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Goals of RA management

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Goals of RA management

The ultimate goals in managing RA are to prevent or control joint damage, prevent loss of function by controlling joint inflammation and swelling, and decrease pain. The initial steps in the management of RA are to establish the diagnosis, perform a baseline evaluation, and estimate the prognosis. An evaluation by a rheumatologist is strongly recommended if the primary care provider is uncertain about any of these initial steps.

Treatment begins with educating the patient about the disease and the risks of joint damage and loss of function, as well as reviewing the risks and benefits of existing treatment modalities. Patients may also benefit from consultation with physical therapists, occupational therapists, social workers, and/or patient educators. Nonsteroidal antiinflammatory drugs (NSAIDs), glucocorticoid joint injection, and/or low-dose prednisone may be considered for control of symptoms. However it is important that patients are seen by an arthritis specialist for implementation of early optimal DMARD therapy.

The majority of patients with newly diagnosed RA should be started on disease-modifying antirheumatic drug (DMARD) therapy within 3 months of diagnosis. Repetitive flares, unacceptable disease activity (i.e., ongoing disease activity after 3 months of maximum therapy), or progressive joint damage require a change in therapy, either in their DMARD regimen (e.g. maximize methotrexate use, ensure it is given parenterally) or using a biologic agent such as a TNF antagonist.

If joint inflammation is confined to one or a few joints, then local glucocorticoid injection may help. For patients with severe symptoms, bridging therapy with corticosteroids can be considered but these patients would likely reuqire a biologic agen if they had failed a number of DMARDs.

Some patients have resistant disease and experience a progressive course despite exhaustive trials of DMARDs, whether used alone or in combinations.While the ultimate goal of treating RA is to induce a complete remission, this occurs infrequently. Complete remission is defined as the absence of the following:

1) symptoms of active inflammatory joint pain (in contrast to mechanical joint pain),

2) morning stiffness,

3) fatigue,

4) synovitis on joint examination,

5) progression of radiographic damage on sequential radiographs,

6) elevation of the erythrocyte sedimentation rate or C-reactive protein levels.

If complete remission is not achieved, the management goals are to control disease activity, alleviate pain, maintain function for activities of daily living and work, and maximize quality of life. Achieving these goals challenges the management skills of the rheumatologist to determine the most efficacious combination of pharmacologic therapy, rehabilitation support, and analgesics.

Education and cognitive ? behavioral interventions, such as the Arthritis Self-Management Program, can improve health status and decrease health care utilization.*

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*Based on Guidelines for the Management of Rheumatoid Arthritis.