Rheumatoid Arthritis: Pathophysiology, Treatment Ladder, and Prognosis
Treatment Pyramid (Treat‑to‑Target)
- csDMARDs: Methotrexate anchor; add leflunomide, sulfasalazine, hydroxychloroquine.
- bDMARDs: TNF inhibitors (adalimumab, etanercept), IL‑6R (tocilizumab), CTLA4‑Ig (abatacept), anti‑CD20 (rituximab).
- tsDMARDs: JAK inhibitors (tofacitinib, upadacitinib, baricitinib).
- Glucocorticoids: Bridge therapy; minimize dose/duration.
- NSAIDs/analgesics: Symptomatic only.
Non‑Pharmacologic Measures
- Physical/occupational therapy for joint protection.
- Weight loss, smoking cessation, cardiovascular risk management.
Prognosis
Early aggressive treatment yields remission in ~50–60%; most maintain function. Lifelong monitoring for extra‑articular manifestations (lung, heart, vasculitis) and drug toxicity.
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