Rheumatoid arthritis treatment

 I) Medications

Note:- Actually there is no cure for RA , but treatments can uplifts symptoms & slow the progression of the disease.

A)  NSAIDs : first line drugs( eg; indomethacin , naproxen,diclofenac etc.) for RA used to reduced inflammation.

B)  Disease modifying antirheumatic drugs (DMARDs) - Secon
d line of drugs for RA.

1. Immunosuppressants

Methotrexate (MTX) , Azathioprine, Cyclosporin.

• Methotrexate(MTX):-  single oral low-dose (7.5-15 mg) weekly. Maximun weekly dose -20 mg. Duration of treatment unknown.

Side effects:- nodulosis, oral ulceration, GI upsest . with prolonged therapy liver get damaged      leading to cirrhosis, incidence of chest infarct also may cause.

Contraindication:- pregnancy, breast feeding ,liver disease, active infection, leucopenia & peptic ulcer.   

• Azathioprin:- 50-150 mg per day. It is not combined with MTX. It's given  along with corticosteroids ,it has steroid sparing effect.

2. Sulphasalazine

Doses 1-3 g / day in 2-3 divided doses. It's used as a seond line drug for milder cases. 

Side effects:- neutropenia , thrombocytopenia & hepatitis.

3. Chloroquine and hydroxychloroquine

Doses - Chloroquine 150 mg per day . hydroxychloroquine 400 mg/day for 4-6  weeks, followed by 200 mg/ day for maintenance.

Side effects:-Retinal dmage ,corneal opacity , rashes,graying of hairs, irritable bowel syndrome , myopathy, and neuropathy.

Note :- Chloroquine / hydroxychloroquine are used in milder non erosive diseases , especially when only one or a few joints are involved ,or they are combined with MTX/ Sulfasalazine. 

4. Leflunomide

Dose of 100 mg daily for 3 days followed by 20 mg OD.

Adverse effects:diarrhea, headache, nausea,rashes, loss of hair, thrombocytopenia, leucopenia, increased chance of chest infection and raised hepatic transaminase .

Contraindication:- children and pregnant /lactating mother.

Note:- it's alternative to MTX or can be added to it,but their combination is more hepato toxic. Leflunomide combination with sulfasalazine improves quality.

5. Gold sod. thiomalate, Auranofin

6. d- Penicillamine

Start with 125-250 mg OD, then 250 mg BD.

Side effects:- loss of taste, systemic lupus, myasthenia gravis  etc.

Note:- It' can be used in stage II and III scleroderma .

C)  Biologic response modifiers ( BRMs)

1.TNFalpha inhibitors

• Etanercept:-SC injection 50 mg weekly.

Side effect:- pain, redness, itching & swelling occurs at injection site, chest infection chances may develop. 

• Adalimumab:- SC injection every 2 weeks 
• Infliximab:- 3-5 mg/kg IV every 4-8 weeks.

2. IL-1 antagonist

• Anakinra:- It's less effective than TNF inhibitars.somehow used in patient who have failed on 1 or more DMARDs. Dose- 100 mg SC daily. Local reaction & chest infection are main side effects.

3. Adjuvant drugs

• Corticosteroids :- Prednisolone long term used of it caries serious disadvantages .Thus, either low doses ( 5-10 mg prednisolone or equivalent) are used to supplement NSAIDs or high doses are givenover short periods in cases with severe systemic manifestations.

II) Life style modifications

• Regular exercise useful to maintain muscles strength and over all physical functions .
• Occupational therapy has (+) role for RA.
• Physical activity
• In past it was thought that "night -shade" foods,eg : tomatoes would aggravate RA so better to avoid it.
• There is no  any special food to avoid in RA patients.
•  Folic acid  supplements used to prevent side effect of MTX while treating RA.
• fish oil, such as in salmon, and omega- 3 fatty acid supplements have been shown to be beneficial in RA.
•  Curcumin in dietary turmeric ,an ingredient in curry may be beneficial in reducing symptoms of RA.
• Vitamin D and calcium used to prevent osteoporosis in RA .
• Avoid alcohol or minimize taking it when someone on MTX.
• yoga , swimming  and others exercises should be suggested because they are important in maintaining joint mobility and strengthening the muscles around the joints.