Treatment
Because rheumatoid arthritis can cause irreparable damage to the joints (and organs) very early on, early and consistent treatment is very important. A number of effective medicines are available, and research has made great progress in rheumatology in particular in recent years.
Cortisone
When cortisone was discovered in 1948, it was thought that a medicine had been found that could cure or at least adequately treat inflammatory rheumatism. Only over the years did it become clear that cortisone has a number of very unpleasant and not harmless side effects. We now have more than 60 years of experience with cortisone, so we are able to use its positive effects without causing serious side effects. Cortisone still plays an important role in the treatment of inflammatory rheumatic diseases and is a highly effective, indispensable and beneficial medicine once you have learned how to use it.
The basic rules of cortisone therapy are that it is always taken in the morning and that the dose is reduced gradually, i.e. it must not be stopped suddenly. Higher doses of cortisone should only be taken for a short time (a few weeks). A dose of 5 to 7 mg or less, however, can be taken relatively safely for a longer period. If a dose of 7.5 mg or more is absolutely necessary for a longer period, a calcium/vitamin D supplement must be taken regularly to prevent osteoporosis (bone loss). Today, the aim is to end cortisone treatment as soon as possible in the long term and to continue treatment with basic therapies alone.
Basic therapy
So-called basic therapies are the most important pillar of drug treatment for rheumatoid arthritis. In many cases, basic therapies considerably reduce disease activity and often stop it completely.
Basic therapies are medicines that only start to work after some time; it usually takes several weeks to a few months for the desired effect to occur. Additional temporary treatment with anti-inflammatory drugs (NSAIDs) or low-dose cortisone is therefore often needed to bridge the time until they take effect.
Conventional basic therapies (DMARDs, disease-modifying anti-rheumatic drugs)
Active rheumatoid arthritis, i.e. with marked inflammation, is often treated with methotrexate as the gold standard. This substance is also used in cancer therapy, but at much higher doses. Experience over the last decades has shown that the medicine is well tolerated (apart from occasional nausea) and that its possible side effects are very predictable if regular check-ups, in particular regular laboratory tests, are carried out. Permanent damage can then be reliably avoided. The medicine is usually given once a week as an injection or as a tablet. Other basic therapies are available if methotrexate is not tolerated or cannot be used for other medical reasons. If several basic therapies are not effective enough, certain medicines can also be combined.
Biologics
A new era in the treatment of rheumatoid arthritis and other inflammatory rheumatic diseases began with the highly effective so-called biologics. These are new medicines that act very specifically on certain cells or messenger substances, the so-called cytokines, which play an important role in inflammation. Medicines that act on the cytokine TNF-alpha are called TNF-alpha inhibitors. A medicine that works by modulating T-cell activation is abatacept. Tocilizumab and sarilumab are interleukin-6 receptor inhibitors, and rituximab is a monoclonal antibody against a surface structure of B cells. Some of these medicines are only approved in combination with methotrexate.
tsDMARDs (targeted synthetic disease-modifying anti-rheumatic drugs)
Alternatively, tsDMARDs, which are taken as tablets, are also available for patients with severe inflammation. Medicines in this group, e.g. JAK inhibitors, can very effectively and specifically block signalling pathways in inflammatory cells. When using tsDMARDs, other existing conditions must be taken into account, among other things.
Non-steroidal anti-inflammatory drugs (NSAIDs)
Finally, non-steroidal (cortisone-free) anti-inflammatory drugs should be mentioned. There are many different medicines in this group with a weaker anti-inflammatory and a pain-relieving effect. The best known are diclofenac and ibuprofen. Their biggest disadvantage is the increased risk of gastritis, stomach ulcers and stomach bleeding. The newer so-called COX-2 inhibitors (etoricoxib, celecoxib) can significantly reduce this risk. Possible damage to the kidneys must also be considered.
In summary, the treatment options for rheumatoid arthritis have improved considerably in recent years. Crucial for successful treatment are early diagnosis, usually made by a rheumatologist specialising in internal medicine, an early start of treatment, and consistent and monitored continuation of therapy as long-term treatment.