Medication Summary
Optimal care of patients with rheumatoid arthritis (RA) requires an integrated approach that includes both nonpharmacologic and pharmacologic therapies. The following pharmacologic agents are commonly used in RA:
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Nonbiologic and biologic disease-modifying antirheumatic drugs (DMARDs)
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Nonsteroidal anti-inflammatory drugs (NSAIDs)
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Analgesics
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Corticosteroids
DMARDs, Other
Class Summary
DMARDs represent the most important measure in the successful treatment of rheumatoid arthritis. These agents can retard or prevent disease progression and, thus, joint destruction and subsequent loss of function. Successful DMARD therapy may eliminate the need for other anti-inflammatory or analgesic medications; however, until the full action of DMARDs takes effect, anti-inflammatory or analgesic medications may be required as bridging therapy to reduce pain and swelling.
Leflunomide (Arava)
Leflunomide is indicated for the treatment of active RA to reduce signs and symptoms, inhibit structural damage and improve physical function. Corticosteroids, aspirin, or other NSAIDs may be continued during leflunomide use. Leflunomide is contraindicated in women who are or may become pregnant.
Leflunomide is a pyrimidine synthesis inhibitor that blocks autoimmune antibodies and reduces inflammation. It also inhibits dihydroorotate dehydrogenase, an enzyme in the de novo pyrimidine synthesis pathway and has antiproliferative activity.
Sulfasalazine (Azulfidine, Azulfidine EN-tabs)
Sulfasalazine (SSZ) is indicated for the treatment of patients with RA who have had an inadequate response to salicylates or other NSAIDs. It acts locally to decrease inflammatory response and systemically inhibits prostaglandin synthesis.
SSZ delayed-release tablets do not have an immediate response; therefore, concurrent treatment with NSAIDs or other analgesics is recommended at least until the effect of the delayed-release tablets is apparent. The initial dosage is 0.5-1 g/day. The dosage can be adjusted to a dose of 3 g/day after 12 weeks if an adequate clinical response is not seen.
Hydroxychloroquine (Plaquenil)
Hydroxychloroquine (HCQ) is approved for the treatment of acute or chronic RA. The initial dosage is 400-600 mg/day; dosages should be computed on the basis of patient body weight. If a good clinical response is seen over a period of 4 to 12 weeks, the dosage can be reduced by 50% and continued at a level of 200-400 mg/day. The risk of retinopathy is greater when this dosage is exceeded. It should be noted that each 200 mg tablet contains only 155 mg of active drug.
Patients must have a baseline eye examination (including color and vision testing, funduscopic examination, and visual-field testing) performed before starting HCQ therapy. Most rheumatologists recommend an HCQ eye examination every 6-12 months.
Rituximab (Rituxan)
Rituximab is most often used in combination with methotrexate (MTX). It has been shown to be effective at reducing signs and symptoms in adult patients with moderately to severely active RA who have had an inadequate response to therapy with 1 or more tumor necrosis factor (TNF) antagonists. Treatment with rituximab may deplete CD20+ B cells. The usual regimen consists of 2 intravenous (IV) infusions of 1000 mg, separated by 2 weeks, in combination with MTX.
DMARDs, Immunomodulators
Class Summary
DMARDs represent the most important measure in the successful treatment of RA.
Methotrexate (Rheumatrex, Trexall, Otrexup)
MTX is a folic acid antagonist that is approved for the management of severe active RA in patients who have had an insufficient therapeutic response to or are intolerant of an adequate trial of first-line therapy, including full-dose NSAIDs. It inhibits dihydrofolic acid reductase, which ultimately interferes with DNA synthesis, repair, and cellular replication.
Tocilizumab (Actemra)
Tocilizumab is an IL-6 receptor inhibitor. It is indicated for moderate to severe active RA in adults who have had an inadequate response to 1 or more TNF-antagonist therapies. It has been approved as an IV infusion or SC injection that may be used alone or in combination with MTX or other DMARDs.
Sarilumab (Kevzara)
Human monoclonal antibody that binds to both soluble and membrane-bound IL-6 receptors (sIL-6R and mIL-6R). It is administered as a SC injection. May be prescribed as monotherapy or with methotrexate or other conventional DMARDs.
Azathioprine (Imuran)
Although azathioprine is not a first-line agent, it is sometimes used in the treatment of active RA to reduce signs and symptoms, particularly in patients who may have coinciding connective tissue diseases, such as systemic lupus erythematosus. Aspirin, NSAIDs, or low-dose glucocorticoids may be continued during treatment with azathioprine. The mechanism whereby azathioprine affects autoimmune diseases is unknown; however, it works primarily on T cells.
The initial dosage is 1 mg/kg/day (50-100 mg/day) given as a single dose or in divided doses twice daily. The dosage may be increased by 0.5 mg/kg/day at 6-8 weeks and thereafter at 4-week intervals, up to a maximum dosage of 2.5 mg/kg/day. Azathioprine is available in tablet form for oral administration or in 100-mg vials for IV injection.
Cyclosporine (Gengraf, Neoral)
Although cyclosporine is approved for the treatment of patients with severe active RA in which the disease has not adequately responded to MTX, it is not commonly used to treat RA, because of its nephrotoxicity. When cyclosporine is used, patients' renal function must be closely monitored.
Cyclosporine can be used in combination with MTX in RA patients who do not have an adequate response to MTX alone.
Anakinra (Kineret)
Anakinra is a recombinant, nonglycosylated form of the human interleukin (IL)-1 receptor antagonist (IL-1Ra) that is indicated for reducing signs and symptoms and slowing the progression of structural damage of moderately to severely active RA that has failed treatment with 1 or more DMARDs. Anakinra can be used alone or in combination with DMARDs other than TNF-blocking agents.
Abatacept (Orencia)
Abatacept is a selective costimulation modulator that inhibits T-cell activation by binding to CD80 and CD86, thereby blocking their interaction with CD28. CD28 interaction provides a signal needed for the full T-cell activation that is implicated in RA pathogenesis.
This agent is approved for reducing signs and symptoms, inducing major clinical response, inhibiting the progression of structural damage, and improving physical function in adult patients with moderately to severely active RA. Abatacept can be used as monotherapy or concomitantly with DMARDs other than TNF antagonists.
DMARDs, TNF Inhibitors
Class Summary
The recognition of TNF-α and IL-1 as central proinflammatory cytokines has led to the development of agents that block either these cytokines or their effects. In addition to improving signs and symptoms and quality of life, all biologic agents significantly retard radiographic progression of joint erosions.
The TNF inhibitors, which bind TNF and thus prevent its interaction with its receptors, include etanercept, infliximab, golimumab, certolizumab, and adalimumab. Consensus statements do not recommend their use until at least one xenobiotic DMARD, usually MTX, has been administered without sufficient success.
Adverse effects associated with the biologic agents include the generation of antibodies against these compounds, the emergence of antinuclear antibodies (ANAs), occasional drug-induced lupuslike syndromes, and infections. Rarely, demyelinating disorders and bone marrow suppression occur.
Acute and chronic infections, demyelinating disorders, New York Heart Association (NYHA) class III or IV heart failure, and recent malignancies are contraindications for the use of TNF inhibitors. A thorough search for latent tuberculosis using chest radiography or purified protein derivative (PPD) testing is recommended before these agents are started. Patients taking anti-TNF agents must avoid live-virus vaccines to avoid the risk of serious infection.
Infliximab (Remicade, Inflectra, infliximab-dyyb, Renflexis, infliximab-abda, Ixifi, infliximab-qbtx)
Infliximab, a chimeric monoclonal antibody against TNF-α, is approved for reducing signs and symptoms, inhibiting the progression of structural damage, and improving physical function in patients with moderately to severely active RA, in combination with MTX. This agent binds to cells that express membrane TNF. FDA approved infliximab-dyyb, infliximab-abda, and infliximab-qbtx as biosimilars and not as an interchangeable drug.
Etanercept (Enbrel, Erelzi, etanercept-szzs)
Etanercept, a bivalent p75–TNF receptor linked to the Fc portion of human immunoglobulin G (IgG), is approved for reducing signs and symptoms, inducing major clinical response, inhibiting the progression of structural damage, and improving physical function in patients with moderately to severely active RA. It can be given alone or in combination with MTX. This agent binds lymphotoxin (formerly termed TNF-β) in addition to soluble TNF-α.
Golimumab (Simponi, Simponi Aria)
Golimumab, a human monoclonal antibody to TNF-α, inhibits TNF-α bioactivity, thereby modulating immune activity in patients with RA. It is approved for the treatment of adults with moderately to severely active RA, in combination with MTX. It may be administered as either a SC injection every month, or as an IV infusion every 2 months following 2 once monthly doses. Golimumab should be given in combination with MTX.
Certolizumab (Cimzia)
Certolizumab is a pegylated anti−TNF-α agent, which results in disruption of the inflammatory process in RA. It is indicated for the treatment of adults with moderately to severely active RA.
Adalimumab (Amjevita, Cyltezo, Humira, Hadlima, Hyrimoz, Adalimumab-atto, Adalimumab-adbm, Adalimumab-bwwd, Adalimumab-adaz)
Adalimumab is a recombinant human IgG1 monoclonal antibody that is specific for human TNF. It binds specifically to TNF-α and blocks interaction with p55 and p75 cell-surface TNF receptors. It is indicated to reduce inflammation and inhibit progression of structural damage in moderate to severe RA, alone or in combination with MTX or other nonbiologic DMARDs. This agent is reserved for those who experience an inadequate response to 1 or more DMARDs. Adalimumab can be used alone or in combination with MTX or other DMARDs. FDA approved adalimumab-atto, adalimumab-adbm, adalimumab-adaz, adalimumab-bwwd, as biosimilars and not as interchangeable drugs.
DMARDs, JAK Inhibitors
Class Summary
Janus kinase (JAK) pathway inhibitors consist of a group of intracellular tyrosine kinases that transmit signals from cytokine or growth factor-receptor interactions on the cellular membrane to influence cellular processes of hematopoieses and immune cell function. Within the signaling pathway, JAKs phosphorylate and activate Signal Transducers and Activators of Transcription (STATs) which modulate intracellular activity including gene expression.
Tofacitinib (Xeljanz, Xeljanz XR)
Tofacitinib is an oral JAK inhibitor. It is indicated as second-line treatment for moderate to severe active RA in patients with an inadequate response to or intolerance of MTX. Tofacitinib may be used as monotherapy or in combination with MTX or other nonbiologic DMARDs, but it should not be used in combination with biologic DMARDs or potent immunosuppressive agents (eg, azathioprine and cyclosporine). Tofacitinib is a JAK inhibitor that modulates the signaling pathway at the point of JAKs, preventing the phosphorylation and activation of STATs.
Baricitinib (Olumiant)
Oral JAK inhibitor indicated for moderately to severely active RA as second-line treatment in adults who have had an inadequate response to one or more TNF-antagonists. It may be used as monotherapy or in combination with methotrexate or other nonbiologic DMARDs. It should not be used in combination with biologic DMARDs or potent immunosuppressive agents (eg, azathioprine or cyclosporine).
Upadacitinib (Rinvoq)
Indicated for moderately to severely active RA in adults who have had an inadequate response or are intolerant to methotrexate. It may be used as monotherapy or in combination with methotrexate or other nonbiological DMARDs.
Tetracyclines
Class Summary
Although tetracyclines are not typically used to treat RA, the ACR recommends minocycline monotherapy in patients with a disease duration shorter than 24 months who have low disease activity and no poor prognostic factors. [148, 153]
Minocycline (Dynacin, Minocin)
The anti-inflammatory effects of minocycline may result from inhibition of inflammatory cell migration and transformation of lymphocytes.
Nonsteroidal Anti-inflammatory Drugs
Class Summary
NSAIDs interfere with prostaglandin synthesis through inhibition of the enzyme cyclooxygenase (COX), thus reducing swelling and pain. However, they do not retard joint destruction and therefore are not sufficient to treat RA when used alone. Like corticosteroids, NSAIDs can be reduced in dose or discontinued with successful DMARD therapy. These agents decrease intraglomerular pressure and decrease proteinuria.
The several dozen NSAIDs available can be classified into several different groups of compounds. Commonly used NSAIDs include ibuprofen, naproxen, ketoprofen, celecoxib, and diclofenac.
Ibuprofen (Advil, Motrin)
Ibuprofen is indicated for patients with mild to moderate pain. It inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Naproxen (Naprosyn, Aleve, Anaprox, Anaprox DS, Naprelan)
Naproxen is used to relieve mild to moderate pain. This agent inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, which is responsible for prostaglandin synthesis.
Diclofenac (Voltaren, Cambia)
Diclofenac is one of a series of phenylacetic acids that have demonstrated anti-inflammatory and analgesic properties in pharmacologic studies. It is believed to inhibit COX, which is essential in the biosynthesis of prostaglandins.
Ketoprofen
Ketoprofen is used to relieve mild to moderate pain and inflammation. It reversibly inhibits cyclooxygenase-1 and 2 (COX-1 and 2) enzymes, which results in decreased formation of prostaglandin precursors.
Celecoxib (Celebrex)
Celecoxib is approved for the relief of signs and symptoms of RA. It primarily inhibits COX-2, which is considered an inducible isoenzyme (induced during pain and inflammatory stimuli). Inhibition of COX-1 may contribute to NSAID gastrointestinal (GI) toxicity. At therapeutic concentrations, celecoxib does not inhibit COX-1, thus potentially resulting in decreased GI toxicity. Administer the lowest possible dose for each patient. Use of celecoxib has been associated with an increased risk of cardiovascular toxicity.
Analgesics, Other
Class Summary
Analgesics such as acetaminophen may be used in patients with RA.
Acetaminophen (Tylenol)
Acetaminophen is used for analgesia in patients with documented hypersensitivity to aspirin or NSAIDs, those with upper GI disease, and those who are taking oral anticoagulants. This agent does not have anti-inflammatory properties.
Opioid Analgesics
Class Summary
Tramadol has been used to reduce pain in patients with RA. However, this agent only provides analgesic effects and does not have anti-inflammatory properties.
Tramadol (Ultram)
The immediate-release formulation of tramadol is approved for the management of moderate to moderately severe pain in adults. The extended-release formulation is used for the management of moderate to moderately severe chronic pain in adults who require around-the-clock treatment of pain for an extended period of time. Tramadol and its active metabolite (M1) binds to mu-opiate receptors in the central nervous system causing inhibition of ascending pain pathways, altering perception of and response to pain.
Topical Skin Products
Class Summary
Topical agents such as diclofenac can provide analgesia for patients with RA. This agent is commonly used in patients who experience acute pain.
Diclofenac topical (Voltaren)
Diclofenac topical gel is approved in patients with osteoarthritis at a dosage of 32 g/day applied over all affected joints. It has also been used to provide analgesic effects in patients with RA.
Corticosteroids
Class Summary
Corticosteroids are potent anti-inflammatory drugs commonly used in patients with RA to bridge the time until DMARDs become effective. Prednisone dosages as high as 10 mg/day are typically used, but some patients may require even higher dosages. Adverse events associated with long-term steroid use make dose reductions and cessation important in due course.
Prednisone (Prednisone Intensol, Rayos)
Prednisone is an immunosuppressant for the treatment of autoimmune disorders; it may decrease inflammation by reversing increased capillary permeability and suppressing polymorphonuclear leukocyte activity. Prednisone stabilizes lysosomal membranes and suppresses lymphocytes and antibody production.
Circadian (ie, bedtime) administration of modified-release prednisone (Rayos) has been shown shown to decrease morning stiffness with RA.
Methylprednisolone (Depo-Medrol, Medrol, Solu-Medrol)
Methylprednisolone decreases inflammation by suppressing the migration of polymorphonuclear leukocytes (PMNs) and reversing increased capillary permeability. It is as adjunctive therapy for short term administration (for an acute episode or exacerbation) in RA.
Prednisolone (Orapred ODT, Pediapred)
Prednisolone controls or prevents inflammation by controlling the rate of protein synthesis, suppressing the migration of PMNs and fibroblasts, reversing capillary permeability, and stabilizing lysosomes at the cellular level. It is as adjunctive therapy for short term administration (for an acute episode or exacerbation) in RA.
Chelators
Class Summary
Chelation therapy in RA may suppress inflammation and arthritis by depressing T-cell activity.
Penicillamine (Cuprimine, Depen)
Penicillamine depresses circulating IgM rheumatoid factor and T-cell activity (but not B-cell activity). It is indicated in patients with severe, active RA who have failed to respond to an adequate trial of conventional therapy.
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Juvenile rheumatoid arthritis. Ankylosis in the cervical spine at several levels due to long-standing juvenile rheumatoid arthritis (also known as juvenile idiopathic arthritis).
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Juvenile rheumatoid arthritis. Widespread osteopenia, carpal crowding (due to cartilage loss), and several erosions affecting the carpal bones and metacarpal heads in particular in a child with advanced juvenile rheumatoid arthritis (also known as juvenile idiopathic arthritis).
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Rheumatoid arthritis. Rheumatoid changes in the hand. Photograph by David Effron MD, FACEP.
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Rheumatoid arthritis. Rheumatoid nodules at the elbow. Photograph by David Effron MD, FACEP.
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Rheumatoid arthritis. Soft-tissue swelling and early erosions in the proximal interphalangeal joints in a patient with rheumatoid arthritis of the hands.
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Rheumatoid arthritis. Subluxation in the metacarpophalangeal joints, with ulnar deviation, in a patient with rheumatoid arthritis of the hands.
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Rheumatoid arthritis. Coronal, T1-weighted magnetic resonance imaging scan shows characteristic pannus and erosive changes in the wrist in a patient with active rheumatoid arthritis. Courtesy of J. Tehranzadeh, MD, University of California at Irvine.
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Rheumatoid arthritis. Lateral view of the cervical spine in a patient with rheumatoid arthritis shows erosion of the odontoid process.
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Boutonniere deformity.
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Rheumatoid arthritis. Anteroposterior radiograph of the knee shows uniform joint-space loss in the medial and lateral knee compartments without osteophytosis. A Baker cyst is seen medially (arrowhead).
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Rheumatoid arthritis. Ultrasonography-guided synovial biopsy of the second metacarpophalangeal joint of the right hand in a patient with rheumatoid arthritis of the hands. The biopsy needle is seen as a straight echogenic line on the left side of the image in an oblique orientation.
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Plain lateral radiograph of the normal cervical spine taken in extension shows measurement of anterior atlantodental interval (yellow line) and posterior atlantodental interval (red line).
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Rheumatoid arthritis. Lateral flexion view of the cervical spine shows atlantoaxial subluxation.
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Rheumatoid arthritis. Lateral view of the cervical spine in a patient with rheumatoid arthritis shows erosion of the odontoid process.
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Rheumatoid arthritis. T1-weighted sagittal magnetic resonance image of the cervical spine shows basilar invagination with cranial migration of an eroded odontoid peg. There is minimal pannus. The tip of the peg indents the medulla, and there is narrowing of the foramen magnum due to the presence of the peg. Inflammatory fusion of several cervical vertebral bodies is shown.
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Sagittal T2-weighted magnetic resonance image of cervical spine in same patient as in previous image. Compromised foramen magnum is easily appreciated, and there is increased signal intensity within upper cord; this is consistent with compressive myelomalacia. Further narrowing of canal is seen at multiple levels.
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Rheumatoid arthritis. Lateral radiograph of the same patient as in Images 4-5. Midcervical vertebral-body fusions are shown. The eroded peg is difficult to visualize, but inferior subluxation of the anterior arch of C1 is shown.
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Lateral radiograph of a normal cervical spine shows the McGregor line. The odontoid tip should not protrude more than 4.5 mm above the line, which is drawn from the posterior edge of the hard palate to the most caudal point of the occiput.
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Normal lateral magnified radiograph of the cervical spine shows the Ranawat method of detection of cranial settling. This method is used to measure the distance from the center of the pedicles (sclerotic ring) of C2 to a line drawn connecting the midpoints of the anterior and posterior arches of C1. (Normal values are 15 mm or greater for males and 13 mm or greater for females.)
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Lateral radiograph of the cervical spine shows how the cervical height index (CHI) is calculated. The distance from the center of the sclerotic ring of C2 to the tip of the spinous process of C2 (dotted line) is measured. This is then divided into the distance from the center of the sclerotic ring of C2 to the midpoint of the inferior border of the body of C7. A CHI of less than 2 mm is a sensitive predictor of neurologic deficit.
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X-ray shows total hip replacement, with prosthesis, in patient with osteoarthritis.
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Rheumatoid arthritis. This gross photo shows destruction of the cartilage and erosion of the underlying bone with pannus from a patient with rheumatoid arthritis.
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Rheumatoid arthritis. The hallmark of rheumatoid arthritis is a perivascular mononuclear cell infiltrate in the synovium (pictured here). The early stages are noted to have plasma cells as well, and syphilis needs to be part of the differential diagnosis.
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Rheumatoid arthritis. The inflammation involved in rheumatoid arthritis can be intense. It is composed of mononuclear cells and can resemble a pseudosarcoma.
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Rheumatoid arthritis. A 72-year-old man with long-standing rheumatoid arthritis developed blue-grayish discoloration of his skin. He had been on hydroxychloroquine for approximately 15 years. The diagnosis was hydroxychloroquine-related hyperpigmentation. Image courtesy of Jason Kolfenbach, MD, and Kevin Deane, MD, Division of Rheumatology, University of Colorado Denver School of Medicine.
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Rheumatoid arthritis. A 64-year-old woman with rheumatoid arthritis has developed nodules on the dorsal and volar aspect of her fingers, as well as the posterior aspect of her heels. The diagnosis is rheumatoid nodules with methotrexate-induced accelerated nodulosis. Image courtesy of Jason Kolfenbach, MD, and Kevin Deane, MD, Division of Rheumatology, University of Colorado Denver School of Medicine.
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Rheumatoid arthritis. A 64-year-old woman with rheumatoid arthritis has developed nodules on the dorsal and volar aspect of her fingers, as well as the posterior aspect of her heels. The diagnosis is rheumatoid nodules with methotrexate-induced accelerated nodulosis. Image courtesy of Jason Kolfenbach, MD, and Kevin Deane, MD, Division of Rheumatology, University of Colorado Denver School of Medicine.
Tables
Tool |
Tool Type |
Remission |
Low Disease Activity |
Moderate Disease Activity |
High Disease Activity |
Patient Activity Scale–II (PAS-II) |
Patient-driven |
≤0.25 |
0.25-3.70 |
3.71 to < 8.0 |
≥8.0 |
Routine Assessment of Patient Index Data 3 (RAPID3) |
Patient-driven |
≤3 |
4-6 |
7-12 |
≥13 |
Clinical Disease Activity Index (CDAI) |
Patient and provider composite |
≤2.8 |
>2.8-10 |
>10 to 22 |
>22 |
Simplified Disease Activity Index (SDAI) |
Patient, provider, and laboratory composite |
≤3.3 |
>3.3 to ≤11.0 |
>11.0 to ≤26 |
>26 |
28-joint Disease Activity Score (DAS28-ESR/CRP) |
Patient, provider, and laboratory composite |
< 2.6 |
2.6-3.1 |
3.2-5.1 |
>5.1 |
