018.
Access to Biologics.
Because these are very expensive agents (around £10,000/annum/patient), they are restricted to patients with severe active RA (defined as a DAS score >5.1- see the NRAS website to understand DAS scores) who have failed DMARD treatment with at least 2 drugs and are only delivered through the NHS. UK private medical insurers have never paid for medical therapies. Recent revisions of NICE guidance allow a wide range of decisions about which biologics to use first and to follow. Between 2000 and 2012, I chaired the Kent and Medway Rheumatology Steering committee which involves all of the rheumatologists in Kent advising on the best use of these treatments and designing pathways for their use which have been adopted by the Kent and Medway PCTs and now CCGs