Treating early rheumatoid arthritis in the younger patient

Early diagnosis and intervention may provide the greatest hope for reducing the disability associated with rheumatoid arthritis (RA). In patients with early RA, accurate diagnosis can be delayed by limited access to a specialist service, slow evolution of the clinical features, and lack of definitive diagnostic criteria. However, acute phase reactants, serologic features including presence of rheumatoid factor, and immunohistologic analysis of synovial tissue can provide the basis for differentiating RA from other forms of arthritis. Factors associated with poorer prognosis in patients with early RA are female sex, larger number of joints involved, elevated levels of acute phase reactants, presence of rheumatoid factor, and radiologic evidence of joint damage. Special treatment considerations in younger persons with RA include issues related to conception, pregnancy, and lactation. Methotrexate, hydroxychloroquine, sulfasalazine, and low dose corticosteroids are usually the mainstays of treatment for younger patients with RA. Recommendations for taking these drugs while considering conception vary with their effect on fertility and on the developing embryo. Sulfasalazine, for example, can be taken during pregnancy but caution is advised for breastfeeding mothers. Leflunomide must be discontinued for 2 years before attempting conception; this time can be shortened if the patient opts for drug washout.