CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 6, July 2012
AFRICA
355
Rheumatoid arthritis management options for 2012
The fundamental approach in managing
rheumatoid arthritis is to treat early
to reduce functional loss and to treat
aggressively to achieve a low disease
activity rate. ‘This is because international
research has shown that in 70% of
rheumatoid arthritis patients, irreversible
damage has occurred in the first three
years of the disease’, Prof Simon
Huang, clinical associate professor,
Division of Rheumatology, University
of British Columbia, Canada noted in
his presentation at the FCPSA congress.
‘We need to treat aggressively as early
as possible with disease modifying anti-
rheumatic drugs (DMARDs) and treat to
target’, he stressed.
The objective of therapy is to achieve
remission of symptoms with low disease
activity, being defined as less than or one
painful joint, less than or one swollen
joint and C-reactive protein (CRP) levels
less than 1 mg/l. These classification
criteria were reviewed in 2010 in a joint
American/European effort to focus
attention on the important need for earlier
diagnosis and therapy.
1
‘Drug therapy should be assessed
every three to six months with adaptations
to therapy being introduced if disease-
modifying targets of remission/low
activity are not reached’, Prof Huang
stressed.
The European guidelines compiled
by the European League Against
Rheumatism (EULAR) also aimed to
set practical recommendations to guide
effective therapeutic choices.
2
Their
stepped-up approach is summarised in
Fig. 1. In the USA, guidelines are also
adopting a more aggressive therapeutical
approach.
‘With regard to the traditional,
non-biologic DMARDs, all are slow
acting. Methotrexate should be uptitrated
regularly and patients monitored every
one to three months for individual side
effects. In South Africa, the presence of
HIV infection may reduce the general
“gold standard” status of methotrexate,
as its use is contra-indicated in chronic
hepatitis B and C, and likely also in HIV
infection.’
In terms of biological DMARDs, it is
important to note that the tissue necrosis
factor inhibitors (TNF-I) are regarded
as first-line biological agents and those
that are receptor-type inhibitors, which
interfere in cell-to-cell transmission, are
preferable for use with co-infections.
‘Patients with heart disease should not be
given TNF inhibitors’, Prof Huang said.
Julia Aalbers
1.
Aletaha D, Neogi T, Silman AJ, Funovits J,
et al
. 2010 Rheumatoid arthritis classifica-
tion criteria.
Arthritis Rheum
2010;
62
(9):
2569–2581.
2.
Smolen JS, Landewe R, Breedveld FC,
Dougados M, Emery P,
et al
. EULAR
recommendations for the management of
rheumatoid arthritis with synthetic and
biologic disease-modifying anti-rheumat-
ic drugs.
Ann Rheum Dis
2010;
69
(6):
964–975.
3.
Singh JA, Furst DE, Bharat A, Curtis JR,
Kavanaugh AF,
et al.
2012 Update of the
2008 American College of Rheumatology
recommendations for the use of disease
modifying anti-rheumatic drugs and biolog-
ic agents in the treatment of rheumatoid
arthritis.
Arthritis Care Res
2012;
64
(5):
625–639.
Fig. 1. Algorithm based on the European League Against Rheumatism
recommendations on rheumatoid arthritis management. DMARD, disease-
modifying anti-rheumatic drug; RF/ACPA, rheumatoid factor/anti-citrullinated
peptide antibodies; TNF, tumour necrosis factor. *The treatment target is
clinical remission or, if remission is unlikely to be achievable, at least low
disease activity.
Phase I
Clinical diagnosis of
rheumatoid arthritis
Achieve target*
within 3–6 months
Achieve target*
within 3–6 months
Failure phase I:
go to phase II
Failure phase II:
go to phase III
No
No
Yes
Yes
Continue
Continue
Continue
Phase II
Phase III
No
No
Yes
Failure or lack of
efficacy and/or toxicity
in phase II
Achieve target*
within 3–6 months
Achieve target*
within 3–6 months
No contraindication
for methotrexate
Contraindication
for methotrexate
Prognostically unfavourable
factors present
Prognostically unfavourable
factors absent
such as RF/ACPA, esp. at
high levels; very high disease
activity; early joint damage
Biological agent
±
synthetic DMARD
Combine with short-
term low- or high-dose
glucocorticoids
±
±
Start methotrexate
Start leflunomide,
intramuscular gold or
sulfasalazine
Failure or lack of
efficacy and/or toxicity
in phase I
Start a
second synthetic
DMARD: leflunomide,
sulfasalzine, methatrexate
or intramustcular gold as
monotherapy or eventually as
combination therapy (with
or without addition of
glucocorticoids as
above)
Change the biological
treatment: Switch to second
TNF-blocking drug (+ DMARD) or
Replace TNF-blocking drug by
abatacept (+DMARD) or
rituximab (+ DMARD) or
locilizumab (
±
DMARD)
Add a biological
drug (especially a
TNF-inhibitor)
