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The treatment of rheumatoid arthritis
(RA) has come a long way in the last 20 years. It used to be
that if you could reduce pain and swelling, you were doing your
job as a specialist in arthritis. That is not good enough anymore.
Rheumatoid arthritis presents with
either the acute onset or slow onset of pain and stiffness with
functional impairment; if not treated aggressively, it can result
in irreversible joint damage. Irreversible joint damage may occur
within three to six months of disease onset. If your physician
is not making you aware of these grim statistics, then question
him or her!
Although RA can occur at any age,
most cases are seen in adults between ages 30 and 60 years. Another
smaller peak occurs in the 70-80 year age group. Currently, the
prevalence of RA is estimated at 15% of the US population; 3
million adults in the United States have been diagnosed with
RA. If not adequately treated, progressive deformity will lead
to need for joint replacement surgery.
In the United States in 1997 alone,
there were 256,000 knee replacements and 117,000 hip replacements
associated with arthritis.
Until the entire biology of RA is
better understood, treatment strategies must focus on early diagnosis
and disease management. Early diagnosis and treatment with disease-modifying
anti-rheumatic drugs (DMARDs) are necessary to reduce early joint
damage, functional loss, and mortality.
RA is a heterogeneous disease meaning
it consists of a wide spectrum of presentations in which responses
to treatment vary considerably for any given patient. Despite
recent advances with DMARDs and targeted therapies such as tumor
necrosis factor (TNF) inhibitors, some patients do not show adequate
response and continue to show disease progression. That means
there must be flexibility in producing the optimal clinical response.
The best response will employ the
use of a full spectrum of clinical agents with different therapeutic
targets. As a patient with RA, you must educate yourself to what
is available.
Evidence shows that patients with
refractory RA may benefit from the use of sequential medicines
starting with DMARDS, going on to anti-TNF drugs, and then using
second generation biologic remedies if these treatments fail
to halt disease progression.
Also, in clinical research, there
are a number of excellent options that remain open to you. If
your rheumatologist is not doing clinical research, have them
refer you to a rheumatologist who is.
Among the second generation drugs
are anti-CD20 B-cell depleting agents such as rituximab (Rituxan)
and inhibitors of T-cell activation such as Orencia (abatacept).
Results from randomized clinical
trials have demonstrated improved outcomes as a result of treatment
with these agents, in combination with methotrexate, even in
patients who previously have not responded to DMARDs and TNF
inhibitors.
In the near future, other agents
such as anti-IL 6 (Actemra) and protein kinase inhibitors will
add to the treatment regimen. Third and fourth generation biologic
remedies show a great deal of promise in the research arena.
DISCLAIMER:
This article is NOT intended for medical advice. Always
check with your doctor for diagnosis and treatment of any illness.
About the author: Nathan Wei, MD FACP FACR is a rheumatologist
and Director of the Arthritis and Osteoporosis Center of Maryland.
He is a Clinical Assistant Professor of Medicine at the University
of Maryland School of Medicine. For more info: http://www.arthritis-treatment-and-relief.com/arthritis-treatment.html
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