Recent years of research on RA have proven that the effectiveness of the treatment used, regardless of the type of drug, depends on the duration of the disease. For RA, the concept of the so-called therapeutic window, i.e. the time when the application of treatment gives the patient the best chance of achieving remission, i.e. complete inhibition of disease progression, and thus maintaining full fitness. This period has been defined as 12 weeks. How is rheumatoid arthritis successfully treated?

Treatment of RA is based on 3 main principles

  1. Diagnosis and treatment initiation within 12 weeks of the first symptoms of the disease.
  2. Selection of therapy through constant monitoring of the patient's well-being and disease activity so as to obtain remission of the disease as soon as possible, and when it is impossible - low disease activity.
  3. Monitoring the safety of the treatment and comorbidities.

Drugs used in the treatment of RA include:

1.classic synthetic disease-modifying drugs- ksLMPCh (methotrexate, leflunomide, sulfasalazine, hydroxychloroquine),

2.targeted synthetic disease-modifying drugs- csLMPCh - bariticinib, tofacitinim (reimbursed in Poland from September 2022),

3.biological disease-modifying drugs- bLMPCh ""

  • TNF-alpha inhibitors: infliximab, adalimumab, etanercept, golimumab, certolizumab
  • IL-6 inhibitor: tocilizumab blocker of CD80 and CD86 particles on the surface of cells presenting
  • antigen: abatacept (not reimbursed in Poland)
  • monoclonal antibody against CD20 B cells: rituximab

4.biosimilar disease-modifying drugs : biosimilar drugs are currently available for infliximab, etanercept and adalimumab.

The most important drugs in the treatment of this disease and used in the first place are methotrexate. This drug is safe and effective (especially in the early stages of the disease). An additional positive effect of methotrexate is its antiatherosclerotic effect. This is important because atherosclerosis, which is an inflammatory disease, develops extremely quickly in RA patients and is the cause of premature death fromdue to cardiovascular complications. Patients taking methotrexate have been shown to die less from these complications and live longer than patients who do not take methotrexate.

This drug increases the effectiveness of biological drugs and should be used together with them. The effective dose of methotrexate is 25-30 mg taken once a week.

In the case of contraindications to the use of methotrexate or its intolerance, other drugs from this group can be used alone or in combination therapy, except for hydroxychloroquine, which should only be used in combination therapy due to its low potency.

Glycocosticosteroids (GCS) should be used only at the beginning of treatment, in low doses and not longer than 6 months. The use of glucocorticosteroids together with methotrexate as an initiating therapy increases the patient's chance of achieving remission and is therefore recommended.

Important

It is not recommended to use glucocorticosteroids for a period longer than 6 months due to side effects such as an increased risk of cardiovascular complications and death depending on the dose and duration of use, as well as the risk of hypertension, diabetes, osteoporosis, cataracts, glaucoma and many other diseases.

If treatment with classical disease-modifying drugs is ineffective, biological or biosimilar drugs or targeted synthetic disease-modifying drugs should be administered immediately.

In the case of ineffectiveness of one biological or biosimilar drug, it is exchanged for another, and the therapy can include 2 TNF-alpha inhibitors, tociluzumab or abatacept (not reimbursed in Poland), and rituximab is a last-line drug - it is used when current treatment is ineffective.

Starting RA therapy before the diagnosis of the disease

Many studies are conducted even at an earlier stage of the disease and the inclusion of therapy concerns the so-called preclinical conditions of RA, such as when there is a high probability of developing RA, but the typical clinical symptoms of RA are not yet present.

EULAR (European League Against Rheumatism) defined that these are people whose family members (first line of kinship) had RA, who had pain in the hand joints, metacarpophalangeal joints with morning stiffness lasting for more than an hour and who have a positive pressure test. The presence of anti-CCP antibodies is also one of the factors that increase the risk of developing RA. Nevertheless, there are currently no recommendations to treat this group of he althy people prophylactically.

The most important elementseffective treatments for RA are:

  • good cooperation between the patient and the doctor,
  • detection and monitoring of comorbidities, incl. such as: depression, fibromyalgia, cardiovascular diseases, lung diseases, diabetes,
  • reducing the impact of environmental factors adversely affecting the course of the disease, such as obesity, smoking, infections in the oral cavity (parodontosis),
  • use of the Mediterranean diet as the only one with documented anti-inflammatory effects,
  • vitamin D supplementation,
  • permanent rehabilitation.

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Anatomy