Early DMARD treatment in rheumatoid arthritis
Rheumatoid arthritis (a cause of inflammatory joint pain and morning stiffness) is treated early with a disease-modifying anti-rheumatic drug (DMARD), and most DMARDs need regular blood monitoring.
Remember
Start a DMARD such as methotrexate (a drug that calms the overactive immune system) early, use a short-term steroid as a bridge if needed (cover until the DMARD takes effect), and arrange regular blood monitoring for side effects.
A DMARD (disease-modifying anti-rheumatic drug) changes the course of rheumatoid arthritis by calming an overactive immune system. Painkillers only relieve symptoms. A conventional DMARD (the type used as initial treatment), such as methotrexate, leflunomide or sulfasalazine, should ideally be started within 3 months of symptoms starting, because early use can improve outcomes and prevent progression of the disease.
DMARDs can take 2 to 3 months to work. To cover that gap, a short course of a corticosteroid (a steroid such as prednisolone, which mimics the body's own anti-inflammatory hormone, cortisol) may be given as a bridge. Steroids reduce inflammation quickly, but long-term use causes significant side effects, such as bone thinning, infection and weight gain. They are therefore kept for short periods, either as a bridge or during acute flare-ups; NICE advises continuing them long-term only after the risks have been discussed and all other options offered.
Most DMARDs are immunosuppressive (they dampen the immune system), so patients should be told that their risk of infection is higher. Methotrexate can also affect the bone marrow, where blood cells are made, and the liver. Regular blood monitoring is therefore needed: a full blood count screens for neutropenia (a low neutrophil count), and liver function tests screen for inflammation of the liver. For methotrexate, full blood count, kidney and liver function tests are checked before starting, then every 1 to 2 weeks until the dose is stable, then every 2 to 3 months.
Key facts
- Common DMARDs
- methotrexate, hydroxychloroquine, sulfasalazine and leflunomide are among those commonly prescribed.
- Timing
- a DMARD should ideally be started within 3 months of symptoms starting.
- Time to work
- a DMARD can take 2 to 3 months to work, so a short steroid course may bridge the gap.
- Steroid role
- short courses for bridging or acute flare-ups, using the lowest dose for the shortest time.
- Monitoring
- most DMARDs need regular full blood count and liver function tests, which screen for neutropenia and for inflammation of the liver; with methotrexate, kidney function is checked too.
- Infection
- immunosuppression raises the risk of infection, so patients should know to seek help early.
Exam traps
- A biologic drug (a targeted treatment made from living cells) such as adalimumab is not the first treatment after diagnosis, because it is used for moderate or severe rheumatoid arthritis that has not responded to an intensive combination of conventional DMARDs such as methotrexate.
- Long-term oral prednisolone on its own is not recommended to control rheumatoid arthritis, because long-term use causes serious side effects, including infection, osteoporosis (thinning of the bones) and weight gain.
- Steroids are not withheld during an acute flare-up just because methotrexate has already been started: short courses of corticosteroid are still used to treat flares.
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