Pharmacological Treatments in Rheumatoid Arthritis
Drug treatments for rheumatoid arthritis are divided into those used to manage symptoms – analgesia and NSAIDS, and those used to modulate the immune system – Disease modifying anti-rheumatic drugs (DMARDs). Steroids are an adjunct especially in early or active disease.
Rheumatoid Arthritis Analgesia
Symptomatic relief of symptoms in RA starts with simple analgesia based on the WHO pain ladder. Most patients without contraindications will require non steroidal anti-inflammatory drugs. Some patients will benefit from compound analgesics e.g. co-codamol.
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Disease modifying anti rheumatic drugs treat the underlying inflammation but are slow in onset. This means they can take weeks to months to reach maximal therapeutic effect. These medications are often used in combination even in early disease in order to gain early remission and better long-term outcomes. The majority of these drugs require regular monitoring and local guidelines for this can be found on the BNSSG Formulary.
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For more information on DMARDs visit:
Arthritis Research UK www.arthritisresearchuk.org/arthritis-information/drugs.aspx
Rheumatoid Arthritis Steroids
Corticosteroids are used to gain rapid control of active disease in rheumatoid arthritis. This may be oral in the form of prednisolone, intramuscular injection (typically depomedrone), joint injection or occasionally by intravenous pulse. Because of the long-term side effects associated with steroids the aim is to use short courses as infrequently as possible. Low dose oral prednisolone has been found to have disease-modifying properties in early disease therefore may be used as maintenance therapy in some cases, particularly in the first two years (e.g. prednisolone 7.5mg alongside standard DMARD therapy).
Rheumatoid Arthritis Biologics
The biological therapies are step up therapy for those with disease not adequately controlled by standard disease modifying drug (DMARD) therapy. These drugs target specific molecules (e.g. TNF, IL-6) or cells (e.g. B cells) known to be pathological in rheumatoid arthritis. Their use is guided by NICE and at present most are given by infusion or subcutaneous injection. These potent immune modulators require additional vigilance for complications such as infection. Because of their immune modulatory effects patients with infections may not present in the typical way therefore a high index of suspicion and prompt antibiotic therapy are needed. There should be a low threshold for withholding these medications in those suspected of or being treated for infection and those undergoing surgery.
Any queries regarding these medications should be directed to the specialist or specialist nurse responsible for the patient’s care.