Treat to Target

Rheumatoid arthritis (RA) can affect many tissues and organs in the body. The symptoms of RA differ from person to person, and may even change on a daily basis. Many people with RA experience swelling and pain in the joints, most often in the hands, wrists and feet, and may also experience symptoms such as fatigue, loss of appetite, and low-grade fever. If the disease goes untreated, it can lead to joint erosion and even permanent disability. A prompt diagnosis and effective treatment plan may help restore health and quality of life.

Once you are diagnosed with RA, your rheumatologist will consider several factors (outlined below) before choosing a treatment plan. Most health professionals use the “treat to target” approach, which aims to reduce and maintain the inflammation at the lowest explicitly specified and measurable level. This may be achievable through appropriately chosen medication, constant monitoring, and your feedback.

The first step in RA treatment is to relieve your symptoms. The long-term goal is to not only control symptoms, but also to slow or stop joint damage. Once initial symptoms are under control, your doctor will need to evaluate (a.) how your joints have been affected, (b.) if any other organs have been impacted, and (c.) if you can tolerate your current medications. Your doctor may check some blood tests to see if you have normal kidney, liver, and bone marrow function.

Once you have begun your therapy, constant vigilance and feedback on your and your doctor’s part can help improve the results of RA management.

Advice for Improving Treatment Outcomes

Your health is also in your hands. There are many things you can do to help improve your treatment outcomes:

  • Have an open and thorough dialogue with your doctor. Your input is critical to your health. If your doctor doesn’t know how your body reacts to a medication, they cannot make necessary adjustments to ease your pain. You should also share any adverse or unusual reactions you may experience so that your doctor can instruct you how to avoid any serious complications of treatment.
  • Observe your reactions to different kinds of foods. Some may trigger inflammation.
  • Maintain as close to ideal body weight as you can to reduce pressure on your joints.
  • Try to quit smoking, as smoking may worsen the symptoms of RA.
  • Take up low-impact exercise such as swimming or walking. Strong muscles and supple tendons protect the joints. Talk to your doctor before starting a new exercise routine.
  • Maintain good dental hygiene, which can reduce the severity of your RA.
  • Maintain a diary to track your body’s reactions and any other changes.

To that end, your doctor may start with a Routine Assessment of Patient Index Data 3 (RAPID-3), which evaluates how much you are limited by your disease in performing everyday activities. You will answer 13 questions about simple activities, as well as sleep difficulties and emotional problems. You will rate, on a scale of 0-10, your pain level and the ability to carry out every day activities. The RAPID-3 gives your doctor a sense of the severity of your RA and a baseline against which to measure improvements.

Your doctor may also order CRP (C-reactive protein) test periodically to monitor your response to therapy. The level of CRP, a protein produced by your liver, is measured in your blood. Normal CRP levels are below 3.0 mg/dL. These levels increase when there is inflammation in your body. Therefore, if you begin a new medication, a decreased CRP level (checked a few weeks later), may suggest that your new treatment is working. If the level remains increased, the doctor may choose to start another form of treatment.

Your doctor may order joint x-rays initially to see how advanced the joint damage is. X-rays may need to be repeated periodically, if you have stubbornly swollen or tender joints that do not respond to treatment. If a particular joint continues to give you great discomfort, even though the x-ray is normal, your doctor may order an MRI or an ultrasound which can show the soft tissues and excessive amount of fluid in the joints.

Your rheumatologist may also use the Clinical Disease Activity Index (CDAI) to assess your improvements. The CDAI is calculated by adding the number of swollen and tender joints (out of 28 joints available for evaluation), the Patient Global Disease Activity score (0-10), and the Evaluator’s Global Disease Activity score (0-10). The CDAI can range from 0 to 76. A 6.5 reduction in CDAI score suggests moderate improvement in disease activity.

Ultimately, your doctor should make frequent assessments of your disease activity, followed by adjustments to treatment (such as changing the dose of a prescribed medication or adding new medications) until your disease activity is brought down to your target level.