---
title: Rheumatoid Arthritis Treatment
description: A comprehensive clinical reference on the diagnosis, treatment, and management of rheumatoid arthritis.
keywords: [rheumatoid arthritis, DMARDs, biologics, corticosteroids, NSAIDs]
category: clinical
---

## Rheumatoid Arthritis Overview

Rheumatoid arthritis (RA) is a chronic, autoimmune inflammatory disorder that primarily affects the synovial joints, leading to progressive joint damage, disability, and systemic complications. The etiology of RA is multifactorial, involving genetic predisposition and environmental triggers that result in the aberrant activation of the immune system and production of autoantibodies such as rheumatoid factor (RF) and anti-citrullinated protein antibodies (ACPA).

## Diagnostic Criteria

The 2010 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) classification criteria for RA are as follows:
- Joint involvement (score 0-5): 1 large joint = 0, 2-10 large joints = 1, 1-3 small joints (with or without involvement of large joints) = 2, 4-10 small joints (with or without involvement of large joints) = 3, >10 joints (at least 1 small joint) = 5
- Serology (score 0-3): Negative RF and negative ACPA = 0, Low-positive RF or low-positive ACPA = 2, High-positive RF or high-positive ACPA = 3
- Acute-phase reactants (score 0-1): Normal CRP and ESR = 0, Elevated CRP or ESR = 1
- Duration of symptoms (score 0-1): <6 weeks = 0, ≥6 weeks = 1

A total score of ≥6 out of 10 is required for the classification of definite RA.

## Treatment Approach

The primary goals of RA treatment are to achieve rapid control of inflammation, prevent or minimize joint damage, and improve functional status and quality of life. The treatment approach typically involves a combination of pharmacological and non-pharmacological interventions.

### Non-Pharmacological Interventions
- Patient education and self-management strategies
- Physical therapy and occupational therapy
- Assistive devices and joint protection techniques
- Weight management and exercise programs

### Pharmacological Interventions

#### Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
- Examples: naproxen, ibuprofen, celecoxib
- Dosage: Varies based on specific NSAID, typically dosed 2-3 times daily
- Monitoring: Monitor for gastrointestinal, cardiovascular, and renal adverse effects

#### Glucocorticoids
- Examples: prednisone, methylprednisolone
- Dosage: Typically start with 10-15 mg/day of prednisone or equivalent, taper as tolerated
- Monitoring: Monitor for adverse effects such as hyperglycemia, hypertension, and osteoporosis

#### Conventional Synthetic Disease-Modifying Antirheumatic Drugs (csDMARDs)
- Examples: methotrexate, sulfasalazine, leflunomide, hydroxychloroquine
- Dosage: Varies based on specific csDMARD, typically dosed once or twice daily
- Monitoring: Monitor for adverse effects such as liver enzyme elevations, cytopenias, and gastrointestinal side effects

#### Biologic Disease-Modifying Antirheumatic Drugs (bDMARDs)
- Examples: tumor necrosis factor (TNF) inhibitors (e.g., adalimumab, etanercept, infliximab), interleukin-6 (IL-6) inhibitors (e.g., tocilizumab), T-cell costimulation inhibitor (abatacept), B-cell depleting agent (rituximab)
- Dosage: Varies based on specific bDMARD, typically administered subcutaneously or intravenously
- Monitoring: Monitor for infections, malignancies, and other adverse effects specific to each bDMARD

#### Targeted Synthetic Disease-Modifying Antirheumatic Drugs (tsDMARDs)
- Examples: Janus kinase (JAK) inhibitors (e.g., tofacitinib, baricitinib, upadacitinib)
- Dosage: Varies based on specific tsDMARD, typically dosed once or twice daily
- Monitoring: Monitor for infections, laboratory abnormalities, and other adverse effects specific to JAK inhibitors

## Treatment Recommendations

### Initial Treatment
- The 2021 ACR Guideline for the Treatment of Rheumatoid Arthritis recommends initiating treatment with a csDMARD, typically methotrexate, as first-line therapy for most patients with newly diagnosed RA.
- For patients with high disease activity or poor prognostic factors (e.g., presence of RF, ACPA, or early erosive disease), the guideline suggests initiating therapy with a combination of a csDMARD and a bDMARD or tsDMARD.

### Treat-to-Target Approach
- The treatment of RA should follow a "treat-to-target" strategy, with the goal of achieving a target of low disease activity or remission, as measured by validated disease activity assessments such as the Disease Activity Score (DAS28), Clinical Disease Activity Index (CDAI), or Simplified Disease Activity Index (SDAI).
- If the treatment target is not achieved within 3-6 months, therapy should be adjusted by optimizing the dose of the current medication, switching to a different medication within the same class, or adding a new medication.

### Monitoring and Adverse Effects
- Patients with RA should be monitored regularly (every 1-3 months) for disease activity, functional status, and adverse effects of medications.
- Routine laboratory monitoring should include complete blood count, liver enzymes, creatinine, and acute-phase reactants (CRP, ESR).
- Specific monitoring requirements and contraindications vary for each class of DMARD, and clinicians should refer to the prescribing information and guidelines for the appropriate monitoring parameters.

## Comorbidities and Special Considerations

Patients with RA are at increased risk of developing various comorbidities, which should be addressed as part of their comprehensive management:
- Cardiovascular disease: Increased risk of myocardial infarction, stroke, and heart failure
- Osteoporosis: Increased risk of fractures due to inflammation and glucocorticoid use
- Infection: Increased susceptibility to infections, especially with biologic and tsDMARD therapies
- Malignancy: Increased risk of certain cancers, such as lymphoma and lung cancer

Clinicians should also consider special circumstances, such as pregnancy, older age, and the presence of other autoimmune or chronic conditions, when tailoring the RA treatment plan.

## Conclusion

The management of rheumatoid arthritis requires a multifaceted approach, including both pharmacological and non-pharmacological interventions, to achieve the primary goals of controlling inflammation, preventing joint damage, and improving the patient's quality of life. Clinicians should follow evidence-based guidelines and employ a treat-to-target strategy, regularly monitoring disease activity and adverse effects, and addressing comorbidities and special considerations as part of the comprehensive care of patients with RA.