Rheumatoid arthritis treatment
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
Click here: Second Opinion Arthritis Treatment Kit
Rheumatoid arthritis (RA) is one of the most common and serious forms of arthritis.
It affects a little more than 2 million Americans, about 70% of whom are women. RA is characterized by chronic inflammation in the joints which causes pain, swelling, and stiffness. RA can cause permanent joint damage leading to joint deformities and loss of joint movement. As a result, many people with RA experience limitations on their ability to perform daily activities; this has a major impact on quality of life. Studies have shown that early aggressive treatment of RA can limit joint damage.
RA is a systemic disease and affects other body organs. It is a major contributor to morbidity and mortality. Mortality rates among people with RA are twice that of the general population and disease severity is an independent risk factor of mortality regardless of other medical conditions. The incidence of cardiovascular events in RA is independent of traditional cardiovascular disease in RA. People with RA are twice as likely to develop congestive heart failure is compared to those without RA.
A report by the Centers for Disease Control and Prevention describes arthritis as the most prevalent chronic condition. It is the most reported case of disability in the United States and the third leading cause of work limitations. Medical and indirect costs due to lost wages are estimated at $3 billion annually and less than 50% of working age adults with RA are still employed 10 years after onset of the disease.
The major goals of therapy are to relieve pain, swelling, and fatigue; improve joint function; stop joint damage; and prevent disability and disease-related morbidity.
The cause of RA is unknown, but multiple genetic and environmental factors (infectious agents, reproductive status, and smoking) are thought to be involved. There is considerable debate within the medical community at this time as to whether RA is one disease or several different diseases with common features- ie. a spectrum of diseases. What is known is that the immune system plays an important role.
RA is a complex, multipathway disease. There are many cells, molecules (big and small), and other processes involved in the pathogenesis of RA. A type of cell, called the CD4+ T cell mediates joint damage both directly and also by driving non-T effector cells to release inflammatory cytokines (inflammatory proteins).
Another model centers on the role of B cells in RA pathology by producing autoantibodies and triggering cytokine secretion by T cells as well as by acting as antigen-presenting cells (APCs) to trigger T-cell activation.
Treatment options including biologic response modifiers, disease-modifying anti-rheumatic drugs, and combinations of these therapies.
The use of these therapies is predicated on the mechanisms that are felt to drive the RA process. For example, when T cells were identified as participants in inflammatory processes, therapeutic agents including TNF antagonists and IL-6 inhibitors were developed to intervene in T-cell mediated processes.
Clarification of the role of B cells in the inflammation cascade has provided the rationale for investigation of B-cell targeted therapies. Two of the most promising therapeutic approaches identified by the Arthritis Foundation as one of the top ten arthritis advances in 2004 include rituximab, which targets B cells and abatacept, which belongs to a new class of drug known as a co-stimulatory modulator that targets T-cell activation.
In the past the traditional treatment pyramid for rheumatoid arthritis was to start with anti-inflammatory drugs, move onto mild disease-modifying drugs, step up to more aggressive disease-modifying drugs if they didn’t work, and finally use powerful immunosuppressive drugs as a last resort. The treatment approach now is to stand the pyramid on its head and use more aggressive immunosuppressive drugs or biologic therapies in concert with methotrexate to effect remission as soon as possible.
Anti-inflammatory drugs- either non-steroidal drugs or low dose corticosteroids- remain an adjunctive therapy but are not considered as important as remittive drugs.
In addition to TNF inhibitors (Enbrel, Humira, Remicade, Cimzia, Simponi), other biologic therapies include Actemra, Orencia, and Rituxan.
The research community is actively involved in searching for biomarkers to identify at risk populations and evaluate treatment effectiveness as well as defining inadequate response to therapy so that treatment can be customized to individual RA phenotypes.
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Click here Second Opinion Arthritis Treatment Kit
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