Medical advancements promise better outcomes for RA patients

Although rheumatoid arthritis (RA) remains incurable, disability and reduced quality of life are no longer inevitable outcomes for patients. Across the medical community, there is optimism that hasn’t been seen before, with innovation and science consistently improving the lives of people with rheumatoid arthritis.

Treatment for rheumatoid arthritis has changed dramatically over the past 25 years, evolving from treating only symptoms to therapeutic interventions that can change the course of the disease and, ultimately, slow or prevent structural joint damage. Now, patients benefit from medical knowledge that supports earlier diagnosis, therapeutic approaches that maintain joint mobility and muscle strength, assistive technologies that help patients protect their joints and live with greater autonomy, and new medications that can influence or arrest disease progression. 

The evolution of rheumatoid arthritis treatment. 

During the first half of the 20th century, RA treatment regimens included drugs that could provide only symptomatic relief, basic anti-inflammatories, like aspirin, pain relievers, and physical measures such as:

• Bed rest
• Splinting
• Physical Therapy

In the 1950s, corticosteroids were introduced for the treatment of RA. While these classes of drugs reduced inflammation and helped relieve pain, they did not slow disease progression. New hope for treatment came in 1988 and 1990 with the approval of disease-modifying antirheumatic drugs (DMARDs) such as methotrexate, a drug that changed the face of modern RA treatment and remains prominent in the treatment plan of rheumatoid arthritis today. 

Infusion therapies improve symptom control and disease progression.

Patients newly diagnosed with rheumatoid arthritis are typically offered a combination of DMARDs to block the symptomatic effects of the chemicals released when the immune system attacks your joints. Without treatment, the inflammation caused by these chemicals would risk further damage to nearby bones, tendons, ligaments, and cartilage. 

DMARDs selectively reduce the immune response, but joints that RA inflames contain many chemicals that can cause or contribute to inflammation. In the late 1990s, researchers discovered ways to address rheumatoid arthritis’ abnormal immune response with biological treatments targeting those chemicals in the blood that contribute to RA inflammation, specifically. These treatments, such as abatacept and infliximab, prevent those chemicals from activating the immune system to attack the joint, limiting inflammation and pain. They are potent and specific therapies combined with methotrexate or another DMARD that are typically prescribed to patients who are unresponsive to the traditional DMARD treatment alone. 

Biologic drugs cannot be taken orally, so they are administered by subcutaneous injection or an infusion into a vein. Some patients with moderate to severe rheumatoid arthritis have a difficult time taking medications - especially those that must be self-injected. By delivering medication directly into the bloodstream, patients get faster, more effective results: pain relief, swelling, and stiffness, joint damage prevention, and slower disease progression.

Several biologic drugs for rheumatoid arthritis come as infusions:

• Abatacept (Orencia). Abatacept attaches to - and blocks - the action of cells that cause inflammation. Patients get an infusion of this medication once every two weeks at the start, then monthly.  
• Infliximab (Remicade). This medication belongs to a group of drugs called TNF inhibitors, which block a substance called tumor necrosis factor (TNF) in your blood that promotes inflammation. Patients have three infusions in the first six weeks of treatment and once every eight weeks. 
• Rituximab (Rituxan). This medication belongs to a group of drugs called B-cell inhibitors. Rituximab infusions are spaced two weeks apart.
• Tocilizumab (Actemra). Tocilizumab blocks an inflammatory protein called IL-6. This drug is administered by infusion once every four weeks. 

Since the introduction of these drugs, clinical remission has become a realistic therapeutic goal for the majority of people living with rheumatoid arthritis. As with any medication, there are possible side effects, but infusion therapy for RA has additional potential to relieve symptoms beyond the effect of traditional DMARDs.

Education and diagnostic technology support prevention and management. 

Early diagnosis and management of rheumatoid arthritis can reduce symptoms, slow the disease, and prevent disability. In rare cases, the disease can go into remission. Several key prevention strategies play an essential role in preventing rheumatoid arthritis and controlling the disease progression to include lifestyle-related behaviors:

• Prevention of/stopping smoking
• Healthy nutrition
• Physical activity
• Maintaining healthy body weight
• Maintaining good dental hygiene

Advancements in diagnostic technology are critical to identifying at-risk individuals with or without early joint symptoms for the development of inflammatory arthritis. Identifying rheumatoid arthritis at early stages can affect the course of the disease, prevent or stop joint erosion, and, in some cases, put the disease into remission. 

Much recent research and development in RA imaging has focused on the role of ultrasound and magnetic resonance imaging (MRI). A 2021 study published in Rheumatology and Immunology Research evaluated the role of imaging in predicting the development of RA. The authors describe that the most potent recent advances in RA research have improved the understanding of RA in patients at risk of developing the disease but have no swelling in the synovial membrane that lines some joints.

When used regularly in clinical settings, imaging can detect early inflammation and structural changes in the joints so that doctors can better identify at-risk individuals and begin a collaborative discussion on prevention and treatment.  

Physiotherapy and assistive technology reduce arthritis pain and increase independence. 

Physiotherapy and low-impact, regular exercise significantly increase the benefits of medical therapy, help people with severe RA cope with pain and inflammation, increase exercise capacity, and improve patients’ ability to perform daily activities. Physiotherapies, like the application of cold and heat, electrical stimulation, hydrotherapy and spa therapy, and massage, improve flexibility and general well-being and can help reduce swelling. Massage, in particular, is effective in reducing stress - a significant trigger for RA flares - depression, anxiety, mood, and pain.

While exercise doesn’t reduce disease activity, it dramatically increases patients’ physical capacity. Muscle weakness in patients with RA is a significant cause of joint immobilization and reduced movement. When patients maintain muscle strength, they keep their biomechanical function and stabilize the joints, preventing traumatic injuries.  

Further, rehabilitation treatment of patients with rheumatoid arthritis, such as splinting, using compression gloves and assistive devices, and adaptive equipment, have significant benefits to patients managing symptoms of rheumatoid arthritis - especially those with joint damage that makes day-to-day activities challenging and exhausting. Through occupational therapy, assistive products - like elevated toilet seats and widened gripping handles - can help RA patients protect their joints, conserve energy, diminish the joint pain of day-to-day activities, and maintain patients' independence and self-efficiency.

The future of rheumatoid arthritis treatment.

The advances in rheumatoid arthritis treatment options over the past 25 years have been profound, and treatment may be headed for yet another shift with new medications, new treatment strategies, and precision medicine.

Amid growing interest in the promise of combining biological therapies, the 2014 release of oral treatment, tofacitinib, a Janus kinase (JAK)  inhibitor, has proven to be effective in decreasing the immune system reaction that can lead to inflammation, pain and stiffness, and other symptoms by blocking JAK enzymes.

New and more effective drugs have been developed, and the early treatment approach to rheumatoid arthritis has been revolutionized by adopting treat-to-target (T2T) strategies. Before treat-to-target care, rheumatologists treated RA by adjusting medications based on their judgment, not with frequent disease activity testing. When RA patients can be treated based on the progression of their disease, doctors can adjust medications until they reach specific targets on your test results, closely monitor disease activity, and make changes to treatment when and if needed. In the 2011 Dutch Rheumatoid Arthritis Monitoring (DREAM) trial, 61.7 percent of patients treated to target achieved remission after three years, and 70.5 percent achieved sustained remission. These patients reached remission faster and had lower RA disease activity than those not receiving T2T treatment.

The medical community is also getting closer to precision treatment of RA. Exploration of precision medicine in RA features increased use of serum biomarkers and novel approaches to biopsy, which offer information on patients’ unique genetic, molecular, and environmental factors to develop personalized plans for the diagnosis and treatment, as well as the management of the disease. To date, progress in precision medicine for RA has been slow. But there is hope that in using modern molecular biology techniques, researchers are on the cusp of developing biomarkers that may directly target appropriate treatment. 

Previously, the progression of rheumatoid arthritis from symptom onset to significant disability was often inevitable and, in some cases, rapid. As people live longer, a more substantial number of patients are being diagnosed with RA, making effective treatment, which slows disease progression, more critical now than ever before.  

Now, with the availability of improved scientific knowledge, assistive technology, and arthritis medications that can slow or halt disease progression and prevent irreversible joint damage, joint replacement surgery is not always the outcome, and patients with RA may live comfortable and productive lives.