Abstract

Management of Rheumatoid Arthritis (RA) is about setting clear goals in the treatment of patients with a disease traditionally seen as potentially very disabling, but also implementing them in practice. We have seen an impressive progress in RA treatment over the last 2 decades but there remains a challenge in installing optimal treatment in all patients in need, with acceptable side effects and reasonable costs. Treatment goals were moving from achieving a certain degree of improvement towards remission of disease activity, halting progression, maintaining function and assuring quality of life and participation. Some of us even start to consider prevention. Progress has been made possible by a few key features: 1.taking this disease seriously and moving away from purely symptomatic treatment, 2. better understanding of the pathophysiology, 3. development and validation of outcome measures in multiple dimensions of health. As a consequence state of the art clinical studies with several old en new (biological) drugs were started and more importantly, treatment strategy trials were initiated, treating patients early and to target to avoid refractory disease, with promising results.

In early disease there is increasing evidence in favor of a classical disease-modifying anti-rheumatic drug (DMARDs) combined with a remission induction scheme of glucocorticoids as the optimal method to achieve good efficacy with a good safety profile. Such schedules have also proven to be feasible in daily clinical practice. Biologicals in combination with traditional DMARDs are showing efficacy in early RA but are limited for practice by economic restraints and the currently insufficient performance of prognostic markers for individual treatment decisions. Upcoming data of tapering and stop studies with biologicals and eventual future better markers could lead to a real targeted approach in early disease. Meanwhile efforts should go to the implementation of early intensive treatment schedules with cheap drugs, focusing on strategies to allow patients to be seen earlier by a rheumatologist, implementing drug combinations in shared decision making with patients, setting clear and measurable goals, optimizing treatment follow up, improving compliance and allowing patients to regain “normality”. We would plead for avoiding the traditional perception of inevitable functional decline and rather focus on helping patients to achieve optimal societal participation. Fortunately the number of instruments to reach these goals has broadened with a revival of glucocorticoids, the confirmation of methotrexate (MTX) as an anchor drug and several biologicals with different modes of action. While all biologicals perform better in combination with MTX, a clear order or preference of which biological to start first in patients refractory to traditional DMARDs, or which biological to switch to after failing the first, is not known. While we have now a wealth of effective biological drugs at our disposal, the difference in treatment outcome is perhaps more determined by the way we use these drugs: setting a proper indication for a specific treatment, proper outcome evaluation but also prevention and treatment of side effects and an additional focus on preventing co-morbidities. Several practical recommendations have been developed by EULAR, but the current challenge is to implement them in a correct way. The use of validated outcome measures helps to improve care but is more than following blindly DAS scores; we can for instance not afford neglecting tendon problems causing important disability or the burden of feet problems. Important progress has already been made but we can do more. Current views and achievements regarding RA management are also not feasible in all parts of the world, which needs to be dealt with.