Non-Pharmacologic Therapy:
Adequate rest, weight reduction if obese, occupational therapy, physical therapy, and use of assistive devices may improve symptoms and help maintain joint function.
Patients with severe disease may benefit from surgical procedures such as tenosynovectomy, tendon repair, and joint replacements.
Patient education about the benefits and limitations of drug therapy is important.
Pharmacologic Therapy:
General Approach:
A disease-modifying antirheumatic drug (DMARD) should generally be started within the first 3 months of symptom onset. DMARDs should be used in all patients except those with limited disease or those with class IV disease in whom little reversibility is expected. Early use of DMARDs results in a more favorable outcome and can reduce mortality.
First-line DMARDs include methotrexate, hydrochloroquine, sulfasalazine, and leflunomide. The order of agent selection is not clearly defined. Hydroxychloroquine or Sulfasalazine may be used initially in mild disease, but methotrexate is often chosen initially in more severe cases because of long-term data suggesting superior outcomes than other DMARDs and lower cost than biologic agents. Leflunomide appears to have long-term efficacy similar to methotrexate.
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