Magazine article Drug Topics

New Guidelines Help Providers Manage Rheumatoid Arthritis

Magazine article Drug Topics

New Guidelines Help Providers Manage Rheumatoid Arthritis

Article excerpt

The American College of Rheumatology has set forth two new sets of guidelines for managing rheumatoid arthritis (RA) and monitoring drug therapy for the condition. The more specific drug guidelines expand on the three main classes of medications outlined in the general guidelines: nonsteroidal anti-inflammatories (NSAIDs), disease-modifying antirheumatic drugs (DMARDs), and glucocorticoids. The guidelines were written by a committee of clinicians from academia, hospitals, and government.

According to the overall guidelines, NSAIDs generally are the first line of treatment and should be employed to "reduce joint pain and swelling and improve function." However, the authors cautioned that while "NSAIDs have analgesic and anti-inflammatory properties, [they] do not alter the course of [RA] or prevent joint destruction." To slow or halt the progress of RA, DMARDs are the appropriate option.

Although all NSAIDs have a comparable degree of efficacy, their side effects and cost vary. The guidelines state that the choice of NSAID is based principally on cost, duration of action, and patient preference.

Reached for comment on the guidelines, Pierre Maloley, Pharm.D., assistant professor, department of pharmacy practice, College of Pharmacy, University of Nebraska Medical Center, Omaha, agreed that "cost is an extremely important selection factor, especially when choosing the initial medication. The newer, more expensive NSAIDs do not necessarily afford any greater benefit than the older, less expensive ones, so drugs such as aspirin and ibuprofen should be tried early in the regimen," he said.

Maloley went on to remark that an NSAID should be administered for approximately two to four weeks before it is considered a failure and another NSAID is implemented. He pointed out that "just because one NSAID doesn't work, it doesn't mean another one won't. You may have to try three or four NSAIDs to find the right one for the patient."

Kelley A. Curtis, clinical pharmacist, Drug Information Services, Brigham & Women's Hospital, Boston, noted that undiagnosed signs of RA are something pharmacists should watch for. "If I found that one of my patients was taking any of these NSAIDs every day for a week and still had joint pain, I'd probably say, 'Go see a physician,' " she said.

Patients who don't respond very quickly to NSAIDs may have to move on to the next drug categoryDMARDs. DMARDs have the potential to reduce or prevent joint damage, preserve joint integration and function, and, ultimately, reduce the total costs of health care [while maintaining] economic productivity of the patient, the guidelines state. The DMARDs include hydroxychloroquine, sulfasalazine, methotrexate, gold salts, D-penicillamine, and azathioprine. The guidelines stress that each DMARD has specific toxicity that requires careful monitoring.

There is not one best initial DMARD for treating RA, in the opinion of the authors. Therefore, when deciding which DMARD to prescribe, the provider should consider such factors as patient compliance and co-morbid diseases. Because of safety, convenience, and cost, hydroxychloroquine or sulfasalazine is often the initial selection for patients with milder disease, according to the guidelines. Hydroxychloroquine is generally well tolerated and requires no laboratory monitoring, although patients need periodic ophthalmic exams for early detection of reversible retinal toxicity. Sulfasalazine requires monitoring for rare hematologic complications. …

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