Rheumatoid Arthritis Treatment Algorithm
What is a treatment algorithm?
RA has many possible treatments but some are backed up with more evidence than others. Some of the rheumatism colleges, such as the British Society for Rheumatology and the American College of Rheumatism, have sifted through the evidence to decide on the best treatments. These are then put into an algorithm, usually a type of flow chart or guideline, which helps physicians decide on which treatments to use at each stage of the process.
Examples of algorithms
Early treatment and monitoring
In most cases, starting aggressive RA therapy early is recommended to avoid irreversible joint damage. This usually involves a disease-modifying anti-rheumatic drug (DMARD) such as methotrexate. Steroids are used depending on the patient and preference of the doctor. Disease activity should be monitored using scores such as the DAS28 Disease Activity Score or the Simplified Disease Activity Index or Clinical Disease Activity Index. If the scores fall to acceptable levels, DMARDs should still be continued to prevent further joint damage. If they are still high, another DMARD or a biologic agent can be added.
One example of a treatment algorithm from the journal of Clinical and Experimental Rheumatology.
DMARD: Disease-Modifying Anti-Rheumatic Drug. MTX: Methotrexate. MDHAQ: Multi-Dimensional Health Assessment Questionnaire. TNF: Tumor Necrosis Factor.
Making way for new drugs
The guidelines are being continually updated to incorporate new evidence and treatments that come out. For example, the American College of Rheumatology updated their 2008 guidelines in 2012 to include newer biologic therapies, as well as screening for tuberculosis, switching between therapies, the use of biologics in patients with heart failure, cancer and hepatitis and vaccinations for patients with RA.
Early treatment of RA
The American College of Rheumatology suggests doctors use the following flow chart when treating patients in the early stages of RA:
ACR algorithm for early RA treatment. HCQ: hydroxychloroquine.
The aim of treatment in all cases is to lower disease activity to the lowest levels achievable with tolerable side effects. If disease activity is high and there are markers suggesting a poorer prognosis, such as blood rheumatoid factor positivity, functional limitations or bony erosions on X-ray, patients should be started on biologic agents straight away. If activity is high without poor prognostic markers, a single disease-modifying drug should be enough. However, these are guidelines only and treatment will depend on the individual patient, physician preference and drug availability.
In patients with low initial disease activity and negative prognostic factors, combination therapy of DMARDs is recommended. Triple therapy usually comprises methotrexate, hydroxycholorquine and sulfasalazine, while in dual therapy the first two are classically used.
For patients who have had RA for some time, the disease activity level and prognostic factors should be assessed. If you have a low activity and no negative prognostic factors, you may be adequately controlled with one DMARD. However, if your symptoms flare or are troublesome, another can be added or changed. If you have either a high activity score or poor prognostic factors, combination DMARD therapy or methotrexate should be started.
The third stage is to add a biologic agent from the anti-TNF class. Abatacept or rituximab are good ones to try. If serious side effects occur or the medication is not effective, a non-TNF can be tried. Your physician will try different types until one is effective.
ACR guidelines for established RA
Algorithms in practice
At the Mayo Clinic in Rochester, US, Dr. John Davis, III, Assistant Professor of Medicine in Rheumatology discusses the treatment algorithms they use, use of methotrexate and steroids, measures of disease activity and the aims of complete remission:
Who should look after patients with RA?
The European League Against Rheumatism, EULAR, has recommended that in most cases, specialist rheumatologists should be involved in the care of patients with rheumatoid arthritis. It also discusses the importance of involving patients in treatment considerations. The initial choice of DMARD recommended is methotrexate since there is more evidence for this medication than the others.
Should steroids be used?
The use of steroids in RA is controversial. They are effective in dampening down inflammation and can act as DMARDs in modifying disease activity but have serious side effects. These include osteoporosis, diabetes, Cushing’s syndrome (high levels of cortisol in the body leading to a moon face, stretch marks and acne) and muscle wasting. EULAR recommends the use of short-term steroids, which can be effective in treating RA combined with other DMARDs, and avoids many of the longer-term side effects.
Why are there so many guidelines and algorithms? A case study
In the UK, the National Institute for Health and Care Excellence (NICE) and the British Society for Rheumatology (BSR) have both published separate guidelines for the treatment of RA. This is for a number of different reasons. Firstly, the guidelines were published at similar times, and have different remits. The NICE guidelines consider cost-effectiveness and aim to determine which treatments should be approved. The BSR guidelines are not constrained by cost considerations although their resources for researching are fewer. BSR algorithms can also cover a wider scope as they do not have to restrict their topics to areas that have not already been covered by previous guidelines.
1. Smolen J, et al. A proposed treatment algorithm for rheumatoid arthritis: Aggressive therapy, methotrexate, and quantitative measures. Clin Exp Rheumatol. 2003;21(Suppl. 31):209-S210.
2. Singh J, et al. 2012 Update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care & Research. 2012 May;64(5):625-639.
3. Smolen J, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs. Ann Rheum Dis 2010;69:964-975.
4. Prednisolone. British National Formulary. March 2013. Accessed 25th April 2013. http://www.medicinescomplete.com/mc/bnf/current/PHP519-prednisolone.htmf.
5. Deighton C, Luqmani R. The NICE and BSR guidelines on the management of rheumatoid arthritis. 2009 Autumn;4(6). Accessed 25th April 2013. http://www.arthritisresearchuk.org/health-professionals-and-students/reports/hands-on/hands-on-autumn-2009.aspx.
Written by Dr Anne Parfitt-Rogers, Medical Writer, UK