How to Choose the Best Course of Treatment to Manage Rheumatoid Arthritis

When a contraindication to methotrexate’s use exists, such as an anticipated pregnancy or a history of liver disease, another synthetic DMARD, such as leflunomide (Arava), or tumor necrosis factor (TNF) inhibitors may be options, Dr. Goodman says.

Dr. Piecyk

For patients with low disease activity, hydroxychloroquine or sulfasalazine may be effective. Because DMARDs can take months to become fully effective, Dr. Piecyk suggests prescribing non-steroidal anti-inflammatory drugs (NSAIDs) or short-term prednisone to patients who are unable to perform certain daily activities, because this may provide more immediate relief of pain and stiffness.

Corticosteroids are a short-term temporary treatment to bridge between therapies or calm flares until therapies indicated for long-term use take effect. Side effects are often concerning to patients and include weight gain, inability to sleep, onset of diabetes or worsened glucose control. Determine a patient’s response to therapy and make adjustments in dose, route of administration or drug over the first one to three months of treatment, Dr. Goodman advises. This requires frequent follow-up evaluations.

“I am more likely to add a second DMARD or a biologic more quickly in patients with poor prognostic signs after three months of prescribing methotrexate,” Dr. Piecyk says.

Also, keep in mind recognized prognostic predictors for poorer outcomes exist, such as smoking and anti-citrullinated protein antibody positivity.

A Closer Look at DMARDs

Methotrexate reduces daily symptoms of RA and lowers the risk for long-term joint damage by modulating the immune system. An optimal dose is 20–25 mg per week. Remission is achievable using methotrexate monotherapy in early RA 30–40% of the time.³

Patients with an inadequate response to oral methotrexate (or adverse gastro­intestinal side effects) may benefit from subcutaneous methotrexate.⁴ Subcutaneous administration results in a higher relative bioavailability than does oral administration of methotrexate.⁵ “A higher relative bioavailability equals a higher effective dose of the medication for the patient, which may better control symptoms and RA progression compared with a lower dose,” Dr. Piecyk explains.

Patients are often reluctant to give a self-injection, however. “I tell patients that the needle is small, that gastrointestinal side effects should not occur and that if this medication is effective they may not require additional medication,” Dr. Piecyk says.

When pointing out methotrexate’s potential for side effects, such as hair loss and feeling unwell, Dr. Bykerk tells patients that more than 85% of patients have few, if any, difficulties with it. If problems occur, they can always try another medication. Therefore, she believes it’s worth trying because the benefits clearly outweigh the risks. She will usually reassess a patient starting on methotrexate after 8–12 weeks.