Certainly we assume your doctor is doing his or her best to treat your rheumatoid arthritis (RA) according to current standards of medical care. But over time, for many diseases, new standards of care gradually arise. For a long time, there has been debate about how aggressively rheumatoid arthritis should be treated. Is it time to define a new standard?
The issue: what should be the goals of therapy in RA? Should we be more aggressive? Some doctors say yes, hoping to help their patients feel even better and to prevent joint damage. Others worry that more aggressive use of medications will produce more side effects – problems doctors call adverse events. Here's the range of possibilities under discussion:
At the recent American College of Rheumatology scientific sessions, the case for targets was made by Duncan Porter, MD, in his report on the TACORA (Tight Control of Rheumatoid Arthritis) study1. Dr. Porter pointed out the similarities between RA and diabetes:
In diabetes, targets have helped. Doctors don't just aim to "improve" control of blood sugar. They aim for a specific number, based on HbA1c – a blood test that measures your blood sugar control over the prior 2 to 3 months. Medications and dosages are changed to aim for a specific HbA1c target. The target gets blood sugar levels as close to normal as possible. This is called tight control. Research has proven that reaching that target – and staying there – reduces the risk of the serious complications of diabetes.
TACORA sought to determine whether tight control of early RA could provide significantly better outcomes – patients who feel better and had less damage to their joints.
The target they used is based on the Disease Activity Score (DAS) – a way of measuring RA problems developed in Europe2. It is based on points for: how many tender and swollen joints you have, your sedimentation rate (a blood test), and your report of how you feel (scored 1-100) – plus some complex math to come up with a number. A DAS score of more than 3.7 indicates high disease activity; a score equal or lower than 2.4 indicates low disease activity. A score of less than 1.6 indicates that you are in remission.
The TACORA target was less than 2.4 for this experiment. The study enrolled 110 patients who had had active RA for less than 5 years. They were randomly assigned to two groups and participated for 18 months.
The "intensive care" group saw their rheumatologist every month. Their DAS was calculated at every visit. If it had not reached 2.4 or lower, therapy was changed to higher doses or new drugs – every month, if needed – to reach that goal. Drugs used included sulfasalazine, prednisolone, methotrexate, cyclosporine, and other disease-modifying anti-rheumatic drugs (DMARDs). Sometimes a persistently painful joint was injected with steroids. All of this was done based on a written plan – called a protocol – for the experimental group.
The "routine care" group saw their rheumatologist every three months. Their doctors aiming for the best for each individual patient – without specific targets. They increased or changed drugs as they thought appropriate.
At the end of 18 months, a physician who did not know who was in which group evaluated all the patients – looking at their test scores for disease activity, quality of life and physical function, and at the X-ray scores of joint damage.
The more aggressive therapy led to significant improvements on every measure. And, overall, the intensive group achieved a DAS of 1.4 – they were in remission.
The routine care group, which had received excellent but traditional care, only achieved a DAS of 2.7.
Another measure of how well RA patients are doing is the ACR 70. What percent of the patients in the group had achieved a 70% improvement in their RA over the course of 18 months? Only 18% of the routine group compared to 67% of the intensive group.
But did this aggressive approach cause any problems? Did those extra drugs cause more side effects? Interestingly, adverse events were less frequent in the intensive group than in the routine group.
It is also interesting that the latest drugs for RA – the anti-TNF agents such as etanercept (Enbrel), infliximab (Remicade) and adalimumab (Humira) – were not used in this study. It is not known how the use of anti-TNF agents might have changed the results of the study. They might have led to further improved outcomes – in both groups of patients.
The researchers concluded that "patients with early RA should be treated intensively using standard DMARDs according to a protocol that targets persistent disease activity." Thus, this study joins many others that support aggressive early treatment of RA.
Is a DAS of less than 2.4 the right target? Should we be even more aggressive? For the moment, the message of this article is that we should be more rather than less aggressive with each patient. But individualization – taking the individual patient into consideration rather than just a number on a chart – is essential. (See footnote 2 for 2 resources for online DAS calculator)
The case for pushing further – to "no evidence of disease" in all patients – is provocative. It does not seem possible in all patients at this time. But it remains a valuable goal as research moves forward – and requires further study.
Answered by Stephen A. Paget, MD, FACP, FACR
What are the symptoms of RA?
Symptoms of RA can be similar to other inflammatory diseases. For that reason, it is important to seek definitive diagnosis early on to ensure appropriate treatment. Symptoms include swollen, painful, warm joints, often in the hands (knuckles, mid-finger joints) and wrists. This inflammation is symmetrical; that is, both sides of the body are involved. Morning stiffness lasting longer than 1 hour and marked fatigue/malaise are often present. Unexplained fever is also sometimes an accompanying symptom.
I’m currently on Methotrexate and seem to be doing well. Should I consider speaking to my doctor about adding a biologic like Enbrel or Humira?
That depends on what you consider “doing well.” How is your feeling of well-being measured? Similar to the way we view therapeutic goals for other chronic illnesses like diabetes, we should view our goals for treatment for RA using tightly controlled measures. Our goal for treatment is to achieve “no evidence of disease,” a term borrowed from cancer treatment.
In treatment of RA, we look to achieve normal functioning – no signs of redness, warmth, swelling, or tenderness. In order to prevent joint erosion, we treat RA aggressively to try to achieve this goal. Current research indicates that using one or more disease-modifying drugs with NSAIDs, or in combination with a biologic early on, can yield excellent results. Ultimately, you and your rheumatologist should look at your current treatment plan and determine if it is working for you.
Is there anything one can do, using diet, vitamins, exercise, etc., to prevent RA?
Certainly, a well-balanced diet and daily exercise are important to overall health. To date, there is no known method of preventing RA. What we do know is that there is a therapeutic window of opportunity to prevent extensive joint damage and halt the progress of the disease once it’s diagnosed. The most important issue is early diagnosis. Consulting with a rheumatologist – a specialist in the diagnosis and treatment of RA – is the first, most important step. Appropriate, early intervention is the best method we know of to prevent onset of the severe damage this disease can cause.
Do I need to take a disease modifying drug if my inflammation seems under control with NSAIDs? I’m worried about the side-effects of these drugs.
Only you and your rheumatologist can determine the proper course of treatment based on “the personality” of your RA. It is important to note, however, that nonsteroidal anti-inflammatory drugs (NSAIDs) only address inflammation – they do not halt disease progression and joint damage. In making medication recommendations, your rheumatologist will carefully consider your medical history and drug allergies to minimize the risks of side-effects and reactions. Further, while on disease-modifying antirheumatic drugs (DMARDs), patients are closely followed to determine if the medication is working effectively and if there are any reactions or side-effects.
Reviewed: 12/14/2010 Posted: 12/7/2005