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Although homeopathic remedies such as omega 3 and 6 may help alleviate pain and inflammation, there is no scientific evidence to prove that they in any way modify the outcome of the disease.
Disease-modifying antirheumatic drugs (DMARDs) are the cornerstone of all therapy for RA and should be introduced as soon as possible in order to achieve remission. Remission is defined as the absence of any tender or swollen joints, or laboratory indicators of inflammation in patients on treatment.
The goals of rheumatoid arthritis therapy are:
• Pain relief
• Reduction of inflammation
• Control of the disease with early induction of remission
• Preservation of function
Exercise and physiotherapy
Exercise and physiotherapy can help. Exercises are aimed at maintaining muscle strength and joint mobility without exacerbating the joint inflammation.
Early on this includes immobilising inflamed joints with splints but allowing passive stretch to maintain range of movement. As the swelling is controlled, activity and exercise are encouraged. The message is – “If it’s swollen – rest it. If it isn’t swollen – move it”.
Medication
(a) Relief of symptoms and reduction of inflammation
Simple painkillers, analgesics, and anti-inflammatories, NSAIDs, are used to decrease pain and stiffness.
Cox 2 selective anti-inflammatories (COXIBs) are available with less gastro-intestinal side-effects. These include Celebrex and Prexige. The safety profile of the COXIBs are superior to the older NSAIDs. However, they should be used with caution in patients with cardiovascular disease.
(b) Disease-modifying Antirheumatic Drugs (DMARDS)
Early aggressive treatment with DMARDS is essential. These drugs reduce the amount of joint destruction and X-ray damage.
Methotrexate is the most commonly used DMARD. Although developed as chemotherapy, it is extremely effective in RA and remains the backbone of most treatment programmes.
Chloroquine (Nivaquin), an anti-malarial drug, and Sulphasalazine (Salazopyrine) are older drugs which are commonly used alone or in combination with Methotrexate. Leflunomide (Arava) is a more expensive but powerful DMARD which is often used when Methotrexate fails to produce remission.
Newer biological therapies are now available and include drugs that block the actual chemical pathways of the inflammatory cells.
The new Tumour Necrosis Factor blocking agents (TNF-antagonists) have shown excellent results in controlling disease activity and preventing joint damage, but are very costly (approximately R10 000 per month).
At the moment those available in South Africa include Etanercept, Infliximab and Adalimumab (Enbrel, Revellex and Humira).
(c) Cortisone
Cortisone is very useful in low dose for treatment of the symptoms of disease whilst waiting for the disease-modifying drugs to work. It works rapidly to counter all aspects of the disease.
However, side effects are dose-dependent and preclude long-term use thereof. Persistent need for oral cortisone indicates incomplete control of the underlying disease and the need for more aggressive DMARD therapy.
Judicious injection of cortisone either intramuscularly or directly into joints is helpful in controlling flare-ups of the disease. Large doses are restricted for the potential life-threatening situation where there is systemic disease and organ involvement. In these cases the drug may be life-saving.
Surgery
Surgery can be helpful relatively early in the disease if there is persistent inflammation of a single large joint such as the knee or wrist. This is called a synovectomy and can produce prolonged relief of symptoms.
Replacement surgery is reserved for patients with severely damaged joints. The most successful procedures are carried out on hips and knees. Goals of surgery are to relieve pain, correct deformity and provide functional improvement.
Rheumatoid arthritis is primarily a medical problem and surgery should be for patients who are under the care of an experienced rheumatologist or physician.
