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Established rheumatoid arthritis: Rationale for best practice – Physicians’ perspective of how to realise tight control in clinical practice

https://doi.org/10.1016/j.berh.2011.10.012Get rights and content

Abstract

Developments in the understanding of the pathogenesis of rheumatoid arthritis (RA) and the introduction of targeted biologic therapies have greatly advanced the management of RA in clinical practice. The management of RA is now aimed at achieving remission, to prevent joint damage and disability. In particular, a critical period early in disease is recognised, in which early aggressive treatment with disease-modifying therapy is advocated. Although a state of remission is the ideal, this chapter discusses the difficulties which may arise in achieving this goal in patients with established disease.

The evidence for best management, aimed at achieving clinical remission in established disease, is reviewed. The consequences of incomplete control of chronic inflammation in established disease, including pain, disability and co-morbidities (such as cardiovascular disease and osteoporosis), also pose a significant clinical challenge. The rationale for a multidisciplinary team approach in reducing the associated morbidity and mortality of the disease are examined.

Section snippets

‘Early’ versus ‘established’ RA

There is, at present, no accepted consensus on the precise definition of ‘early’ or ‘established’ RA. Previously, clinical trials have classified patients with disease duration of less than 2 years as having early RA. However, studies of synovial histology demonstrate that pathological changes in the synovium in patients with disease duration of less than 1 year, or even 6 months, are no different to those seen in patients with disease of longer duration [8]. Patients with established RA vary

The acute phase response

The acute phase response describes the local and systemic inflammatory and repair processes that accompany inflammation. The acute phase markers most commonly used in assessment of disease activity in RA are the C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), both of which are used in composite scores for the assessment of disease activity. ESR and CRP have been shown to correlate with radiographic progression. CRP is now considered the preferential acute phase marker as it

Plain radiography

When treating patients with RA, it is important to consider radiological and functional outcome as well as clinical outcome measures. Joint damage in patients with RA is related to disease activity and correlates with disability; correlation coefficients between 0.3 and 0.7 have been described, with a strong relationship seen between joint damage and disability in established RA and a weaker relationship in early disease [24]. Conventional radiography is a widely available resource and

Non-biologic DMARDs

Methotrexate (MTX) is a folate antimetabolite and is the most commonly used DMARD. It is recommended by EULAR as first-line therapy unless contraindications are present [5], and is regarded as the anchor drug in RA; it is effective as monotherapy, but also widely used in combination with other non-biologic or biologic DMARDs (in the knowledge that its combination with biologic therapies increases the efficacy of these agents). Results of a systematic review suggest that predictive factors for

Patient education

Recent guidelines recommend patient involvement in establishing a target for treatment at diagnosis [9], the premise being that improved patient knowledge leads to improved compliance and outcome. Studies of formal patient education programmes, such as self-management programmes and cognitive behavioural therapy, have shown efficacy in reducing pain, disability and depression [67]; however, the long-term benefits of such interventions have not been convincingly demonstrated in trials or

Cardiovascular disease

Patients with established RA have a cardiovascular mortality rate of approximately 1.5 times that of the general population [84]. Risk factors for cardiovascular disease should be addressed at least on an annual basis [85]. The mechanism for increased rates of premature cardiovascular disease seen with chronic inflammation is incompletely understood; systemic inflammation is likely to have multiple effects such as platelet activation, disease-related dyslipidaemia and presence of

Summary

Despite lack of formal definition, the term ‘established RA’ is generally used to describe patients with disease duration of 2 years or more. The clinical spectrum of established RA varies from patients whose disease was recognised at an early stage in whom treatment with DMARDs has been largely effective, and patients with long-standing disease with consequences of chronic inflammation, including marked joint deformity and co-morbidities such as cardiovascular disease.

Recent guidelines suggest

Conflict of interest statement

Professor Paul Emery has provided expert advice and undertaken clinical trials for Pfizer, Merck, Abbott, UCB, BMS and Roche. Dr Ceara Walsh has received honoraria and speaking fees from Roche and GE healthcare (less than €2000).

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    These authors contributed equally to development of manuscript.

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