Treatment Guideline Chart

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 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
  • Prophylactic antiviral therapy for hepatitis B infection is recommended over frequent monitoring alone for patients who are anti-HBc and HBsAg positive who will be starting bDMARD or tsDMARD

Tapering of Therapy

  • Prior to tapering, patients should have low disease activity or be in remission for at least 6 months 
  • A dose reduction (decrease in dose or increase in dosing interval) is recommended over gradual discontinuation of a DMARD, and a close evaluation of patients should be performed during any taper 
  • For patients in persistent remission, can consider tapering bDMARDs or tsDMARD therapy after tapering glucocorticoid therapy
    • Tapering of 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, careful 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 prior good response upon prompt 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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