Vnitr Lek 2008, 54(1):84-99

Recommendations of Czech Rheumatological Society for the treatment of rheumatoid arthritis. Efficacy and treatment strategies

R. Bečvář^1,*, J. Vencovský¹, P. Němec², D. Suchý³, L. Procházková², K. Pavelka¹

¹ Revmatologický ústav Praha, ředitel prof. MUDr. Karel Pavelka, DrSc.

² II. interní klinika Lékařské fakulty MU a FN u sv. Anny Brno, přednosta doc. MUDr. Miroslav Souček, CSc.

³ Oddělení klinické farmakologie FN Plzeň, přednosta doc. MUDr. Otto Mayer, CSc.

Rheumatoid arthritis (RA) is an autoimmune disease of unknown aetiology characterized by presence of chronic symmetric synovitis, which leads to the formation of joint erosions. Generally recommended method for activity assessment of RA is so called Disease Activity Score (DAS). In early RA when low disease activity is present with oligo- or monoarthritis antimalarials are drugs of choice, while sulfasalazine (SAS) is recommended in cases with medium activity without erosions. Initial treatment with methotrexate (MTX) or leflunomide (LEF) should be applied in a very active polyarthritis with a rapid development of erosions. MTX is often combined with other disease modifying drugs (DMARD) and the blockers of tumour necrosis factor α (TNF-α). LEF is to be administered to the patients in whom the other DMARD are contraindicated or not tolerated. In established RA with oligo- or monoarthritis with permanent low activity SAS is DMARD of choice. In cases with insufficient response and medium activity MTX is used and if it is inefficient LEF or combination of DMARD should be considered. In a very active disease with a rapid evolution of erosions high doses of MTX or LEF are recommended. When extraarticular symptoms of RA are present azathioprine is to be applied and in case of involvement of vital organs cyclophosphamide should be used. When DMARD are failing or contraindicated TNF-α blockers are to be applied. When one TNF-α blocker is inefficient it should by replaced by another one from the same group or another biological should be used. For indication of biologicals the activity limit is DAS28 5.1 and the decrease of DAS28 more than 1.2 is an efficacy criterion. Nonsteroidal antirheumatic drugs are an important part in the management of RA, and also corticosteroids are often of used in oral or parenteral form. To the complex therapy of RA nonpharmacological means are usually implemented - different physical procedures and various surgeries.

Keywords: rheumatoid arthritis; activity; disease modifying drugs; biological therapy

Received: October 26, 2007; Published: January 1, 2008  Show citation