Initial treatment of mildly active rheumatoid arthritis in adults
- Peter H Schur, MD
Peter H Schur, MD
- Editor-in-Chief — Rheumatology
- Section Editor — Basic Science
- Professor of Medicine
- Harvard Medical School
- Ravinder N Maini, BA, MB BChir, FRCP, FMedSci, FRS
Ravinder N Maini, BA, MB BChir, FRCP, FMedSci, FRS
- Section Editor — Rheumatoid Arthritis
- Emeritus Professor of Rheumatology, Imperial College London
- Visiting Professor, Oxford University
- Stanley Cohen, MD
Stanley Cohen, MD
- Clinical Professor of Medicine
- University of Texas Southwestern Medical School
The treatment of rheumatoid arthritis (RA) is directed toward the control of synovitis and the prevention of joint damage. Joint damage, which may ultimately result in disability, begins early in the course of disease, and patients are less likely to completely respond to therapy the longer active disease persists . Improved outcomes have resulted from the availability and use of potent and well-tolerated disease-modifying antirheumatic drugs (DMARDs) used alone and in combination to aggressively induce and maintain tight control of disease [2-10]. These DMARDs can control synovitis and slow, or even stop, radiographic progression [2,9,11,12]. (See "Clinical manifestations of rheumatoid arthritis" and "Pathogenesis of rheumatoid arthritis" and "General principles of management of rheumatoid arthritis in adults", section on 'Tight control'.)
These observations regarding the course of disease and the efficacy of newer therapeutic approaches, coupled with limits in the ability to accurately identify individuals with a poor prognosis, support our view that every patient with established active RA should be treated with DMARDs at the earliest stage of disease, ideally within less than three months of symptom onset. (See "General principles of management of rheumatoid arthritis in adults", section on 'Prognosis' and "General principles of management of rheumatoid arthritis in adults", section on 'Early use of DMARDs'.)
The choice of therapeutic agents, including both antiinflammatories and DMARDs, is influenced by the degree of disease activity, the risk of a particular medication for a given patient, and patient preferences. The initial treatment of patients with mildly active RA will be reviewed here. The diagnosis and differential diagnosis of RA, the general principles of management, an overview of the therapy of RA, the initial treatment of moderately to severely active RA, and the treatment of disease resistant to initial therapy are presented separately. (See "Diagnosis and differential diagnosis of rheumatoid arthritis" and "General principles of management of rheumatoid arthritis in adults" and "Initial treatment of moderately to severely active rheumatoid arthritis in adults" and "Treatment of rheumatoid arthritis in adults resistant to initial nonbiologic DMARD therapy".)
DEFINITION OF MILDLY ACTIVE RA
Patients with mildly active rheumatoid arthritis (RA) typically meet American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) criteria for RA and have all of the following (see "Diagnosis and differential diagnosis of rheumatoid arthritis"):
●Fewer than five inflamed joints
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- DEFINITION OF MILDLY ACTIVE RA
- GENERAL PRINCIPLES
- NONPHARMACOLOGIC AND PREVENTIVE THERAPIES
- PHARMACOLOGIC THERAPY
- Use of DMARDs
- - Patients who lack poor prognostic features
- - Patients with mild activity and poor prognostic signs
- - Other therapies
- - Patients resistant to initial DMARD therapy
- Symptomatic treatment
- - Antiinflammatory agents
- Initial symptomatic therapy
- Inadequate response to NSAIDs
- - Analgesics
- MONITORING AND REEVALUATION
- DRUG THERAPY FOR FLARES
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS