Treatments for rheumatoid arthritis

Who will treat my rheumatoid arthritis?

Clinical studies to assess the efficacy of multidisciplinary team (MDT)-led care in rheumatoid arthritis suggest that outpatients benefit from treatment and care from MDTs (1).

If you are diagnosed with rheumatoid arthritis, the MDT may devise a care plan for you.

The different people involved in the treatment of your rheumatoid arthritis will include:

  • GP - your first port of call if you think you might have inflammatory arthritis or are experiencing joint pain of any kind or if available
  • GP with a Special Interest in Rheumatology (GPwSI)
  • Consultant Rheumatologist is a specialist in conditions related to the muscles and skeleton
  • Rheumatology Nurse Specialist (RNS) has specialist rheumatology experience and will work closely with your consultant and the rest of the MDT. The RNS will give advice and support about disease management and will monitor your drug treatment. In many clinics, consultants share patient care with a nurse specialist who sees patients once they're diagnosed and getting established on treatment
  • Physiotherapist can help you keep mobile, get the best from your joints and strengthen your muscles. He/she can advise on:
    • difficulties with movement
    • protecting joints from stress or injury
    • safe stretching and exercises
  • Occupational therapist can help you adapt and find new ways of carrying out everyday activities. The aim is to take the strain off painful joints and help you feel less tired. He/she can give advice about equipment (including splints for affected joints) and changes at work or at home to protect your joints, make things easier to use and help you remain independent
  • Podiatrist /Chiropodist - can help you with many foot problems such as troublesome nails, corns and calluses, and will also be able to provide advice and help with obtaining special shoes or orthotics
  • Orthotist - works in collaboration with podiatry services and makes orthotics tailored to the individual's feet
  • Pharmacist - dispenses medication to patients and advises them on their proper use and any side-effects
  • Dietician - helps patients maintain good health and prevent and control disease by assessing and advising patients on diet
  • Psychological counselling - rheumatoid arthritis can cause low mood and even depression. Guidance from the National Institute for Health and Clinical Excellence (NICE) states anti-depressants should not routinely be used as a first choice of treatment for mild depression. For mild-to-moderate depression, psychological treatments, such as Problem-Solving Therapy (PST), Cognitive Behavioural Therapy (CBT) and counselling, can be as effective as drug treatments and should be offered as treatment options. If you are offered psychological treatments, your GP will refer you to your local service. Very few hospital rheumatology departments may be able to refer you to a psychologist directly
  • Non-clinical issues may need the assistance of social workers, voluntary organisations and other services
  • The Voluntary Sector - There is a lot of information, help and support which can be provided by voluntary sector organisations:

What medication is used to treat rheumatoid arthritis?

Rheumatoid arthritis cannot at present be cured, although today much more is understood about the cause of the inflammatory process, so treatment is targeted at reducing the activity of the immune system and reducing pain and inflammation in the joints.

If caught and treated early enough before irreversible joint damage occurs, it is now possible with the latest drugs to talk about being able to put people with rheumatoid arthritis into remission.

If you are in pain or experiencing other symptoms, you may be prescribed a range of medication. If you follow the instructions that come with your medicine, many side-effects can be avoided.

You will be monitored to see that your medication is working and not causing side-effects. If you have any problems, your consultant or GP may decide to alter your prescription.

Pain-killers (analgesics) include paracetamol or stronger painkillers, such as codeine. If this does not control pain, you may be prescribed a morphine-based drug alongside paracetamol, such as Co-dydromol or an NSAID (2).

Non-steroidal anti-inflammatory drugs (NSAIDs) reduce inflammation and associated pain. Some, like aspirin, indomethacin and ibuprofen, are associated with stomach problems such as ulcers when taken long-term. Your doctor will aim to only prescribe NSAIDs for as short a period as possible and may also provide you with an additional stomach-protecting drug to take with the NSAIDs.

COX-2 inhibitors are less irritating to the stomach than standard NSAIDs. There have been high profile safety concerns (3) with regard to cardiac damage, however. If you have high blood pressure or significant heart disease, COX-2s may not be suitable. Examples of COX-2s include celecoxib (Celebrex®) and etoricoxib (Arcoxia®).

Corticosteroids - Corticosteroids are very effective in controlling inflammation and may have some disease-modifying effects. If used for a long time (many months) or in high doses they produce unwanted side-effects. For this reason, doctors try to avoid these drugs or use them in as low a dose as possible for as short a period as possible. They can be given orally or as intra-muscular or intra-articular (joint) injections where appropriate.

DMARDs (disease modifying anti-rheumatic drugs) are likely to be prescribed. This group of drugs (sometimes called 'second-line drugs') includes methotrexate, sulfasalazine, gold and hydroxychloroquine. They reduce pain, swelling and stiffness and can slow down the progression of the disease, but may take several weeks to work.

Immunosuppressant drugs suppress the immune system and include:

Methotrexate, mentioned earlier, also has effects on the immune system. Because these drugs affect the immune system they may produce side-effects and so need careful monitoring.

Biologic Therapies - Biological response modifier drugs (BRMs), such as tumour necrosis factor blockers (anti-TNFs), work by blocking TNF, which is thought to cause inflammation. Anti-TNFs are often taken together with methotrexate (4).

Anti-TNFs available in the UK are infliximab, adalimumab and etanercept.

Anti-TNF drugs have transformed the treatment of rheumatoid arthritis, especially for those people who have failed on standard DMARD therapy. Many people who go onto anti-TNF therapy do well, and experience a significantly increased quality of life.

In the past, if DMARD therapy failed there was little option for doctors other than to prescribe steroids, which can have negative side effects when used long term.

There are now other biologic therapies available in addition to the anti-TNF drugs mentioned before, which target other parts of the immune system. For example, rituximab can be used should anti-TNF therapy not work or you experience unpleasant side-effects with other anti-TNFs.

Other biologic drugs are in the pipeline and will become available in due course.

Can I have a joint replacement operation?

If you are in severe pain and your rheumatoid arthritis is preventing you from enjoying a good quality of life, you may be offered joint replacement surgery.

Joint replacement surgery is only offered if, in spite of your drug treatments, your consultant judges that a joint has become unstable and that you would benefit by seeing an orthopaedic surgeon to review whether replacement would give you greater mobility with less pain.

What joints can I have replaced?

Sometimes other types of surgery such as tendon repair may be advised. In rare cases cervical spine surgery may be required to reduce pain and increase stability of the neck.

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