Unbranded Rheumatoid Arthritis Booklet written for BMS while working at Corbett Accel.

1. Managing rheumatoid arthritis
Seize the moment
e
pl
m
sa
g
in
rit
iw
sk
w
ko
cz
Ka
al
st
ry
C
© 2005 Bristol-Myers Squibb Company B5-D0003 5/05 Printed in USA
Discovering the Next Future™ Discovering the Next Future™

2. Establishing Diagnosis
Diagnosis of RA can be difficult, particularly in the Considering the average delay before an RA patient
early stages of the disease.1 Patients will often first receives treatment, it is imperative for a physician,
self-treat their symptoms before seeing a general especially a rheumatologist, to diagnose RA as early
practitioner (GP). Considering the subjective as possible and initiate the appropriate treatment in
nature of RA symptoms, many GPs have difficulty order to potentially reduce disease progression.7
determining the etiology of the patient’s complaints
Initial Evaluation
due to their limited experience in diagnosis and
The initial RA patient evaluation may incorporate
management. Difficulties such as these may delay
both objective and subjective measures including1:
the correct diagnosis of RA and subsequent treatment.3,4
According to one thought leader, the median time I physical examination
to diagnosis of early RA is 18 weeks.4 Only 6% to
I laboratory tests
14% of GPs refer patients to a rheumatologist within
I radiography
6 weeks. Most GPs refer new arthritic patients to a
e
I duration and degree of joint pain, morning
rheumatologist within 3 months, but many wait to
pl
m
stiffness, and fatigue
refer patients from 3 to 6 months.5 Thus, the
sa
g
majority of patients appear to be waiting longer I actively inflamed joints (eg, synovitis)
in
rit
than they should for treatment, even though 70%
iw
I functional status
of RA cases can be diagnosed by a rheumatologist
sk
w
I mechanical joint problems
within 2 weeks of the first visit.4 The American
ko
cz
I extraarticular disease
College of Rheumatology (ACR) guidelines state that
Ka
the majority of newly diagnosed patients should be
al
st
Comorbidities and other assessments of active RA
started on DMARDs within 3 months of diagnosis.1
ry
C
damage should also be documented. Baseline data
can be collected regarding quality of life (QOL),
patients’ and physicians’ pain assessments of disease
RA treatment is often delayed activity using visual analog scales (VAS), or other
validated QOL measurement tools.1 There is growing
I Many patients wait >3 months from
evidence that these QOL measures, such as the
symptom onset to first GP appointment6
Stanford Health Assessment Questionnaire (HAQ),
I Many patients wait >3 months for a
are correlated with underlying structural damage
specialist referral6
and long-term reduction in functional ability.8,9
I Only 6% to 14% of GPs refer patients to
A baseline laboratory assessment should include
a rheumatologist within 6 weeks5
a complete blood cell count with white blood cell
I DMARD therapy delayed even after seeing
differential and platelet counts; measurement of
a specialist6
erythrocyte sedimentation rate (ESR) or C-reactive
protein (CRP); and measurement of rheumatoid
factor (RF). Hepatic and renal function should be
3

3. evaluated since many antirheumatic agents can cause is now widely accepted that aggressive treatment Ongoing Assessment
Baseline evaluation of disease
toxicity problems and would be contraindicated if should be initiated as soon as diagnosis is made
of Disease Activity
activity and damage 1
organs are impaired.1 since numerous studies have concluded that DMARDs
can inhibit disease progression in patients with early Subjective The physician should assess whether the patient’s
Radiographs of the hands, feet, and other affected RA. For those patients with unfavorable prognostic I Degree of joint pain disease is active or inactive at each follow-up visit.
joints should be used to establish a baseline for future factors, early DMARD treatment should be initiated I Duration of morning stiffness Symptoms of active disease, functional status,
assessment of structural damage.1 immediately upon diagnosis.1 I Duration of fatigue mechanical joint problems, presence of extraarticular
I Limitation of function disease, and radiographic damage should be
Estimating Prognosis Baseline assessment of disease activity documented.1
A patient’s prognosis is closely related to disease activity Physical Examination
at onset since it has been shown that persistent
Creating a plan for treatment requires an estimate I Actively inflamed joints Symptoms of inflammation including prolonged
inflammation of the joint leads to joint destruction.7
of prognosis. Earlier age of disease onset, elevated (tender and swollen joint counts) morning stiffness, fatigue, and active synovitis on
ESR, high titer of RF, and swelling of 20 or more I Mechanical joint problems: loss of motion, joint examination indicate active disease and may
e
In early RA, analysis of the feet is critical since damage
joints are associated with a poorer prognosis. Other
pl
crepitus, instability, malalignment, necessitate treatment modifications. Because the
m
usually occurs there first.10 A consistent predictor of
factors that may be related to poor prognosis
sa
and/or deformity examination of joints may not always adequately
g
later damage is the radiological score of the feet
include: extraarticular manifestations of RA (eg, I Extraarticular manifestations
in
gauge disease activity, periodic assessments of
rit
and/or hands in the first 3 years of disease.11,12
rheumatoid nodules), Sjögren’s syndrome, episcleritis
iw
functional status, ESR or CRP measurement,
sk
However, not all patients have
and scleritis, interstitial Laboratory and radiography should also be made.1
w
radiographic evidence of structual
lung disease, systemic
ko
I Erythrocyte sedimentation rate/C-reactive
cz
damage in the first year.11
vasculitis, pericardial protein level
Ka
Functional status may be assessed by a questionnaire
involvement, and
al
I Rheumatoid factor such as the HAQ. The HAQ is an indicator of disease
st
Felty’s syndrome.1 Predictive models to determine
ry
I Complete blood cell count outcome and severity. It is important to determine
C
progressive disease have been I Electrolyte levels whether a functional decline is due to inflammation,
developed based on some of the
Studies have demonstrated I Creatinine level mechanical damage, or both. Strategies for
prognostic markers discussed in
that patients with active I Hepatic enzyme levels (AST, ALT, and albumin) treatment will differ according to the cause
the previous section12,13; however,
polyarticular, RF-positive I Urinalysis of the functional decline.1
there is a need for validation of
RA have more than a 70% I Synovial fluid analysis
these models in early and
chance of developing I Stool guaiac While the ACR response criteria and the disease
persistent RA.10
structural damage (joint
activity score (DAS) are routinely used in clinical trials
damage or erosions) within Other to measure efficacy, these scales should not be used
2 years. Because of this, it I Functional status or quality of life assessments as the only measure to monitor an individual
using standardized questionnaires patient’s clinical response. A combination of clinical
I Physician’s Global Assessment of Disease Activity
I Patient’s Global Assessment of Disease Activity
Radiography
Radiographs are an important tool in establishing a
I Radiographs of selected involved joints
diagnosis of RA and estimating baseline disease
activity/joint damage. Disease progression can be
monitored with subsequent x-rays.
4 5

4. judgment and quantitative measures should be used I RF (positivity and titer) erosions. Those patients with two RA-associated alleles New Imaging Techniques for
6p25.3—
6p25.2—
in addition to other validated measures such as1: (DRB1*04 or DRB1*01) have demonstrated more
I radiographic scores within Diagnoses and Prediction
6p25.1—
6p24.3— radiographic erosions and joint replacement
the first year of disease onset 6p24.2—
of Outcomes
compared with patients without these alleles.13,16
6p24.1—
I VAS
I HAQ 6p23—
I scales of global response or pain by 6p22.3—
I CRP or ESR Immunological factors Efficient methods for diagnosing, estimating
the patient 6p22.2—
Rheumatoid factor prognosis, and monitoring disease progression are
I the presence of HLA-DRB1*04 6p22.1—
I scales of global response by the physician As immunological markers go, RF has received the essential in RA. Magnetic resonance imaging (MRI)
HLA- 6p21.33—
shared epitope (SE) alleles10,11 DRB1
gene 6p21.32—
I joint tenderness and/or swelling most attention for use in predicting prognosis.10 and musculoskeletal ultrasonography (MUS) are
(ie, any of the alternative
6p21.31— There is evidence that in early RA, RF is associated imaging techniques that are playing an increasingly
forms of a gene that may
I laboratory data
6p21.2—
with a more severe radiological outcome.13,17-19 Some valuable role in the assessment of patients with
occur at a given locus)
6p21.1— studies suggest that a positive test for RF or a high RF inflammatory diseases. These tools are now
These measures should be followed in each patient
titer at baseline is indicative of poor outcome in early routinely used in many early arthritis clinics
Genetic factors
to gauge improvement. In addition to monitoring 6p12.3—
e
RA. Another study has demonstrated the validity of in the evaluation of joint, tendon, and soft tissue
Several genes have been
disease activity and progression, a patient’s
pl
6p12.2—
m
6p12.1— RF positivity at 1 year.20 By and large, the literature inflammation and bone damage. Their ability
examined in RA, but HLA-DRB1*
tolerance of adverse events (or side effects) and
sa
6p11.2—
suggests that a positive IgM RF at disease onset
6p11.1— to visualize, quantify, and characterize the earliest
g
are the only genes that have been
concern of risks (such as infections) should be
in
6q11.1—
rit
predicts high radiographic progression.10 inflammatory changes provides useful clinical
6q11.2—
repeatedly associated with RA.10
addressed.14 Patients with an incomplete response
iw
6q12— tools and contributes to an understanding of
sk
This is particularly true for
or who are intolerant of their medication may need
w
Anticyclic citrullinated peptides
6q13— disease pathogenesis.23
HLA-DRB1 alleles with a similar
ko
a different treatment plan.15
cz
The most specific marker for RA is anticyclic
6q14.1—
amino acid sequence referred to
Ka
6q14.2— citrullinated peptides (anti-CCP); however, this For assessment of joint damage, x-ray is the traditional
Biomarkers that assess ongoing as the shared epitope. Among
al
6q14.3—
st
marker has not been routinely used in practice.10
disease activity gold standard.24 However, conventional radiographs
alleles examined, HLA-DRB1*0401
ry
6q15—
C
Thus, there is a limited amount of literature limit visualization of the joint and do not allow
With the advent of new treatment strategies and and DRB1*0404 have been
evaluating anti-CCP as a tool for prognosis.
6q16.1— assessment of changes in joint tissues that can
therapeutic options, there is a need for a predictive associated with radiographic
Longitudinal studies in early arthritis cohorts
6q16.2— precede joint damage by months or years.25,26
model for use in clinical practice in order to design
6q16.3— have demonstrated, however, that the presence A preliminary study comparing conventional
the most appropriate therapeutic strategy for patients
of anti-CCP at baseline is a good predictor of radiograph, MRI, ultrasound, and computerized
in early and persistent RA. The ideal prognostic index 6q21—
radiographic joint damage in follow-up periods tomography assessed erosions of the humeral
would include reliable markers such as10:
of 5 to 6 years.21,22 head in patients with RA. MRI, ultrasound, and
6q22.1—
6q22.2— computerized tomography were all more sensitive
6q22.31—
than conventional radiograph at detecting bone
6q22.32—
erosions. Furthermore, MRI and ultrasound were
6q22.33— better than computerized tomography at detecting
small erosions.27 Computerized tomography emits
6q23.1—
6q23.2—
6q23.3—
6q24.1—
6q24.2—
6q24.3—
Gene map of chromosome 6 showing the
location of the HLA-DRB1 gene that has 6q25.1—
been associated with RA. 6q25.2—
6q25.3—
6q26—
6q27—
6 7

5. MRI of a hand early in the RA disease
process. Edema is apparent on the third
and fourth metacarpophalangeal joints
indicating inflammation and disease
activity. Reproduced with permission
from the Arthritis Research Campaign
(www.arc.org.uk).
ionizing radiation28 and its Ultrasound validation is required regarding the potential use of The advantages and disadvantages of
sensitivity to detect small ultrasound in early RA.23 There are still very limited MRI and ultrasound35
Traditional MUS has been
erosive changes is inferior to data regarding the diagnostic and prognostic value
used for some time for
MRI or MUS27,28; thus, it is rarely of ultrasound, as well as areas such as the monitoring
detecting joint and soft Advantages Disadvantages
used in clinical practice. of joint inflammation and destruction. Ultrasound
tissue inflammation.32 It has
is a more accessible, lower-in-cost, and patient-friendly
also been described as the
I Safe I Higher costs than
MRI
Magnetic resonance technology than MRI.35 In the near future, it may
gold standard imaging radiography
I No ionizing radiation
imaging become a routinely used clinical tool for the
technique for evaluating
I Less availability than
I No increased risk of
rheumatologist.36
Magnetic resonance imaging of tendon involvement in radiography
malignancies
the joints has stimulated great rheumatic diseases.33 More
I Longer examination
I Allergic reactions to
interest as a research tool.29 The Certainly, the fact that rheumatoid activity and
recent MUS techniques, such time
contrast agents
main advantage of MRI is that it damage can be imaged and measured in new
as Doppler, have shown
are rare I Evaluation of only a
allows 3-dimensional assessment ways using MRI and ultrasound opens a new frontier
promise for assessing patients few joints per session
e
of a large number of anatomical in disease management for rheumatologists.
with inflammation. Doppler
pl
I Time required to
m
structures in and around a joint.23 Opportunities for clinical practice include earlier
is a technique that makes
sa
evaluate an MRI
g
The multiplanar properties of MRI and its ability and more accurate diagnoses and meticulous
noninvasive measurements of blood flow. Power examination
in
rit
to identify small cortical defects allow superior evaluation of therapeutic response. These
Doppler is valuable for assessing low-velocity
iw
sensitivity to conventional radiography for techniques provide optimal opportunities for
sk
vascular flow in small vessels such as the I Physical limitations
I Noninvasive
Ultrasound
w
detecting bone erosions.23 MRI can assess osseous disease control.7,35 There are technical challenges,
synovium. Therefore, it can measure and detect (ie, not all areas are
ko
I Relatively inexpensive
cz
accessible, thus whole
changes and has the ability to visualize soft tissue however, with MRI and ultrasound, for instance, in
changes in the vascularity of joints and soft tissue
Ka
I No ionizing radiation joint assessment is
with high spatial resolution and good contrast.25,29 standardizing scoring systems.23,29,30,36,37 A thorough
due to inflammation.32 A study in patients with
al
I Ability to visualize rarely possible)
st
validation of MRI findings as a substitute for
inflammatory arthritis proposes that MUS may even
ry
both inflammatory
C
I Dependency on a
radiographic outcome measures is required before
have more sensitivity than MRI for the detection of
The increased popularity of MRI is a result of better and destructive skilled operator
routine use in clinical trials is recommended. But
synovitis in finger joints.34 However, further
access, reduction in cost, and developments in disease mechanisms
I Poor objective
these tools have a possible future in the diagnosis
resolution, sequences, and I Easily repeated documentation
and management of RA.
software. It is contended that I Possibility of of findings
these features make MRI an examining several
ideal technique for detecting joints in 1 session
the earliest pathological changes I Potential for being
performed by
associated with inflammatory
rheumatologists in
arthritis.23 Furthermore, there
outpatient clinics
is evidence that using MRI in
I Potential for guiding
patients with early RA can
interventions
A sonogram of the wrist
assist in identifying those with produced by ultrasound can be
used as a diagnostic tool for RA
aggressive disease.30,31
and to monitor ongoing disease
progression.
8 9

6. Treatment Goals
From a physician’s perspective, goals central to the I risk factors Remission some suggestion that the standard primary
treatment of RA include decreasing pain, preventing endpoint of RA clinical trials should be a response
The notion of setting remission as a treatment goal
I comorbid conditions
loss of function, improving QOL, and inhibiting of ACR 70 or greater to more accurately indicate
for RA is becoming more prominent within clinical
I what drug monitoring is needed
structural damage.1,38 While patients may benefit from treatment efficacy.9
settings.9 The challenge of introducing remission as
I patient preferences
the outcomes of these goals, they often rate the the standard goal of treatment lies in establishing a
following symptoms as most important: functional I patient expectations of treatment In addition to the discussion over which accumulative
universally accepted definition that can be easily
ability, pain, cognition, gastrointestinal side effects, measurement should be used to indicate a state of
assessed and is accurately quantified. It is essential
I potential barriers to treatment recommendations
fatigue, and sleep.39 Since RA is a complex, chronic remission, there is also debate over which core
to define the point at which disease activity has
Current therapeutic options allow physicians the
autoimmune disease that is prone to periods of criteria most accurately reflect the degree of disease
been stably reduced or repressed sufficiently.
ability to treat RA patients at any stage of disease.
increasing and decreasing severity, patient progression.8,9,43 Some experts argue that, although
Furthermore, in order to set remission as a study
Although early intervention is important, so is
involvement in the development of a long-term swollen joint counts and tender joint counts are
endpoint within a clinical trial, concise criteria that
assessing the efficacy of treatment and controlling
treatment plan is important for improving outcomes. important indicators of disease activity, only
can be easily measured and provide reliable data
disease long term for patients with more advanced
Key opinion leaders recommend that physicians and radiographic analysis can provide objective evidence
must be identified.8,40,42,43
disease or who are nonresponsive to therapy.
e
patients should first discuss treatment options. of joint degradation and true disease progression.8,9
pl
m
Discussions should revolve around1: Neither ACR nor DAS standards include radiographic
Currently, there is much discussion on what constitutes
sa
While efficacy is critical for successful clinical
g
assessment in their core analytical criteria. Advocates
remission in RA. For many years, major clinical
I the patient’s prognosis and treatment options
in
rit
outcomes, good tolerability is also important. Thus, of more advanced methods of visualizing disease
studies had equated a response of ACR 70 or
iw
I associated costs both safety and tolerability should be monitored activity suggest that even more sensitive methods,
sk
greater40 and/or a DAS28 score less than 2.6 with
w
I possible adverse effects as patients progress on therapy. such as MRI, be utilized to better detect early erosions
ko
a state of remission.43 Another recently introduced
cz
I when the patient may expect a response and pre-erosive inflammation that cannot be seen
measure is the major clinical response (MCR), in
Ka
on early radiographs.26
which a response of an ACR 70 or greater is
al
st
maintained for at least 6 consecutive months.44
ry
C
Common definitions of remission in RA40,41 Achieving remission for more RA patients is becoming
increasingly possible with the introduction of
Previous studies have traditionally reserved responses
ACR DAS28 DMARDs. With the reality of remission, however,
of ACR 70 or DAS28 <2.6 as secondary endpoints,
comes the necessity to identify the most accurate
using ACR 20 and ACR 50 criteria as the primary
5 of the following for at least DAS28 <2.6
criteria for monitoring treatment efficacy and
measurements to indicate clinical efficacy. Recent
2 months: DAS28 score calculated from:
Definition
measuring patient success so that remission can be
statistics demonstrating an increased probability of
I No fatigue I No tender joints I 28 tender joint counts targeted and measured as a new treatment goal.
work disability in patients only achieving responses
I No joint pain I No swollen joints I 28 swollen joint counts of ACR 20 or ACR 50, but never experiencing
ACR 70, suggest that ACR 20 and ACR 50 are not
I Normal ESR I Morning stiffness I Patient global assessment of
<15 minutes disease activity adequate responses and, therefore, not reliably
reflective of treatment efficacy. There has been
I ESR or CRP
Originally defined in 1981. These The DAS28 criteria for remission are
criteria are still preliminary. The becoming widely used in today’s clinical
Future
ACR definition has been criticized trials. The DAS28 is considered to be less
for being too stringent, since few patients restrictive than the ACR definition for
achieve remission by these criteria. remission.
10 11

7. Treatment Options
Pharmacological Options with RA immunopathology. However, DMARDs The guidelines for RA treatment are as follows1:
have the ability to alter the disease through reduction
or prevention of joint damage, and preservation of
Since preventing loss of function, decreasing pain, I Establish diagnosis of RA early
joint integrity and function.1
improving patient QOL, and inhibiting structural I Document baseline disease activity and damage
I Estimate prognosis
damage are central goals of treatment, drug therapy
All RA patients are considered candidates for DMARD
should be tailored to achieve these outcomes. In
therapy. DMARD therapy should be initiated within
addition, some things to be considered when
Primary Care Physician
3 months in patients with confirmed diagnoses who
selecting a medication include the ability to deliver Initiate therapy
continue to have the following symptoms despite I Patient education
an adequate response, the incidence and seriousness
adequate NSAID treatment1: I Start DMARD(s) within 3 months
of adverse events, and the likelihood of patient
I Consider NSAID
I ongoing joint pain
compliance.1 Therapies that achieve an ideal balance
I Consider local or low-dose systemic steroids
of efficacy, safety, and tolerability deliver true I considerable morning stiffness or fatigue I Physical therapy/occupational therapy
clinical effectiveness.
I active synovitis
e
pl
m
I continuous elevation of ESR or CRP levels
sa
In order to achieve optimal patient outcomes,
Rheumatologist
g
Periodically assess disease activity
I radiographic joint damage
in
pharmacological therapy usually consists of a
rit
iw
combination of NSAIDS, DMARDs, and/or steroids Any untreated patient with persistent synovitis and
sk
(corticosteroids).1 joint damage should be immediately started on
w
ko
Inadequate
DMARD treatment to prevent or slow further damage.1
cz
Adequate response response (ie, ongoing
Ka
NSAIDs with decreased active disease after
al
disease activity
These drugs reduce inflammation and have analgesic 3 months of
Traditional
st
ry
maximal therapy)
properties, but they do not prevent joint destruction Traditional DMARDs have been used in RA therapy
C
or alter the disease course.1 to successfully reduce inflammation and associated
symptoms.1,45
Change/Add DMARDs
Steroids
Corticosteroids work quickly to alleviate damaging Rheumatologists often select traditional DMARD MTX* naive Suboptimal MTX response
and painful inflammation. They are associated with therapy initially, especially for patients with more
MTX Other Combination Combination Other Biologics
potential side effects like brittle bones, cataracts, and active disease.1 mono Rx Rx Rx mono Rx
elevated blood sugar, especially if they are taken in
Mono Rx Combination
high doses or over the long term. Inflammation Biologic DMARDs Rx
may be controlled in a few affected joints by Six years ago, if a patient had RA and did not
injecting a corticosteroid compound directly respond to traditional DMARDs, there was little a Multiple DMARD failure
into inflamed joint(s).38 rheumatologist could do. Today there is the option
of biologic DMARDs.
Symptomatic and/or
DMARDs structural joint damage
Although NSAIDs and corticosteroids may reduce
inflammation and alleviate pain, they do not interfere
Surgery
*MTX = Methotrexate
12 13

8. Biologic DMARDs continued The use of traditional DMARDs and the introduction Nonpharmacological options flares and concomitant loss of function. Cognitive-
Current guidelines recommend a combination of of the biologic DMARDs have begun to redefine behavioral programs that help patients take a greater
Optimum treatment requires more than just drug
NSAIDs, corticosteroids, and early introduction of both expectations for the effectiveness of RA therapies.1,47 role in their disease management can improve patient
therapy. Sometimes, RA patients may require periods
traditional and biologic DMARDs. The more recent DMARDs have allowed physicians to go beyond health and reduce health care utilization.1
of rest, job modification or time off from work, a
availability of targeted therapeutics for the treatment of just treating symptoms and start inhibiting disease change of occupation, or termination of work
RA has led to a significant difference in the ability to progression and joint destruction, while also The risks and benefits of existing treatment plans
altogether. Patients will likely benefit from instruction
inhibit disease progression and improve patient preserving joint function.1 should also be reviewed with the patient. The health
in joint protection, energy conservation, and creation
response and quality of life. Moreover, it has opened care team may use an interdisciplinary approach.
of a home exercise program (joint range of motion
the door for major advances in the treatment of RA Advances in biologic treatments for autoimmune Rheumatologists, primary care physicians, nurses, and
and strength exercises).1
and led to more aggressive treatment guidelines.1 disease have set a new standard for RA therapy, and other health care staff members often play a significant
elaborate research of immune pathways has led to a role in educating patients and their families about the
Treatment starts with educating the patient about the
more intricate understanding of RA immunopathology.
The American College of Rheumatology’s most recent disease and how to offer long-term supportive care.
disease. Patients will have to learn to live with RA and
As a result, potential new therapeutic targets within
position statement dictates that, when clinically Patients may find consultations with
become involved in the treatment process
e
RA immunopathology, such as IL-6, B cells, and
appropriate, all patients with serious rheumatic disease physical therapists, occupational
decisions. Emotional difficulties may arise
pl
m
T-cell activation, have been investigated. Hopefully,
must have these biologic agents.46 therapists, patient educators, and
if treatment does not fully control this
sa
g
new alternatives will be identified to stop disease social workers beneficial.1,38
chronic disease. The patient should be
in
rit
progression and prevent permanent disability while
Although the genetically engineered biologic made aware that RA is associated with
iw
preserving patient immune response.47
sk
DMARDs all work in different ways, they all
w
block proteins called cytokines, which contribute to
ko
cz
Low-impact exercises such as pool
inflammation.38 This development has been a major
Ka
therapy are beneficial for RA patients as
advance in RA treatment. nonpharmacological treatment options.
al
st
ry
C
Some of the most effective anticytokine drugs are
antagonists to TNFα, which is a critical mediator of
the RA inflammatory cascade. Clinical trials have shown
these drugs improve clinical signs and symptoms,
measured by ACR 20, 50, and/or 70 scores. These drugs
have demonstrated efficacy in combination therapy with
traditional DMARDs when administered to patients with
ongoing active RA despite sufficient doses.1
14 15