Treatment of established RA

Apollo Medicine 2012 DecemberVolume 9, Number 4; pp. 347e348 Algorithms

Treatment of established RA

Sundeep Upadhyaya*

Senior*Tel.: þReceivhttp://d

ABSTRACT

The treatment of established Rheumatoid Arthritis (RA) is a multistep process and includes prognostic features forclassification into a disease that may have a poorer outcome, versus a disease that may be gentler on the patient.This algorithm borrows from and refers to the ACR-2012 modification of the 2008 guidelines for management of RA(Biologic & Non Biologic Management)1 as also referring to the Indian Rheumatology Association consensusstatement for the medical management of RA.2 Individual opinion and unpublished expert consensus for the Indiansetting is also incorporated in this algorithm (example more liberal use of corticosteroids, longer waits (6 months)before initiating biologics). Also, the treatment of RA with comorbidities; use of NSAIDs, osteoporosis medication, etc.have been excluded from this algorithm. The use of Biologics for patients with severe disease is generally continuedindefinitely at least in the developed countries. In India and other developing countries, there are experts in the field ofrheumatology who will use biologics intermittently and also at lower doses; this is a deviation from standard of care.This current algorithm also makes a case for short term use of biologics (example 6 months of Anti-TNF use) and ifthe patient achieves LDA/CR, then the biologics may be discontinued while continuing with conventional DMARDs.This practice is based on expert opinion only and there are no formal trials endorsing such a practice from the Indiansubcontinent. While such therapy may “debulk” the swollen and active joints in patients with RA, there is noconfirmation that radiological progression will be inhibited.In the context of Rituximab use in Rheumatoid arthritis patients, please note that in parallel with the greateracceptance of this molecule earlier in the RA disease process (rather than for Anti-TNF failures alone), a case ismade for use in Biologic-naive patients who have longstanding, seropositive RA. This is again based on personal andexpert opinion (unpublished), as also on the wider and cheaper availability of Rituximab in India and other developingcountries.

REFERENCES

1. Singh JA, Furst DE, Bharat A, et al. 2010 update of the2008 American College of Rheumatology recommenda-tions for the use of disease-modifying antirheumaticdrugs and biologic agents in the treatment of rheumatoid

Consultant, Rheumatology, Indraprastha Apollo Hospitals, Sarita Vih91 9818359408, email: sundeepupadhyaya@hotmail.com

ed: 27.9.2012; Accepted: 29.9.2012; Available online 13.10.2012x.doi.org/10.1016/j.apme.2012.09.006

arthritis. Arthritis Care Res (Hoboken). 2012 May;64(5):625e639.

2. Misra R, Sharma BL, Gupta R et al. Indian Rheuma-tology Association consensus statement on the manage-ment of adults with rheumatoid arthritis. Indian JRheumatol. 2008;39:S1eS6.

ar, New Delhi 110076, India.

348 Apollo Medicine 2012 December; Vol. 9, No. 4 Upadhyaya