Signs You May Need to Change RA Treatmentsby Lisa Emrich Patient Advocate
One of the best ways you can protect yourself against the devastating effects of RA is to aggressively treat the disease with one or more disease-modifying anti-rheumatic drugs (DMARDs). Damaging inflammation from RA attacks not only joints, but also many internal organs (such as the heart or lungs). So even if your joints feel okay, it is still important to stay on therapy.
What are my options to treat RA?
Shortly after diagnosis, many RA patients may be started on a treatment protocol called triple therapy, which combines the DMARDs methotrexate, sulfasalazine, and hydroxychloroquine (Plaquenil). This might also be combined with steroids such as prednisone and/or non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen, or celecoxib. NSAIDs and steroids act more quickly to reduce inflammation, but the effect doesn't last for long, while DMARDs are slower to build up effectiveness but have a more lasting effect against the disease.
Some rheumatologists may prescribe a combination of DMARDs, anti-inflammatory medications, and biologics either at diagnosis or later when chosen treatments begin to prove ineffective or intolerable.
What is the goal of treatment?
As an RA patient, my personal goal of treatment is remission; however, that is not an achievable goal for a significant number of RA patients. Identifying remission is also a challenge as there is no single definition. Using strict criteria, only 6% of people with RA achieve remission according to studies. By more lenient criteria, 40-50% of patients may experience remission while on treatment. Often a low level of disease activity is acceptable, especially in patients with comorbidities.
When should I change treatments?
Over time, therapies that were once effective may not provide the relief you need to stay active and independent. While it is not the end of the world, if you need to change treatments it can be difficult to know when to bring up the topic with your rheumatologist.
If you have a good rheumatologist (like I'm blessed to have), then he/she is actively monitoring you for signs of disease activity. I just had an appointment with my own doctor earlier this week. At the beginning of each visit, I am required to fill out a form that helps me communicate how RA is affecting my day-to-day life. Each question is scored and if the numbers add up too high, it may indicate that something we're doing isn't working as we'd like it to.
Common considerations for altering treatment
As near remission or low disease activity are common goals of RA treatment plans, signs of disease activity would indicate that your plan may need adjustment. However, minor flare-ups of symptoms, such as sudden and temporary increases in painful, swollen, tender or red joints, may indicate the need for corticosteroids to reduce and control inflammation or an increase in the dosage of your current medication. If you have many flare-ups, consider talking to your doctor about adding or changing to a more effective DMARD or biologic.
The early symptoms of RA are also signs that your disease has become more active or that treatment is no longer working. Symptoms such as pain, fatigue, swollen or tender joints, and morning stiffness that lasts longer than 45 minutes, warrant a discussion with your rheumatologist. The return of symptoms may be subtle and not reach the same intensity you experienced before diagnosis, so you may not think to bring this up to your doctor. but you should.
New symptoms often indicate increased disease activity. Definitely tell your doctor when you've noticed that RA symptoms seem to have spread to other parts of your body or are behaving differently than they have in the past. If RA previously only affected your hands and now you notice new problems with your shoulders or knees, or if you experience painful breathing or heart arrhythmias, or anything else out of the ordinary, call your doctor without delay.
Other signs of disease activity, such as laboratory results that indicate high levels of inflammation (such as increased SED rate or C-reactive protein levels) or x-rays showing additional joint damage, may also indicate that your current treatment plan is no longer effective. Your doctor should periodically measure you for signs of disease activity and document them in your medical record for future reference.
Increased risk of infection is a potential side-effect of a number of RA medications. If you are experiencing more infections or changes in white blood cell counts, your doctor may suggest a change in medication. Complications of infection can quickly become rather serious. In addition, there are some drugs, such as methotrexate, which your doctor may want you to skip while you use antibiotics and until an infection has cleared up.
A number of RA medications can have an impact on liver or kidney functions. If your laboratory results indicate increased liver enzymes or other abnormal results, your doctor may want you to change therapies.
RA is a disease that attacks primarily during child-bearing years for many patients. If you are pregnant or planning to become pregnant, you need to talk to your doctor about what you should do to protect an unborn fetus against birth defects or miscarriage. If you plan to breastfeed, your doctor may suggest an altered treatment plan to keep your RA under control while you are breastfeeding and until you are able to return to your previous therapy.
Effectively talk to your doctor
When you visit your doctor, be sure to describe any symptoms you are experiencing or have experienced since your last visit. Make special note of any new symptoms or difficulties. Be sure to mention how RA is affecting your ability to engage in everyday activities, such as bathing or dressing yourself, turning knobs, holding a cup, getting up out of a chair or the car, or walking for a short distance. If RA is keeping you from doing the things you want to do, don't be afraid to discuss treatment options with your rheumatologist.