What is the ideal treatment for rheumatoid arthritis?

Q: My aunt is suffering from rheumatoid arthritis since last 9 years and she is not responding to any medicine. She is also allergic to drugs like Leflunomide, Azoran and methotrexate though she is on methotrexate. She developed high blood pressure about a year ago and has recently developed diabetes (208 mg/dl fasting and 385 mg/dl PP). She is sensitive by nature and is on drugs (Omnacortil 5, Paracetmol, Methotrexate 2.5, cyclosporine, calcium, livogen). She used to take hydroxychloroquine but her doctor has stopped it now. What is best option for her?

A:Standard treatment of rheumatoid arthritis consists of methotrexate given by injection every once a week at the dose of 25 mg weekly along with folic acid 1-5 mg daily except within 12 hrs of methotrexate dose. It is quite often combined with hydroxychloroquine as well as either sulfasalazine or ARAVA. Usually prednisolone is added to this combination at a small dose and if there is no contraindication. Calcium + vitamin D2 are usually added to all these medicines. If DEXA-scan shows osteoporosis, medicine for this is also usually added. As many patients also have hyperlipidaemia, a statin is also usually added. Low-dose aspirin is often needed as rheumatoid arthritis causes premature atherosclerosis that may cause premature heart attack. Of course, full and proper control of any co-morbidity (e.g. diabetes, high blood pressure etc.) is done along with these medicines - under the directions of specialists in this field.If methotrexate given as injections (along with all the other drugs mentioned above) at the dose of 25 mg weekly does not lead to remission of the disease in 4-8 weeks, then the newer drugs called BIOLOGICALS are added. Two commonly used biologicals are infliximab (brand name Remicade) and etanercept (brand name Enbrel) that are added to the above medicines. There are several additional BIOLOGICALS that are now available in case Remicade or Enbrel prove ineffective in any patient. Now, going through the above details you would realise that treatment of rheumatoid arthritis is a highly specialised area that can be carried out ONLY by a highly trained and experienced RHEUMATOLOGIST and not by any orthopaedic surgeon or any other type of doctor.It is highly advisable, therefore, that you immediately contact a highly trained and experienced RHEUMATOLOGIST for the management of your mother.