Conventional Disease-Modifying Antirheumatic Drugs for the Treatment of Rheumatoid Arthritis [Internet]

Excerpt

Rheumatoid arthritis (RA) is a chronic, systemic, autoimmune disease that can affect the entire body.^, RA is characterized by inflammation in the lining of the joints and other tissue, causing swelling, pain, and stiffness, which can lead to permanent joint damage. RA is a debilitating chronic disease and people with RA are often at a higher risk of mortality because of associated comorbidities such as cardiovascular disease.^, In Canada, approximately 374,000 people aged 16 or older are currently living with diagnosed RA and approximately 1% of the global population is affected by RA. The prevalence and incidence of diagnosed RA generally increases with age and females in Canada are more likely to experience diagnosed RA compared to males.

There is no cure for RA; however, early diagnosis and treatment can play a large role in reducing symptoms, preventing lasting joint damage, and reducing the risk of developing comorbidities.^, Early treatment for RA (e.g., as soon as a patient is diagnosed) can mean that disease remission is more likely. A “treat-to-target” strategy is often used in RA management, where the target for patient treatment is remission or low disease activity when remission is not possible.

Disease-modifying antirheumatic drugs (DMARDs) are commonly used course in the treatment for RA because they slow disease progression and provide symptom relief. RA treatment regimens can consist of conventional synthetic DMARDs (csDMARDs), biologic DMARDs, or targeted synthetic DMARDs (tsDMARDs). Common csDMARDs include methotrexate (MTX), leflunomide (LEF), sulfasalazine (SSZ), and antimalarials such as hydroxychloroquine (HCQ). Biologic DMARDs usually include either tumour necrosis factor inhibitors or non-tumour necrosis factor inhibitors. Janus kinase (JAK) inhibitors are a commonly used tsDMARD in advanced RA treatment. csDMARDs were the first DMARD agents approved for RA treatment, are the most commonly prescribed treatment for RA, and are typically the least expensive. csDMARD monotherapy is typically the first course of treatment for newly diagnosed individuals. However, if disease progression continues, then additional csDMARDs may be added as a “step-up” approach, followed by adding or switching to biologic DMARDs or JAK inhibitors if disease progression does not slow down.^, Glucocorticoids are also commonly used on a short-term basis in the treatment of RA. Glucocorticoids, which have anti-inflammatory and immunosuppressive effects, may also be used as an adjunct therapy when a patient is starting a new DMARD treatment or changing from one DMARD to another. DMARD therapy for the treatment and management of RA has shown to be effective in providing symptom relief and slowing disease progression; however, there are a variety of treatment approaches that may be used to manage RA disease progression and evidence-based guidance is helpful in determining the best course of action for patients with RA.

The purpose of this report is to review the evidence-based guidelines regarding the use of csDMARD therapy prior to the use of biologic DMARDs or JAK inhibitors. Evidence-based guidelines containing recommendations related to the use of csDMARDs, combination approaches for csDMARD therapy, csDMARD trial periods, and combining glucocorticoids with csDMARD therapy will be sought for this report and any relevant recommendations will be summarized.