18th January 2024

Pharmacological management 

Disease-modifying anti-rheumatic drugs (DMARDs) can be classified as either conventional DMARDs or biologic DMARDs. The first-line therapy is with conventional DMARD monotherapy, either with oral methotrexate, leflunomide, or sulfasalazine, but in practice is usually Methotrexate. Treatment should be started as soon as possible and ideally within 3 months of onset of persistent symptoms. Hydroxychloroquine is an alternative for mild or palindromic disease. The dose of the initial DMARD can be escalated as tolerated. If this is not sufficient, a second DMARD can be added as combination therapy.

The beneficial effect of DMARD therapy may not be seen immediately. Therefore, short-term bridging therapy with glucocorticoids can be started when initiating therapy with a DMARD. A step-down strategy can be considered in patients who stay in remission for at least a year without requiring glucocorticoids.

Biological therapy can be considered, usually in addition to Methotrexate, if the treatment target has not been achieved despite intensive therapy with 2 or more conventional DMARDs and the DAS28 score is between 3.2 and 5.1 (moderate activity). TNF-alpha inhibitors (including Infliximab, Adalimumab and Etanercept)  are usually 1st line biologic therapy. If there is a contraindication to the use of Methotrexate, Adalimumab and Etanercept can be used as monotherapy. In cases where conventional DMARDs and TNF-alpha inhibitors have failed, Rituximab (B cell depletion) can be used- again in combination with Methotrexate. Other rarer biological DMARDs include Tocilizumab (IL-6 receptor blocker) and Abatacept (disruption of T cell function). These agents may be called upon when none of conventional DMARDs, TNF alpha- inhibitors or Rituximab have managed to achieve the treatment target.

Symptom control

There is limited evidence for the use of paracetamol, opioids, and tricyclic antidepressants in symptom control. Non-steroidal anti-inflammatory drugs (NSAIDs) can be considered for pain control and stiffness. However, potential GI, liver and cardiorenal adverse effects should be considered, and a proton pump inhibitor (PPI) should be offered.