Management of rheumatoid arthritis

The management of rheumatoid arthritis (RA) has changed substantially over recent years. The emphasis is now on making an early diagnosis of RA, which still relies largely on clinical experience. When determining which treatment is most appropriate, clinical and laboratory markers on disease prognosis act as a guide. The choice of single or combination disease modifying drug therapies (DMARDs) has to be tailored to the individual patient. Steroids can act as DMARDs but are not a good long term choice as single therapy for most patients. A multidisciplinary team is important, and patient education is vital. The team needs to assess the response to treatment and modify it if it is less than satisfactory. Anti-TNF drugs have had a big impact on the management of RA not responding to conventional DMARDs, but in the UK their use has been restricted by cost to patients who have failed on 2 DMARDs with ongoing active disease. It is sometimes possible to reduce therapy in patients who are doing well, but whether DMARDs can be safely stopped in all patients in remission is highly contentious. In the future it is hoped that there will be progressive improvements in early diagnosis, better prognostic markers and that health economic arguments will be able to extend the eligibility for anti-TNF drugs so that these will make remission the rule and not the exception.