, Volume 9, Issue 1, pp 1-16

Remodeling the therapeutic pyramid: evolving therapeutic strategies for rheumatoid arthritis

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Abstract

The approach to treatment of rheumatoid arthritis (RA) is undergoing dramatic change, With a prevalence of 1% of the general population. RA is the most common cause of disability that is potentially reversible if correct management of the disease is begun in the early phases. While the traditional therapeutic pyramid model has been in place for the past 25 years, evolving therapeutic strategies suggest that it is appropriate primarily for patients with benign synovitis, and an inverted pyramid is necessary to treat aggressive synovitis, control inflammation early and to prevent rapid joint destruction, disability and early death. Important principals underlying the remodeling of the therapeutic pyramid and evolving therapeutic strategies include: identifying patients with benign and aggressive synovitis: early control of inflammation to stabilize functional status at near normality; need for combination therapy in aggressive synovitis until a major breakthrough or ‘magic’ bullet becomes available; awareness that drugs that control inflammation in a more fundamental manner, such as disease-modifying anti-rheumatic drugs, are more effective in pain control and disability than non-steroidal anti-inflammatory drugs; and, most importantly, education of patients, primary and managing care physicians, health maintenance organizations, insurance companies, and government officials that two-thirds of the cost of RA lies in the complications of the disease and that providing resources for early aggressive therapy is a good investment for all. Successful treatment of rheumatoid arthritis is best accomplished by a coordinated team of a consultant rheumatologist and a managing primary care physician. Much like an early consultation with an oncologist when cancer is suspected, an early consultation with a rheumatologist can help separate benign and aggressive synovitis. If the latter, the rheumatologist can help identify important co-morbid conditions and recommend appropriate therapy. Follow-up programs can then be outlined to maintain control of inflammation at all times, utilize appropriate pharmacologic and non-pharmacologic physical and occupational therapy modalities for mechanical pain, and highlight potential toxicities to be monitored. This program, initiated early, will help prevent administration of toxic drugs to patients with benign synovitis. And, just as important for patients with aggressive synovitis, this strategy is designed to reduce the high incidence of morbidity and mortality and the costly episodes of hospitalizations and salvage surgery that can be so devastating to patients and their families.