rheumatoid%20arthritis
RHEUMATOID ARTHRITIS

Rheumatoid arthritis is a systemic autoimmune rheumatic disorder of unknown etiology.
It is the most common form of inflammatory arthritis.
Patient usually complains of joint pain and/or swelling with morning stiffness that lasts for more than an hour.

Goals of treatment are clinical and radiological remission of disease and to reduce functional limitations and permanent joint damage.

Rheumatoid%20arthritis Management

Follow Up

Monitoring for Drug Toxicity

  • Eg complete blood count, serum creatinine, liver function tests, hepatitis B and C screening, ophthalmologic exam, latent tuberculosis screening [for biological DMARDs (bDMARDs), with chest X-ray]
  • Recommended prior to resuming or increasing therapy with DMARDs
  • It is important to monitor for toxicity due to the potential risks of serious adverse effects of DMARDs

Tapering of Therapy

  • For patients in persistent remission, can consider tapering bDMARDs or targeted synthetic DMARD (tsDMARD) therapy after tapering glucocorticoid therapy
    • Tapering of conventional synthetic DMARD (csDMARD) therapy may also be considered
  • To decrease risk of flares, gradual withdrawal of biological therapies should be done
    • Flare risk is inversely proportional to disease activity and sustained response duration
  • As discontinuation of therapy is associated with high risk of flares, reduction of dose or increase in interval can be done with all bDMARDs and tsDMARDs with little risk of flares 
    • Most patients who flare can regain their good state upon re-institution of the same bDMARD or tsDMARD therapy 
  • Ceasing treatment with csDMARDs is associated with increased flare frequency, hence tapering should be done cautiously and should be evaluated rigorously

Disease Activity Monitoring

  • Disease activity should be measured and documented regularly
    • Moderate-high disease activity: Monthly
    • Sustained low disease activity: Every 6 months
    • Clinical remission: Every 6 months (with DAS and DAS28)
    • Sustained remission: Every 3-6 months
  • Consider structural changes, comorbidities, and functional impairment when formulating treatment decisions on follow-ups
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