The treatment of rheumatoid arthritis (RA) has come a long way in the last 20 years. It used to be that if you could reduce pain and swelling, you were doing your job as a specialist in arthritis. That is not good enough anymore.

Rheumatoid arthritis presents with either the acute onset or slow onset of pain and stiffness with functional impairment; if not treated aggressively, it can result in irreversible joint damage. Irreversible joint damage may occur within three to six months of disease onset. If your physician is not making you aware of these grim statistics, then question him or her!

Although RA can occur at any age, most cases are seen in adults between ages 30 and 60 years. Another smaller peak occurs in the 70-80 year age group. Currently, the prevalence of RA is estimated at 15% of the US population; 3 million adults in the United States have been diagnosed with RA. If not adequately treated, progressive deformity will lead to need for joint replacement surgery.

In the United States in 1997 alone, there were 256,000 knee replacements and 117,000 hip replacements associated with arthritis.

Until the entire biology of RA is better understood, treatment strategies must focus on early diagnosis and disease management. Early diagnosis and treatment with disease-modifying anti-rheumatic drugs (DMARDs) are necessary to reduce early joint damage, functional loss, and mortality.

RA is a heterogeneous disease meaning it consists of a wide spectrum of presentations in which responses to treatment vary considerably for any given patient. Despite recent advances with DMARDs and targeted therapies such as tumor necrosis factor (TNF) inhibitors, some patients do not show adequate response and continue to show disease progression. That means there must be flexibility in producing the optimal clinical response.

The best response will employ the use of a full spectrum of clinical agents with different therapeutic targets. As a patient with RA, you must educate yourself to what is available.

Evidence shows that patients with refractory RA may benefit from the use of sequential medicines starting with DMARDS, going on to anti-TNF drugs, and then using second generation biologic remedies if these treatments fail to halt disease progression.

Also, in clinical research, there are a number of excellent options that remain open to you. If your rheumatologist is not doing clinical research, have them refer you to a rheumatologist who is.

Among the second generation drugs are anti-CD20 B-cell depleting agents such as rituximab (Rituxan) and inhibitors of T-cell activation such as Orencia (abatacept).

Results from randomized clinical trials have demonstrated improved outcomes as a result of treatment with these agents, in combination with methotrexate, even in patients who previously have not responded to DMARDs and TNF inhibitors.

In the near future, other agents such as anti-IL 6 (Actemra) and protein kinase inhibitors will add to the treatment regimen. Third and fourth generation biologic remedies show a great deal of promise in the research arena.