Treatment and management of rheumatoid arthritis

At present there is no cure for rheumatoid arthritis. The Australian Models of Care for the management of the disease focus on early diagnosis, early management, and coordination of multidisciplinary care needs [1, 2]. The goal of rheumatoid arthritis treatment is to stop inflammation (put the disease in remission), relieve symptoms, prevent joint and organ damage, reduce complications and improve physical function. Early treatment for rheumatoid arthritis is aggressive in order to stop inflammation as soon as possible [2].

Medications are primarily used to treat rheumatoid arthritis, however physical therapy and surgery can also be used.

Medications

Treatment for rheumatoid arthritis has improved dramatically over the past 20 years, with new medicines now very helpful for people, particularly in the early stages of the disease.

Medications for symptoms

Paracetamol, codeine, and nonsteroidal anti-inflammatory drugs (NSAIDs) are sometimes called the 'first-line' medicines in management of rheumatoid arthritis, as these are the initial medicines provided for symptom relief [3].

Medications for slowing disease

Stronger medications such as corticosteroids, disease-modifying anti-rheumatic drugs (DMARDs) and biologic disease-modifying anti-rheumatic drugs (bDMARDs) may be prescribed when insufficient symptom control is obtained from first-line medicines. Corticosteroids and DMARDs are typically prescribed and monitored by specialist rheumatologists and require close medical monitoring to ensure effectiveness and to minimise side effects. Evidence suggests initiation of aggressive treatment with DMARDs within 12 weeks of symptom onset is associated with less joint destruction and a higher chance of achieving DMARD-free remission as compared with a longer delay in assessment [4].

bDMARDs are specialised immunosuppressant medications that have been shown to halt or slow the disease process sufficiently to reduce the joint destruction and disability associated with early rheumatoid arthritis [5]. bDMARDs are also used for other autoimmune conditions such as juvenile arthritis, psoriatic arthritis and Crohn's disease.

Treatment options for rheumatoid arthritis, including bDMARDs are available through the Pharmaceutical Benefits Scheme (PBS) and Repatriation Pharmaceutical Benefits Scheme (RPBS) codes [6].

Physical therapy

Maintaining a healthy and active lifestyle is an important management strategy in rheumatoid arthritis. Low-impact physical activity can assist in reducing inflammation, increasing and maintaining mobility and strengthening muscles around affected joints (7).  A physiotherapist can prescribe an exercise program to assist in the management of rheumatoid arthritis. 

Joint replacement surgery

Joint replacement surgery can relieve pain and restore function to joints severely damaged due to rheumatoid arthritis.

General practitioners and rheumatoid arthritis treatment

Treatment of rheumatoid arthritis often begins with the patient visiting a general practitioner (GPs). This is an important step in the treatment of rheumatoid arthritis because it is optimal for inflammation to be managed early on to reduce the chances of joint damage occurring [1] and improve long-term outcomes [8]. GPs often conduct initial assessment and diagnosis of rheumatoid arthritis. The time from onset of rheumatoid arthritis symptoms and referral to a specialised rheumatologist for treatment needs to be as efficient as possible to improve long-term treatment outcomes [5]. The RACGP recommends GPs complete diagnosis of rheumatoid arthritis as soon as possible and refer patients to a rheumatologist if joint swelling persists beyond 6 weeks [9].

Hospitalisation and the treatment of rheumatoid arthritis

Treatment of rheumatoid arthritis is usually managed by general practitioners in partnership with rheumatologists and allied health professionals (such as physiotherapists) and centres on managing pain, reducing inflammation and joint damage, and preventing loss of function.

Severe disease however may require hospitalisation to relieve pain and restore function to damaged joints.

Data from the AIHW National Hospital Morbidity Database (NHMD) show that, in 2016–17:

  • there were 13,213 hospitalisations with the principal diagnosis of rheumatoid arthritis, a rate of 54 hospitalisations per 100,000 population
  • nearly three-quarters (75%) of rheumatoid arthritis hospitalisations were for females
  • the hospitalisation rate was lowest among those aged 40 and under, increased until the age of 70–74, and then decreased again among people aged 75 and over (Figure 1).

Figure 1: Rate of hospitalisation for rheumatoid arthritis, by sex and age, 2016–17

This vertical bar chart compares the rate (per 100,000 population) of hospitalisations for rheumatoid arthritis, across various age groups by sex, in 2016–17. The rate of hospitalisations was highest in the 70–74 age group for both males (130) and females (252), and lowest in the <40 age group for both males (4) and females (15).

Source: AIHW National Hospital Morbidity Database (Data table).

From 2006–07 to 2016–17, the age-standardised hospitalisation rate for rheumatoid arthritis increased by 53%: from 32 per 100,000 to 49 per 100,000 population. This increase was driven by a 57% increase in hospitalisations for females (from 46 to 72 per 100,000 females), compared with a 47% increase for males (from 17 to 25 per 100,000 males) (Figure 2).

Figure 2: Rate of hospitalisation for rheumatoid arthritis, by sex, 2006–07 to 2016–17

The line chart shows that between 2006–07 and 2016–17, hospitalisation rates (per 100,000 population) for rheumatoid arthritis rose for females and was relatively constant for males. After adjusting for age, the rate of hospitalisations for rheumatoid arthritis for males increased from 17 in 2006–07 to 25 in 2016–17. The rate for females increased from 46 in 2006–07 to 72 in 2016–17.

Note: Rates are age-standardised to the Australian population as at 30 June 2001.

Source: AIHW National Hospital Morbidity Database (Data table).

Common hospital procedures for rheumatoid arthritis

In 2016–17, a total of 21,766 procedures were performed in rheumatoid arthritis hospitalisations. Administration of pharmacotherapy (44%), generalised allied health interventions (including physiotherapy, occupational therapy and dietetics) (23%) and cerebral anaesthesia (5.7%) were the most common groups (blocks) of procedures for rheumatoid arthritis hospitalisations.

References

  1. Speerin R, Slater H, Li L et al. 2014 (in press). Moving from evidence to practice: Models of care for the prevention and management of musculoskeletal conditions, Best Practice & Research Clinical Rheumatology.
  2. Arthritis Australia 2014. Time to move: rheumatoid arthritis, a national strategy to reduce a costly burden. Sydney: Arthritis Australia.
  3. AIHW (Australian Institute of Health & Welfare) 2010. Medication use for arthritis and osteoporosis. Arthritis series no. 11. Cat. no. PHE 121. Canberra: AIHW.
  4. Van der Linden MPM, le Cessie S, Raza K et al. 2010. Long-term impact of delay in assessment of patients with early arthritis. Arthritis and Rheumatism 62 (12): 3537–3546.
  5. Nam JL, Ramiro S, Gaujoux-Viala C et al. 2014. Efficacy of biological disease-modifying anti-rheumatic drugs: a systematic literature review informing the 2013 update of the EULAR recommendations for the management of rheumatoid arthritis. Annals of the Rheumatic Diseases 73 (3):516–528.
  6. AIHW (Australian Institute of Health & Welfare) 2013. A snapshot of rheumatoid arthritis. Bulletin no. 116. Cat. no. AUS 171. Canberra: AIHW.
  7. Cooney JK, Law R-J, Matschke V et al. 2011. Benefits of exercise in rheumatoid arthritis. Journal of aging research 2011.
  8. Bakker M, Jacobs J, Welsing P, Vreugdenhil S, van Booma-Frankfort C, Linn-Rasker S et al. 2011. Early clinical response to treatment predicts 5-year outcome in RA patients: follow-up results from the CAMERA study. Annals of the rheumatic diseases 70 (6):1099–103.
  9. RACGP (The Royal Australian College of General Practitioners) 201. Clinical guideline for the diagnosis and management of early rheumatoid arthritis. Melbourne: RACGP.