The American College of Rheumatology (ACR) recommends treating rheumatoid arthritis (RA) early in order to increase the chances of achieving and sustaining remission.
But the condition doesn’t manifest uniformly in all patients. Taking a detailed patient history, a thorough physical examination and ordering the recommended round of serum tests and diagnostic radiology exams may help arrive at a definitive diagnosis.
A positive finding of rheumatoid factor (RF) and/or anti–cyclic citrullinated peptide (antiCCP) autoantibodies, or an elevated C-reactive protein level or erythrocyte sedimentation rate, may support a diagnosis of rheumatoid arthritis. But a patient can test positive for RF and antiCCP autoantibodies years before physical symptoms manifest.
Treatment recommendations for early rheumatoid arthritis of less than six months may include disease-modifying anti-rheumatic drugs (DMARDs). This treatment could possibly lead to remission if applied aggressively to early onset rheumatoid arthritis. The ACR recommends a treat-to-target approach. In DMARD naïve patients, monotherapy is preferred over combination therapy and methotrexate is recommended as first-line therapy, except in the presence of contraindications, such as liver disease.
If disease activity remains moderate or high, treatment options include a combination of DMARDs, or a biologic (either a tumor necrosis factor inhibitor (TNFi) or a non-TNFi). In these patients, TNFi monotherapy, or TNFi in combination with methotrexate, may be preferable over tofacitinib (either monotherapy or in combination with methotrexate). Glucocorticoids may be added in the lowest possible dose as a short-term treatment for flares.