Rheumatoid arthritis is eminently controllable and the aim with the therapies is to remain "no evidence of the diseases" that means no signs of redness, warmth, swelling or tenderness and normal function.

General treatment recommendation

There are some important general guidelines regarding the modern treatment of RA.

a) Early treatment with disease-modifying drugs is mandatory in order to prevent joint damage and dysfunction (i.e. within the first 2-3 months after the disease onset). Treatment will continue for at least 5 years and possibly lifelong .

b) Once the treatment is started, close observation of the clinical response to the initial regimen is necessary. This should include a combination of clinical, laboratory and functional assessments. Less than a 75 percent improvement within the first 1-2 months of the therapy onset requires that the treatment protocol be reassessed and modified .

c) The treatment regimen should be specifically crafted to be equally aggressive to that of the state of inflammation in the patient. Because the illness may change its personality and presentation, close clinical observation is important.

d) Combinations of an NSAID (Non Steroidal Anti-Inflammatory Drugs) and one or more disease modifying drug are commonly employed and are both effective and safe.

e) Short courses of prednisone (i.e. 20 mg on day one with a taper by 5 mg/day over four days) may be used to re-set the inflammatory thermostat in patients who have significant inflammation and its attendant functional limitation. The use of chronic steroids should be avoided, if possible.

f) Physical and occupational therapy should be and important component of every regimen.

g) Patient education is mandatory for the patient and their families.

Specific treatment recommendations
The treatment should match the tempo, activity, aggressiveness and personality of the RA inflammation. Quantization of the clinical outcome is mandatory. the formula that defines the type of therapy includes the following clinical information .

1. The patient's function: Are they working optimally either inside or outside of the house? If they are working, how limited are they and is their work threatened? If they have stopped working, was it due to their RA? Specific functional scales such as the health assessment questionnaire can be followed serially as an early warning sign to limitation in function. The patient can also measure function in the simple manner: ten is the worst you can be, zero is normal function. Where were you before you started the treatment regimen and where are you now?

2. The level of joint inflammation as defined by the number of swollen and tender joints.

3. The level of fatigue using the same 0-10 scale.

4. The ESR (Erythrocytes Sedimentation Rate) and the level of anemia.

5. The development of joint deformities or erosions.

6. The presence and extent of extra articular manifestations (i.e. nodules, lung disease, eye inflammation).

Medications in the RA
The following medications are prescribed for the treatment of RA. However, there are detailed specific guideline for the administration of these drugs that are not mentioned here. Patients must use these drugs following the prescription of the orthopaedic physicians. The drugs are Nonsteroidal Anti-Inflammatory Drugs (NSAIDS), corticosteroids, disease-modifying Anti-Rheumatic Drugs ( DMARDs ) etc.

Long term management issues
The long term management issues cover surgery of hand and wrist, shoulder, elbow; total hip replacement; surgery of knee like arthroscopic surgery, total knee replacement; ankle and foot surgery.

The importance of treatment
If RA is not treated quickly, as many as 80 percent of the patients will develop erosions in their joints in the first 2 years after RA begins.

If left untreated, over 50 percent of patients have to stop work within 5-10 years of the onset of RA. Active and persistent joint inflammation begets joint damage and functional limitation.

With new medication and a proactive approach to early therapy, development of erosions, joint deformities and functional limitation and loss of work are avoidable.

The writer is the Professor and Head of Department of Orthopaedics of Dhaka Medical College Hospital, Dhaka.