How to treat RA without affecting liver and brain health?

Hello,

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I am sorry to hear about your health challenges.

In rheumatoid arthritis, corticosteroids are normally used for short-term treatment and should be tapered and withdrawn after appropriate control of illness has been achieved. The American College of Rheumatology (ACR), European Alliance of Associations for Rheumatology (EULAR), and others currently advise against the chronic use of steroids due to the possibility of serious side effects.

If you still need to take corticosteroids to control your symptoms of rheumatoid arthritis, this may mean that your present treatment strategy is not hitting the desired therapeutic aim and may need to be adjusted. In these circumstances, a switch to biologic therapy is often recommended. Biologic drugs may be useful steroid-sparing therapies to help regulate disease activity and allow corticosteroids to be tapered and ultimately stopped.

A reasonable initial approach would be to consider an anti-TNF biologic agent, such as infliximab, adalimumab, or etanercept. After approximately three months of treatment, your response can be assessed based on improvements in joint pain, swelling, physical function, and the ability to taper corticosteroids. Depending on your clinical response, the biologic therapy can either be continued or adjusted to an alternative agent if needed.

The likely diagnosis is rheumatoid arthritis (RA)

Recommended prebiologic therapy investigations

1. CBC (Complete Blood Count).

2. Sedimentation rate of erythrocytes (ESR).

3. C-reactive protein (CRP).

4. Liver function tests (ALT, AST).

5. Serum creatinine.

6. Hepatitis C antibody (HCV Ab).

7. Hepatitis B surface antigen (HBsAg).

8. HIV screening.

9. Tuberculin skin test or other tuberculosis screening

10. Chest X-ray.

11. Hand X-rays.

These investigations are important to assess disease activity, establish baseline organ function, and screen for infections or other conditions that may affect the safety of biologic therapy.

Treatment plan includes

1. Initiate anti-TNF biologic therapy following appropriate screening and evaluation.

2. Gradually taper corticosteroids as disease control improves and the biologic therapy becomes effective.

Monitoring the effectiveness and side effects during the entire process of transition.

The follow-up measures include

1. Re-assessment after three months of biological therapy to assess the effectiveness, activity level of disease, improvement in joints, and tapering of corticosteroids.
2. Further adjustments to therapy can be made based on clinical response and treatment goals.

Supportive and preventive measures include the following:

1. Adequate rest during disease flares.

2. Regular physical therapy and appropriate exercise as tolerated to maintain joint mobility and function.

3. Weight management, if applicable, to reduce stress on affected joints.

4. Ongoing monitoring for medication-related side effects and infections.

5. Prompt medical evaluation of any signs of infection, particularly while receiving immunosuppressive therapy.

Given your history of liver illness and consequences from long-term corticosteroid usage, minimizing steroid exposure while still maintaining good management of your rheumatoid arthritis should be a major treatment goal. It will be important that your rheumatologist and hepatologist work closely together to make sure that both your joint condition and liver health are treated safely and successfully.

I hope this addresses your concerns.

Please feel free to follow up if you need any additional clarification.

Thank you.