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Treatment of rheumatoid arthritis in adults resistant to initial nonbiologic DMARD therapy

Authors
Stanley Cohen, MD
Amy Cannella, MD, MS, RhMSUS
Section Editor
James R O'Dell, MD
Deputy Editor
Paul L Romain, MD

INTRODUCTION

The treatment of rheumatoid arthritis (RA) is directed toward the control of synovitis and the prevention of joint injury. In patients whose condition is resistant to an initial course of treatment with a nonbiologic (traditional) disease-modifying antirheumatic drug (DMARD), such as methotrexate (MTX), timely adjustments in the treatment regimen are required to achieve effective disease control and prevent damage to the joints. (See "General principles of management of rheumatoid arthritis in adults", section on 'Tight control' and "General principles of management of rheumatoid arthritis in adults", section on 'Early use of DMARDs'.)

Support for an early aggressive approach to treatment is based upon the observations that joint damage, which may ultimately result in disability, begins early in the course of disease and that the longer disease activity persists, the less likely the patient is to respond to therapy [1]. Improved outcomes have resulted from the use of potent and well-tolerated nonbiologic (traditional) and biologic DMARDs used alone and in combination to induce and maintain tight control of disease [2-10]. These medications and strategies have the potential to control synovitis and to slow or even stop radiographic progression [2,9,11,12].

The treatment of active RA in adults who are resistant to initial therapy with a nonbiologic DMARD (eg, MTX monotherapy) will be reviewed here. The general principles of the management of RA, initial treatment of RA, the treatment of patients resistant to initial therapy with biologic DMARDs, and the approach to RA patients with severe structural damage are presented separately. (See "General principles of management of rheumatoid arthritis in adults" and "Alternatives to methotrexate for the initial treatment of rheumatoid arthritis in adults" and "Initial treatment of rheumatoid arthritis in adults", section on 'Monitoring and reevaluation' and "Treatment of rheumatoid arthritis in adults resistant to initial biologic DMARD therapy" and "Evaluation and medical management of end-stage rheumatoid arthritis" and "Total joint replacement for severe rheumatoid arthritis".)

GENERAL PRINCIPLES AND APPROACH

Principles of management — There are several general principles that are important in the management of all patients with rheumatoid arthritis (RA). Briefly, these include:

Achievement and maintenance of tight control of disease activity, defined as remission or a state of low disease activity, without compromising safety

                              

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Literature review current through: Nov 2016. | This topic last updated: Thu Sep 08 00:00:00 GMT 2016.
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