Disease remission the goal of therapy in rheumatoid arthritis

In order to achieve remission, rapid diagnosis of rheumatoid arthritis (RA) is a key priority. The new RA classification system allows a diagnosis to be made much earlier than previously. The criteria focus on clinical, biochemical and immunological features associated with persistent and/or erosive disease. Following presentation to primary care, patients with symptoms and signs of an inflammatory arthritis should be referred to a rheumatologist. Any patient with suspected persistent synovitis of undetermined cause should be referred for specialist opinion and urgent referral if any of the following apply: the small joints of the hands or feet are affected; > 1 joint is affected; there has been a delay of > 3 months between onset of symptoms and seeking medical advice. Early treatment results in a greater chance of inducing remission. Ideally, this should be within 6 weeks of symptom onset. Patients who develop severe persistent inflammatory arthritis who have normal investigations at disease onset should be referred regardless. Similarly, referral should not be delayed pending investigations. A fundamental shift in the approach to treating RA has occurred with the archaic 'start low, go slow' management pyramid having been rejected. EULAR recommends initiating traditional DMARDs as soon as the diagnosis of RA is made, aiming to achieve the target of remission or low disease activity as rapidly as possible. Once prolonged and satisfactory levels of disease control have been achieved, drug doses may be cautiously reduced to levels that still maintain disease control. EULAR guidelines state that if the treatment target is not achieved following the first traditional DMARD strategy, in the presence of poor prognostic factors, or in patients responding insufficiently to DMARDs, then biologic therapy should be considered.