How to manage Rheumatoid Arthritis? Rapid Jumpstart Advice

Introduction

Rheumatoid Arthritis is the most common disease I manage among the autoimmune disorder. To better understand how to manage Rheumatoid arthritis, let us define autoimmune. Our immune system is complex but simplistically it is responsible to maintain internal order and fight against external invaders such as bacteria, viruses, fungi, parasites, and even non-living substances. The latter could be as simple as piece of sharp wood. It maintains order of other cells and make sure they do not go out of line. This means it kills any cells trying to be cancer. When immune system gets confused, it could either fail to fight invaders (internal or external) or attacks the wrong thing. When it attacks the wrong thing, I mean it attacks self. Some could be simple as fighting thyroid gland leading to wasting out the gland. These individuals end up taking supplement as they no longer have enough gland to produce thyroxine. At times, the immune system attacks multiple organs. When it attacks joints, docs call it inflammatory arthropathy which is confusing name as the word inflammation is thrown out by docs right and left that in practical life it almost lost its meaning. When the immune system attacks multiple organs we call it systemic autoimmunity.

Overview of what a Rheumatologist can do for Rheumatoid arthritis management.

As Rheumatologist we like to believe, the thing most unique to us is that we manage systemic autoimmunity and inflammatory arthropathy. Although some systemic autoimmunities are managed exclusively by other specialists such as multiple sclerosis is dealt with by neurologists. How do we manage them. We use medications that calms down the immune system. Generally, we start with old cheap drugs. Old is still gold. The reason is simple. If a medication has been there for 50 years, we already have seen most its side effects, and the community of docs now easily are aware of how to use it. Usually, older drugs are made up or more likely chemicals extracted from natural elements and manipulated to concentrate the effective component. Yet pharmacists describe these meds as pharmaceutically promiscuous because they work by touching multiple elements of the immunes system at once leading these meds to be effective in multiple diseases. Then newish category of meds came up, we call biologics. These are made in live cells as they are mainly proteins. These proteins are designed to block one element that scientist believe is involved in how a certain disease happens to become. OF course, some elements function more broadly on the immune system. Generally, but not always, the more effective the more it lowers the immune system and leading to higher risk of infection. Note that I said risk NOT amount. Most patients do not get more infections or at least do not get more serious infections.

What determines the choice of Rheumatoid arthritis management?

What makes us choose one med over another. In Rheumatologist mind, we have a list the determine what drug to choose:

1. How bad is your disease. Not all Rheumatoid arthritis is equal.
2. The potential side effects of each meds.
3. What meds are risker for you due to health conditions you have.
4. Organs involved by the disease in your unique case. (this is more in systemic autoimmunity)
5. Realistically speaking insurance has a say in certain choices.

How to choose a biologic for Rheumatoid arthritis management?

Within the biological drugs we categorize meds based on what element on the immune system they work on.  You might hear your doc saying, I prefer anti-TNF in this patient, IL 6 inhibitors, or anti CD-20. That is because each group has unique aspects. You might see in your doc note “ I will avoid anti-TNF for now as patient had quite sever reaction with ………”. Or “I am avoiding IL6 inhibitors as patient already has elevated liver enzymes in setting of fatty liver disease”.

Unfortunately, not all my patients get better from the first med I use, or I would not have needed more than 1 med. Therefore, you would see patients who have tried 4-5 drugs even more prior to finding the right med.

The commonly used chemical drugs for Rheumatoid arthritis management

For the chemical drugs I usually start with there is 2 quite common ones for Rheumatoid Arthritis and 2 less common. In future articles, I will dedicate more explanation about them and possible way I start them and how possibly to do monitoring. Methotrexate is the most common used medication, but I monitor the liver by doing regular blood tests. It is quite effective med and usually must be started first unless there is medical reason not to. Then I usually go ahead and combine with hydroxychloroquine (5mg per Kg of weight). In the past, due to absence of biological drugs, commonly these two were combined with sulfasalazine unless you have sulfa allergies. These were called triple therapy, but sulfasalazine use seems to be reduced to the presence of new biologics that are easier for patients to comply with. I always imagine myself trying to take 10-20 meds a day. Is this possible? What possible confusions can happen? Overdose or under dose. This combination that we called tripled therapy was quite effective. Then if methotrexate was not tolerated by patients, a good replacement is leflunomide which also requires liver monitoring through blood testing.

What are the stronger therapies for Rheumatoid arthritis management?

Then you go to biological drugs. It is impossible to keep this article updated as there is explosion of new drugs and now a new category called biosimilar. The latter I will dedicate an article. The latter I think of as generic in a sense, just not to complex things too much for now.

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