Rheumatoid arthritis treatment optionsJuly 18, 2013 July 18, 2013
Is Rheumatoid arthritis an irreversible disease? Should treatment intervention be started as early as possible? What treatments should be prescribed?
Researchers from the University of Alabama at Birmingham and UCLA led the effort by 18 institutions to update the ACR 2012 recommendations that guide physicians in the use of the two main RA treatment classes — disease-modifying anti-rheumatic drugs, or DMARDS, and biologic agents — for the first time since 2008.
More than 1 million Americans have RA — a chronic disease that causes pain and swelling in the lining of joints — and women represent 75 percent of patients. Physicians and patients must navigate a growing list of treatment choices, including DMARDs like hydroxycholorquine, methotrexate and sulfasalazine. Also important are biological agents, which include tumor necrosis factor-inhibitors etanercept and infliximab and non-TNF biologicals abatacept, tocilizumab and rituximab. New since 2008 are the biologics certolizumab pegol, golimumab and tocilizumab, which must also now be factored into treatment plans.
Though the recommendations vary with each patient, the new guidelines generally recommend physicians start treatment with a DMARD, proceed to therapy combining two or more DMARDs and then to a biologic when and if each option fails to control the disease. When switching from DMARDs to biologics, for example, physicians should use either an anti-TNF biologic or a non-TNF biologic if a patient “has moderate or high disease activity” after three months of methotrexate treatment or DMARD combination therapy.
Under the heading of high-risk patients, the guidelines recommend against the use of biologics in RA patients with untreated chronic hepatitis B because of the potential for strong side-effects. RA patients with cancer may be treated with a biologic if their treatment for a solid tumor happened five years earlier, and with heart failure if their case is not too severe.
Treatments suppress the immune system and make those treated vulnerable to infections.
For that reason, new guidelines recommend that all patients taking biologics for RA be screened for latent tuberculosis infection; 5 to 10 percent of these patients will go on to develop active TB later. (1)
Assessing the patient
The role of vitamin D
There is research suggesting a link between low levels of vitamin D and rheumatoid and psoriatic arthritis. Vitamin D, commonly referred to as the “sunshine vitamin” may play a role in preventing the development and progression of arthritis by positively effecting joint health. So much so that low levels may be a risk factor for rheumatoid arthritis and osteoarthritis.(2)
Treatment Options, Including Prolotherapy
While most physicians feel that there is no cure for arthritis and that there is not a lot that can be done for this problem, the treatments are primarily focused on reducing the symptoms of painful and aching joints. The most frequent conventional treatments to help control the symptoms of arthritis involve the use of nonsteroidal, anti-inflammatory drugs (NSAIDs). These medications do not stop the progression of arthritis, but simply reduce the symptoms. NSAIDs have been associated with significant side effects such as bleeding in the digestive tract, liver damage, or kidney impairment.
At the Magaziner Center for Wellness, we provide a comprehensive arthritis program aimed at both reducing pain and restoring function. It includes nutritional supplements prescribed to support joint function and individual dietary and lifestyle recommendations made by our physicians. We also specialize in curing arthritis pain using prolotherapy, a treatment which rebuilds ligaments and tendons. The technique has proven approximately 80% effective in curing patients of pain.
1. Zahi Touma, Lihi Eder, Devy Zisman, Joy Feld, Vinod Chandran, Cheryl F. Rosen, Hua Shen, Richard J. Cook, Dafna D. Gladman. Seasonal Variation in Vitamin D Levels in Psoriatic Arthritis Patients from Different Latitudes and its Association with Clinical Outcomes. Arthritis Care and Research, 2011; DOI: 10.1002/acr.20530
2. Updated guidelines for rheumatoid arthritis more aggressive. University of Alabama Press Release, April 2, 2012