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Arthritis and Rheumatism

When is it Time to Talk About Surgery as a Treatment for RA?

01/08/2008

Question:

I have RA and have tried a lot of medications for it. But the only biologics that I have tried is Enbrel and that only helped a little bit for about a year. I still have a lot of pain, swelling, tenderness, morning stiffness that lasts 2-3 hour and some times all day. I can`t seem to be able to get off Prednisone either. I have been on it for about 2.5 years. The longest time that I have been off it was this past spring. When I was off it for three months. My symptoms came back big time. Should I try other biologics first? When is it time to talk about surgery as a treatment for RA?

Answer:

Etanercept (Enbrel) belongs to the biologic class of Rheumatoid Arthritis (RA) medicines known as TNF-alpha antagonists. Other FDA-approved anti-TNF agents include adalimumab (Humira) and infliximab (Remicade). There is experience that RA patients who have an inadequate response to one anti-TNF agent may respond to an alternative one.

There are other biologic agents FDA-approved for treatment of RA that have different mechanisms of action. Abatacept (Orencia) blocks T-cell costimulation. Rituximab (Rituxan) acts against B-cells. Regardless of their exact mechanism, the point is that both of these medicines work differently from each other and both medicines work differently than the anti-TNF agents. Thus, one might think that inadequately responding to one agent does not necessarily mean that you are not a candidate for another biologic agent. In fact, there is clear evidence that some people have improvement in their RA activity with either abatacept or rituximab even if they have failed anti-TNF agents.

Anakinra (Kineret) is another biologic agent FDA-approved for the treatment of RA.

Surgery in an individual with RA is dependent on multiple factors. You did not mention a specific joint of concern or a specific procedure; therefore, no specific comment can be made. An important concept to consider is that surgical interventions do not slow or halt the RA process. In general, it is very important that RA treatments be continued after surgery. Moreso, surgical outcomes are likely to improved if disease activity is controlled prior to surgery. Further questions regarding surgery options in RA might be better directed to an orthopaedist.

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Response by:

Raymond  Hong, MD, MBA, FACR Raymond Hong, MD, MBA, FACR
Formerly, Assistant Professor of Medicine
School of Medicine
Case Western Reserve University