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*For medical professionals only
In recent years, the rapid development of therapeutic drugs for RA has brought more choices
to patients.
Rheumatoid arthritis (RA) is a common disease in rheumatology and a representative type of rheumatism
.
In the past few decades, in the field of rheumatoid arthritis, a large number of basic and clinical studies have been carried out, and many new drugs have been launched one after another, which has promoted earth-shaking changes
in the treatment strategy of RA.
A few days ago, the medical community had a dialogue with Professor Dai Shengming of the Sixth People's Hospital affiliated to Shanghai Jiao Tong University, discussing the development of RA drugs and the changes in treatment strategies, and extracting the essence for readers
.
At the right time, the development of new RA drugs benefits the majority of patients
.
" Professor Dai Shengming bluntly said, "In the past, there were few treatment drugs for RA, and we could diagnose patients as RA, but there were no good drugs to improve the disease
.
The doctor had a busy day and did not feel accomplished
.
But now, in addition to traditional disease-modifying antirheumatic drugs (csDMARDs), there are also biological agents such as TNF-α inhibitors, IL-6 inhibitors, and small molecule targeted drugs
represented by JAK inhibitors.
With these drugs, many patients with RA have relieved their pain and doctors have a greater sense of
accomplishment.
This is mainly due to the progress of
science and technology.
"
In the seventies, the main therapeutic agents for RA were nonsteroidal anti-inflammatory drugs (NSAIDs) or glucocorticoids
.
Although NSAIDs can reduce the symptoms of rheumatoid arthritis, they cannot change the course of the disease and prevent joint destruction
.
Many patients are unable to avoid joint destruction and even disability despite long-term treatment [1].
After the eighties, csDMARDs, represented by methotrexate, began to be used for RA treatment
.
Because this type of drug works slowly, patients often need to use 1~6 months to show obvious improvement in clinical symptoms, so it is also known as "slow-acting drugs" [1].
However, it is worth noting that the specific target and mechanism of action of most csDMARDs for the treatment of RA have not been determined [2], and the lack of therapeutic specificity also limits the effectiveness of these drugs and can lead to many adverse reactions [3].
。 Clinical studies have shown that less than half (about 25%~40%) of patients can achieve clinical remission or low disease activity with methotrexate monotherapy, that is, the treatment standard is met [2].
Common adverse effects of methotrexate include nausea, diarrhea, alopecia, rash, and, rarely, bone marrow suppression, hearing impairment, and interstitial lung lesions [1].
Approximately 30 percent of patients with RA may be discontinued within the first year of methotrexate therapy due to poor response or intolerance [3].
The second milestone development of RA drugs came at the beginning of the new century
.
Biologics represented by TNF-α inhibitors and IL-6 inhibitors have been introduced successively, which has greatly improved the treatment response and quality of life of patients [3].
TNF-α inhibitors have been shown to be quick-onset and effective in delaying or inhibiting bone destruction compared with csDMARDs [4].
However, biologics also have their limitations, including parenteral administration (subcutaneous or intravenous), and their targets are a single cytokine or receptor [3].
After the new century, JAK inhibitors such as tofacitinib and baricitinib have successively appeared on the historical stage
.
JAK inhibitors are small molecule chemical synthetic drugs that can be administered orally and are easy
to use.
Currently, irreversible joint damage can be prevented in up to 90% of RA patients with standardized and aggressive treatment [2].
As Professor Dai Shengming said, this is an unprecedented "good era"
for both rheumatologists and RA patients.
Early attainment, two "keys" to treatment strategies
of RA treatment strategies.
Professor Dai Shengming introduced: "In the last century, we treated RA with an 'upper ladder' treatment plan
.
For patients with confirmed RA, it is first recommended to use NSAIDs, if the efficacy is not good, then use slow-acting drugs such as methotrexate, one drug does not work, it is combined with two, two do not, and then three
are used.
But adjusting the drug in this way can take two or three years, during which time many patients have developed joint deformities and bone structure destruction
.
Therefore, in the late 80s, some people proposed a "down-step plan", for patients with more serious diseases, the combination of hormones and other drugs was first used, aiming to control the disease as soon as possible, and after the patient's condition was stabilized, the use of glucocorticoids with greater adverse reactions was
gradually reduced.
Such treatment strategies aim to control the disease
early.
"
After entering the new century, early treatment and treatment-to-target have become the most important treatment strategies for RA, significantly improving the prognosis of patients [5]
.
" We now advocate on-the-standard therapy, which helps patients achieve clinical remission as much as possible, and for particularly refractory patients, the goal can be adjusted to low disease activity
.
Professor Dai Shengming said, "Although we have not yet been able to completely cure RA, that is, to achieve 'root breaking' as the people say, clinical remission is already an achievable treatment goal
.
"
This treatment strategy has also been written into the "2018 China Rheumatoid Arthritis Diagnosis and Treatment Guidelines"
.
The guidelines suggest that for those who do not meet the standard of RA treatment, it is recommended to monitor their disease activity once every 1~3 months (2B); For initial treatment and moderate/high disease activity, the frequency of monitoring is 1 time per month (2B); For those who have reached the treatment standard, it is recommended that the monitoring frequency be 1 time every 3~6 months (2B) [6].
▎RA compliance treatment strategy
- Once diagnosed with RA, traditional synthetic DMARDs (1A)
should be started as soon as possible.
Methotrexate alone is recommended
.
When methotrexate is contraindicated, consider flunomide or sulfasalazine alone (1B) [6].
- When the treatment of a single conventional synthetic DMARDs is not met, it is recommended to combine one or two traditional synthetic DMARDs for treatment (2B); or a traditional synthetic DMARDs combined with a biologic DMARDs for treatment (2B); or a conventional synthetic DMARDs combined with a targeted synthetic DMARDs for treatment (2B) [6].
- Patients with moderate/high disease activity with RA are advised to combine conventional synthetic DMARDs with glucocorticoids to rapidly control symptoms (2B).
Adverse effects
should be closely monitored during treatment.
Monocorticoids (1A) alone or in long-term high doses are not recommended [6].
- After the treatment of DMARDs with biologics or targeted synthetic DMARDs is reached, patients with RA can consider gradually reducing the dose, and close monitoring should be carried out during the reduction process to prevent recurrence (2C).
In the process of dose reduction, if the patient with RA is in a state of continuous clinical remission for more than one year, clinicians and patients can discuss whether to stop it according to the actual situation (2C) [6].
"Although the vast majority of RA patients can now be prevented from developing joint deformities through standardized treatment, there are still many RA patients who are in wheelchairs and have severe deformities
in the joints of their hands.
Such patients are often skeptical of our modern medicine and advanced treatment options, credulously believe in medical remedies, and miss the best window
of opportunity for treatment.
Professor Dai Shengming said sadly, "For such patients, I will explain to him in detail the effectiveness and safety of the treatment plan to dispel the patient's doubts
.
" Monitor closely after treatment and adjust the protocol
in time.
For example, a small number of patients using csDMARDs may have elevated transaminases, for such patients we can adjust the dose of the drug, or switch to other drugs, his or her liver function may return to normal, which is only a small episode in the treatment process, will not affect his health
.
If the patient's treatment is delayed or irregular, and the joint is deformed, our physicians
will be 'unable to return to heaven' and can only replace the joint through surgery, which is very regrettable.
References
: [1] Chinese Medical Association Rheumatology Branch.
Chinese Journal of Rheumatology, 2003, 7(4):5.
[2]Aletaha D,et al.
JAMA.
2018 Oct 2; 320(13):1360-1372.
[3]Geng B,et al.
Ann Allergy Asthma Immunol.
2022 Mar; 128(3):263-268.
[4] Wu Huaxiang, et al.
Zhejiang Medical Journal, 2011, 33(10):4.
[5] Geng Yan, et al.
Chinese Journal of Internal Medicine, 2022, 61(1): 51-59.
[6] Rheumatology Branch of Chinese Medical Association.
Chinese Journal of Internal Medicine,2018,57(4): 242-251.
Expert Profile
Dai Shengming The photo of the professor has obtained the informed consent of the expert
Director of the Department of Rheumatology and Immunology, Shanghai Sixth People's Hospital
Vice Chairman of Shanghai Rheumatology Branch
Member of the Rheumatology Branch of the Chinese Medical Association
Member of Rheumatology and Immunology Branch of Chinese Medical Doctor Association
Member of Rheumatology and Immunology Branch of Shanghai Medical Association
PP-BA-CN-2111
This article is intended solely to provide scientific information to healthcare professionals and does not represent the position ofthe Platform.
