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While some patients with rheumatoid arthritis (RA) have good disease control or even remission after treatment with methotrexate alone, many need additional medications to remain symptom-free and prevent long-term damage to the joints.

Fortunately, many options are available. You and your doctor can discuss these options and decide what approach would be best for you, and develop a plan known as "treat-to-target" that will define your management goals and the means to achieve and maintain the goals.

There is no one-size-fits-all approach to long-term management of RA. It will depend on factors such as your personal preferences, disease severity, and other underlying conditions you might have.

TNF Inhibition

One possibility that is successful for many patients is to add a biologic agent such as a tumor necrosis factor (TNF) inhibitor to be taken along with methotrexate. These medications are given by injection and are very effective for many RA patients.

However, because biologic treatments modify the immune system, there can be an increased risk of undesirable events such as infections. You will need to be careful about potential exposures and let your doctor know if you have any signs of infection such as fever.

However, RA itself increases your risk for long-term problems such as cardiovascular disease, and studies have suggested that treatment with a TNF inhibitor may help decrease this risk.

Triple Therapy

Another option that can be useful for patients who would prefer not to have regular injections or infusions is so-called "triple therapy," which adds two other traditional oral drugs, hydroxychloroquine and sulfasalazine, to your methotrexate.

Some studies have shown this approach to be as effective as adding a TNF inhibitor. This option may be particularly suitable for patients who have underlying conditions that would put them at risk if they used biologic therapies.

Other Options

If you do not reach your target goals with a TNF inhibitor or triple therapy, there are still many other newer approaches. These have been developed to modify specific immune pathways that have been identified as participating in the RA disease process, and include medications targeting proteins such as interleukin-6 or immune cells known as B and T cells.

A Caution: JAK Inhibitors

Researchers had high hopes for a group of medications known as JAK inhibitors, which are oral agents that target the Janus kinase family of enzymes. These drugs have shown excellent efficacy, but it was recently determined that patients on these drugs have an increased risk for major cardiovascular adverse events and cancer, so JAK inhibitors currently are generally used only after other types of medications have been tried.

Cutting Back on Treatment

Once you reach your therapeutic target and have maintained a good response for at least 6 months, you and your doctor may discuss decreasing the therapy. Usually this involves, for example, increasing the time between injections for a TNF inhibitor while maintaining your methotrexate dose.

It is never recommended that you stop your treatments altogether, because you are then very likely to experience a disease flare that may be difficult to control.

Read previous installments in this series:

What Is Rheumatoid Arthritis?

How Is Rheumatoid Arthritis Diagnosed?

Starting Treatment for Rheumatoid Arthritis

"Medical Journeys" is a set of clinical resources reviewed by doctors, meant for physicians and other healthcare professionals as well as the patients they serve. Each episode of this 12-part journey through a disease state contains both a physician guide and a downloadable/printable patient resource. "Medical Journeys" chart a path each step of the way for physicians and patients and provide continual resources and support, as the caregiver team navigates the course of a disease.