Intra-articular steroids in 'treat-to-target' therapy in early rheumatoid arthritis.

R e u m a t o i d a r t h r i t i s ( R A) i s a chronic inflammatory polyarticular autoimmune disease affecting 0.4-1 % of general population. I t causes cartilage destruction and bony erosions in synovial jo ints . Act ivat ion of T lymphocytes by unknown antigens, stimulates monocytes, macrophages and synovial fibroblasts to produce cytokines, interleukin 1, 6 and TNF α in the synovial fluid. This triggers the inflammatory cascade by stimulation of synovial f ibroblasts , osteoclasts and chondrocytes that release matrix metalloproteases (MMP). These MMP’s and the neutrophilic enzymes namely elastases and proteases degrade the cartilage causing joint destruction. Apart from this the activated T cells also cause an osteoprotegerin ligand mediated osteoclastogenesis and consequent bone loss.1 In ear l ier s tages of the disease , there is demonstrable presence of inflammatory markers in blood as well as the synovium. At this stage, there is joint pain and swelling, significant morning stiffness without much radiographic abnormalities that can be picked up on the X-rays. Although musculoskeletal ultrasound (MSU) and MRI of the small joints of hands can pick up early RA, its cost in the developing world prevents its routine use for the diagnosis of early RA. In the developed nations, there are early arthritis clinics run by the doctors as well as qualified trained nurses. In these clinics, there is an opportunity for early diagnosis by MSU where joint inflammation is picked up even before it cl inically manifests as synovitis. Hence there is an opportunity for early aggressive therapy. With an increased Intra-Articular Steroids in ‘Treat-to-Target’ Therapy in Early Rheumatoid Arthritis