Korean J Intern Med.  2016 Mar;31(2):210-218. 10.3904/kjim.2015.137.

Current concepts in the management of rheumatoid arthritis

Affiliations
  • 1The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan. tanaka@med.uoeh-u.ac.jp

Abstract

Rheumatoid arthritis (RA) is a systemic autoimmune disease characterized by inflammation and joint destruction that causes significant morbidity and mortality. However, the combined use of methotrexate, a synthetic disease-modifying antirheumatic drug (DMARD), and biologic DMARD has revolutionized treatment of RA. Clinical remission is now realistic targets, achieved by a large proportion of RA patients, and rapid and appropriate induction of remission by intensive treatment with biological DMARD and methotrexate is prerequisite to halt joint damage and functional disabilities. However, biological DMARD is limited to intravenous or subcutaneous uses and orally available small but strong molecules have been developed. Oral administration of tofacitinib targeting the Janus kinase (JAK) is significantly effective than placebo in active patients with methotrexatenaive, inadequately responsive to methotrexate or tumor necrosis factor (TNF)-inhibitors. The efficacy was rapid and as strong as adalimumab, a TNF-inhibitor. Meanwhile, association of tofacitinib on carcinogenicity and malignancy is under debate and further investigation on post-marketing survey would be warranted. On the other hand, discontinuation of a biological DMARD without disease flare is our next goal and desirable from the standpoint of risk reduction and cost effectiveness, especially for patients with clinical remission. Recent reports indicate that more than half of early RA patients could discontinue TNF-targeted biological DMARD without clinical flare and functional impairment after obtaining clinical remission. Contrarily, for established RA, fewer patients sustained remission after the discontinuation of biological DMARD and "deep remission" at the discontinuation was a key factor to keep the treatment holiday of biological DMARD.

Keyword

Arthritis, rheumatoid; Antirheumatic agents; Biological antirheumatic agents; Remission; Janus kinase inhibitor

MeSH Terms

Administration, Oral
Antirheumatic Agents/*administration & dosage/adverse effects
Arthritis, Rheumatoid/diagnosis/*drug therapy/metabolism/physiopathology
Biological Products/administration & dosage
Disability Evaluation
Drug Administration Schedule
Humans
Janus Kinases/antagonists & inhibitors/metabolism
Molecular Targeted Therapy
Predictive Value of Tests
Protein Kinase Inhibitors/administration & dosage
Recovery of Function
Remission Induction
Signal Transduction/drug effects
Treatment Outcome
Tumor Necrosis Factor-alpha/antagonists & inhibitors/metabolism
Antirheumatic Agents
Biological Products
Janus Kinases
Protein Kinase Inhibitors
Tumor Necrosis Factor-alpha
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