Module 3: Rheumatoid Arthritis Treatment

Question 1

What are the therapeutic goals of treatment for patients with RA?

Answer 1

Early recognition and tx with DMARDs are important to prevent joint damage and disability.

Control of synovitis and prevention of injury.

Achieve and maintain remission or low disease activity with DMARD therapy

Question 2

What is RA?

Answer 2

A symmetric, inflammatory, peripheral polyarthritis of unknown etiology. Typically leads to join destruction through erosion of cartilage and bone.

Question 3

What drug is considered firstline therapy for RA treatment?

Answer 3

Methotrexate

Question 4

What is used for initial symptomatic control of inflammation while waiting for methotrexate to take effect?

Answer 4

NSAIDs (full dose for 10-14 days and reassess) and/or glucocorticoids (prednisone 5-20mg/day)

NSAIDs can be continued with methotrexate but watch for effects of long-term use.

Glucocorticoids should be tapered as rapidly as possible.

Question 5

What screening is done prior to initiating tx with methotrexate?

Answer 5

• Lab test (CBC, serum Cr, aminotransferases)
• Hep C, B and latent TB
• standard immunizations up to date
• Chest radiograph

Question 6

Who is methotrexate contraindicated in?

Answer 6

• Pregnancy or contemplating pregnancy
• Liver disease or excessive alcohol intake
• Sever kidney function impairment

Question 7

What is the dosage for initial therapy with methotrexate?

Answer 7

Single weekly dose orally between 7.5-15mg

Subsequent dose increased as tolerated and as needed to control symptoms and signs of arthritis. Typically increased as tolerated to 17.5-20 mg once weekly after 4 weeks if initial dose inadequate.

Target dose is 15mg, max dose is 25mg/week.

Question 8

What is methotrexate replaced with in patients unable to take it?

Answer 8

leflunomide, sulfasalazine, hydroxychloroquine, or a TNF inhibitor (eg, etanercept or adalimumab). Tofacitinib, baricitinib, and upadacitinib are also effective in such patients.

Question 9

What is used during an RA flare up?

Answer 9

NSAIDs and/or glucocorticoids (short term)

Question 10

What are drug formulary considerations in the treatment of RA?

Answer 10

Methotrexate - partial coverage

NSAIDs - OTC

Glucocorticoid - partial coverage (prednisone)