Receiving a diagnosis of rheumatoid arthritis (RA) used to mean an inevitable deterioration into joint damage, deformity and disability. Receiving an RA diagnosis now means a much better chance for remission or low disease activity so you can lead a better life. Here's a look at the changes in how RA is treated and what it means for you.
The traditional approach to treating RA was a stepped-up pyramid (1). When first diagnosed, you would be prescribed NSAIDs (nonsteroidal anti-inflammatory drugs, such as Voltaren or Orudis) and nothing else for a long time. When that didn't work, you might be upgraded to steroids and, down the road, perhaps shots of gold salts, one of the traditional treatments for RA. Much further down this road, you might be prescribed Plaquenil. The key phrase governing this approach was "go low and go slow." Unfortunately, while you were going low and slow, the disease was going fast and furious, eating up the cartilage in your joints, causing damage that affected your ability to move on a permanent basis.
Not surprisingly, the majority of people with RA used to be quite disabled. This often meant that they had to stop working within a fairly short time of diagnosis. With progressive disability, they also frequently needed mobility aids, such as crutches and wheelchairs, as well as needing a lot of help with activities of daily living. Surgeries and joint replacements were common.
Treat to target
Methotrexate was introduced as an RA treatment in the 1990s, followed by the first biologics around 2000. For the first time, rheumatologists had a tool that could actually control RA. With this came a sea of change in the approach to treatment.
When doctors treat high blood pressure or diabetes, they use a model of treatment called tight control or treat to target. There is a specific goal normal blood pressure or blood sugar and regular assessments determine progress with adjustments of medications until that goal is reached. With the new RA medications, the field of rheumatology was able to adopt the treat-to-target model.
An early study investigated this approach, using two groups of people with RA (2). One group received treatment based on the treat to target model, while the other received routine/traditional care. At the end of the study, the rate of remission for the group receiving treatment based on the traditional approach was 16 percent, while the treat-to-target group had remission rates of 65 percent.
Not surprisingly, this caused a revolution in how rheumatologists approached the treatment of RA. The American College of Rheumatology's (ACR) guidelines for treatment state that "the goal for each RA patient should be low disease activity or remission." (3) This means early and aggressive treatment to maximize the potential for a good response and to minimize damage to joints.
What this means for you
Many people who have just been diagnosed with RA are understandably nervous about being handed prescriptions for strong medication in their first appointment with a rheumatologist. Getting a diagnosis of a chronic illness is a shock and it's normal to need some time to adjust. However, it's important to understand that if you delay treatment while you're adjusting, you risk damage to your joints. Although we are normally told to not take medication whenever possible, the opposite is true with RA. When you have RA, medication protects you.
Currently, the best rates of remission from RA are estimated to be 40 to 50 percent. You may have heard other, much lower rates. This is because there are several different ways of measuring remission. The ACR/EULAR criteria for remission are extremely strict, formulated for a stringent testing of clinical trials. This results in remission rates as low as 6 percent. However, for the purposes of clinical practice and your daily functioning, the DAS-28 method of measuring remission results in higher numbers.
Knowledge is power. Knowing that the ACR recommends early and aggressive treatment that follows the treat-to-target approach can help you in several ways. Understanding why your rheumatologist is recommending you start treatment immediately can make you more comfortable about taking the medication. In addition, knowledge can help you become an empowered and active partner in your care. If your rheumatologist is not treating your RA aggressively, ask questions. Some individuals may require a different approach to treatment due to other factors, including other medical conditions. However, if you feel that you should receive more aggressive treatment, you may consider interviewing other rheumatologists to find someone who follows the ACR guidelines more closely.
(1) Schattner, A., "A new era in rheumatoid arthritis treatment time to introduce a modified treatment pyramid." QJM. _ 2000, 93 (11): 757-760._
(2) Grigor et. Al., "Effect of a treatment strategy of tight control for rheumatoid arthritis (the TICORA study): a single-blind randomised controlled trial." Lancet. 2004 Jul 17-23;364(9430):263-9.
(3) Singh, et.al., "2012 Update of the 2008 American College of Rheumatology Recommendations for the Use of Disease-Modifying Antirheumatic Drugs and Biologic Agents in the Treatment of Rheumatoid Arthritis." Arthritis Care & Research. Vol. 64, No. 5, May 2012, pp 625-639
Lene Andersen writes the award-winning blog The Seated View. She's the author of Your Life with Rheumatoid Arthritis: Tools for Managing Treatment, Side Effects and Pain and 7 Facets: A Meditation on Pain.