Thie treatment plan for RA is focused on controlling pain and limiting joint destruction. Patients with early signs of aggressive disease are treated with a more complex combination therapy early in the disease to deter joint destruction, control pain, and inhibit decreased functionality. The tried and true treatment plan is based on a pyramid, starting with the following:
■ Again, caution is advised for NSAIDs (see section in Section 2, Chapter 3 on risks and benefits of NSAIDs combined with education, physical, and occupation therapy).
■ Adding disease-modifying antirheumatic drugs (DMARDs) early in the disease increases medication-induced disease remission rates by 50% when combined with methotrexate and anti—tumor necrosis factor (anti-TNF) biologics (Gardner, 2010).
■ Biologic agents, such as etanercept, infliximab, and adalimumab
■ Glucocorticosteroids (Strand, Scudder, & Fosam, 2009)
For symptom control, NSAIDs and steroids may be useful; for halting joint destruction, a DMARD is indicated. The recommended DMARDs include the following:
■ Methotrexate, which is used in combination with another medication that seems to provide better effect. Onset of action is 3—8 weeks.
■ Hydroxychloroquine is used for early to mild synovitis. It takes 8—12 weeks to become effective.
■ Minocycline is less commonly used.
■ Sulfasalazine is used for less severe disease. Onset of effect is 4 to 8 weeks (Gardner, 2010; Table 12.1).
Biologic agents are the newest addition to the drugs that can be used to decrease the inflammatory response. These agents, such as TNF, are effective for improving physical function, improving disease activity, increasing quality of life, and showing radiographic improvement in joint destruction1 (Strand, Scudder, & Fosam, 2009). The American College of Rheumatology (ACR) recommendations for biologic agents for treating RA include the following:
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