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Rheumatoid arthritis - Highlights

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of rheumatoid arthritis.

Alternative Names

Arthritis - rheumatoid

Highlights:

New Drug Treatment Guidelines

In 2008, the American College of Rheumatology (ACR) released new guidelines for the use of disease-modifying anti-rheumatic drugs (DMARDs) for the treatment of rheumatoid arthritis (RA). DMARDs include nonbiologic and biologic drugs. This is the first ACR drug guidelines since 2002. Biologic DMARDs were not included in previous treatment guidelines.

The ACR� ' s current recommendations include:

Methotrexate (Rheumatrex) or leflunomide (Arava) as initial therapy for most patients with RA
Methotrexate plus hydroxychloroquine (Plaquenil) for patients with moderate-to-high disease activity
Methotrexate plus hydroxychloroquine plus sulfasalazine (Azulfidine) for patients with poor prognostic features and moderate-to-high levels of disease activity.
For patients with early RA (less than 3 months), anti-tumor necrosis factor (anti-TNF) biologic drugs (along with methotrexate) should be reserved only for patients with high disease activity who have never received DMARDs. For longer duration RA, anti-TNF drugs are recommended for patients who have not been helped by methotrexate. The three approved anti-TNF DMARDs are etanercept (Enbrel), infliximab (Remicade), and adalimumab (Humira).
The biologic DMARDs abatacept (Orencia)and rituximab (Rituxan) should be reserved for patients with at least moderate disease activity and poor disease prognosis who were not helped by methotrexate and other nonbiologic DMARDs.

Drug Warnings

In 2008, the FDA alerted health care professionals to monitor patients taking anti-TNF drugs for signs of opportunistic infections, particularly fungal infections and tuberculosis.
The FDA is investigating the possible association between use of anti-TNF drugs and the occurrence of lymphomas and other cancers in children and young adults who took these drugs for treatment of juvenile rheumatoid arthritis.
Etanercept� ' s prescribing label now includes a stronger warning about the risks of infections, including tuberculosis.
Rituxan� ' s label now includes updated information on the risks for progressive multifocal leukoencephalopathy (PML), a rare and deadly brain infection.

Resources

www.niams.nih.gov -- The National Institute of Arthritis and Musculoskeletal and Skin Diseases
www.rheumatology.org -- American College of Rheumatology
www.arthritis.org -- The Arthritis Foundation
www.fda.gov/cder/drug/infopage/cox2 -- FDA information on COX-2 inhibitors and NSAIDs
www.clinicaltrials.gov -- Find a clinical trial

References

Chen YF, Jobanputra P, Barton P, Jowett S, Bryan S, Clark W, et al. A systematic review of the effectiveness of adalimumab, etanercept and infliximab for the treatment of rheumatoid arthritis in adults and an economic evaluation of their cost-effectiveness. Health Technol Assess. 2006 Nov;10(42):iii-iv, xi-xiii, 1-229.

Donahue KE, Gartlehner G, Jonas DE, Lux LJ, Thieda P, Jonas BL, et al. Systematic Review: Comparative Effectiveness and Harms of Disease-Modifying Medications for Rheumatoid Arthritis. Ann Intern Med. 2007 Nov 19 [Epub ahead of print]

Firestein GS. . Etiology and pathogenesis of rheumatoid arthritis. In: Harris ED, Budd RC, Genovese MC, Firestein GS, Sargent JS, Sledge CB, eds. Kelley's Textbook of Rheumatology. 7th ed. Philadelphia, Pa: Saunders Elsevier; 2005:chap 65.

Furst DE, Breedveld FC, Kalden JR, Smolen JS, Burmester GR, Sieper J, et al. Updated consensus statement on biological agents for the treatment of rheumatic diseases, 2007. Ann Rheum Dis. 2007 Nov;66 Suppl 3:iii2-22.

Gabriel SE. Cardiovascular morbidity and mortality in rheumatoid arthritis. Am J Med. 2008 Oct;121(10 Suppl 1):S9-14.

Goekoop-Ruiterman YP, de Vries-Bouwstra JK, Allaart CF, van Zeben D, Kerstens PJ, Hazes JM,, et al. Comparison of treatment strategies in early rheumatoid arthritis: a randomized trial. Ann Intern Med. 2007 Mar 20;146(6):406-15.

Goldberg RJ, Katz J. A meta-analysis of the analgesic effects of omega-3 polyunsaturated fatty acid supplementation for inflammatory joint pain. Pain. 2007 May;129(1-2):210-23. Epub 2007 Mar 1.

Harris ED Jr. Clinical features of rheumatoid arthritis. In: Harris ED, Budd RC, Genovese MC, Firestein GS, Sargent JS, Sledge CB, eds. Kelley's Textbook of Rheumatology. 7th ed. Philadelphia, Pa: Saunders Elsevier; 2005:chap 66.

O'Dell JR. Rheumatoid arthritis In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 285.

Saag KG, Teng GG, Patkar NM, Anuntiyo J, Finney C, Curtis JR, et al. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis Rheum. 2008 Jun 15;59(6):762-84.

Salmon JE, Roman MJ. Subclinical atherosclerosis in rheumatoid arthritis and systemic lupus erythematosus. Am J Med. 2008 Oct;121(10 Suppl 1):S3-8.

Smolen JS, Aletaha D, Koeller M, Weisman MH, Emery P. New therapies for treatment of rheumatoid arthritis. Lancet. 2007 Dec 1;370(9602):1861-74.

Smolen JS, Keystone EC, Emery P, Breedveld FC, Betteridge N, Burmester GR,. et al. Consensus statement on the use of rituximab in patients with rheumatoid arthritis. Ann Rheum Dis. 2007 Feb; 66(2):143-50.

Wang C, de Pablo P, Chen X, Schmid C, McAlindon T. Acupuncture for pain relief in patients with rheumatoid arthritis: a systematic review. Arthritis Rheum. 2008 Sep 15;59(9):1249-56.

Reviewed last on: 2/19/2009
Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

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