Treating Rheumatoid Arthritis
Intensive treatment of rheumatoid arthritis (RA) requires frequent monitoring to check on how well the treatment is working. Your rheumatologist may want to see you as often as once a month, or every 2 to 3 months, depending on the stage of your disease and the medications you're taking.
Frequent monitoring helps your rheumatologist treat toward a target, in much the same way high blood pressure is treated toward a target. But evaluating progress in RA isn't quite as straight forward as taking a blood pressure reading. To monitor the treatment of rheumatoid arthritis, a combination of subjective and objective measures is used to calculate a disease activity score. The calculation is based on the answers to these four key questions:
1. How do you feel: better or worse? This is your personal opinion and is a subjective measure. Your doctor may ask you to fill out a written questionnaire about how you're feeling. Written answers are less likely than verbal answers to be misinterpreted, can be more easily "scored," and can also be added to your medical records.
2. Do you look and sound better? This is your doctor's opinion, based on what he or she can see, and is also a subjective measure.
3. What do your blood tests show? Blood tests will be done to look for signs of treatment side effects and to check your erythrocyte sedimentation rate (ESR) and/or your C-reactive protein (CRP) levels to see whether the inflammation in your body is being reduced. This is an objective measure of disease.
4. How do your joints look? Your rheumatologist may schedule imaging (x-ray, MRI, CT scan, or ultrasound) to see what effect treatment is having on joint damage and erosion: Has it slowed, gotten worse, or stopped? This is referred to as monitoring the radiographic progression of rheumatoid arthritis. It's a term that's useful to understand because it's frequently used during treatment. Radiographs are x-rays. Monitoring radiographic progression is simply monitoring the damage being caused to your joints, as measured by x-rays. This is an objective measure of disease and may be assessed every 6 to 12 months during the first few years of rheumatoid arthritis.
There are many questionnaires and scoring systems that may be used to help monitor treatment, including the Health Assessment Questionnaire (HAQ), the Clinical Disease Activity Index (CDAI), the Global Arthritis Score (GAS), and the Disease Activity Score (DAS28). They work by assigning points to the results from the questions above: the amount of swelling and tenderness observed in your joints, your blood test results, your answers about how you feel, and the radiographic progression seen on your x-rays. The points are then calculated to come up with a number. It's this number that your rheumatologist is aiming to move toward your target -- or remission -- number.
If your treatment plan isn't moving you toward your remission number, your rheumatologist will likely adjust your therapy, which may involve increasing dosages, adding a drug, or switching to a different medication. This process is called treating toward a target, intensive therapy, or aggressive therapy, and it is the most effective way to treat rheumatoid arthritis. Once you've hit your target, you may be monitored less frequently but will still need to keep an eye on your symptoms and meet regularly with your healthcare team.
Note: Some health insurance companies will cover the most advanced (and expensive) arthritis drugs -- the biologic agents -- only if your rheumatologist can prove that you have not responded to other medications. Regular number-based monitoring is a good way to provide evidence of your treatment history.
