Rheumatoid Arthritis — বাংলায় বিস্তারিত কিন্তু clinically practical

নোট: RA একটি chronic autoimmune inflammatory arthritis। নিচের drug doses adult typical regimen; renal/hepatic disease, pregnancy, infection, TB/HBV/HCV status, CBC/LFT/creatinine অনুযায়ী rheumatologist/registered physician dose adjust করবেন।

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1. Definition / সংজ্ঞা

Rheumatoid arthritis বা RA হলো একটি chronic systemic autoimmune disease, যেখানে immune system নিজের synovial joint-কে attack করে। এর ফলে persistent synovitis → pannus formation → cartilage destruction → bone erosion → joint deformity হয়। RA সাধারণত bilateral symmetrical small-joint inflammatory polyarthritis হিসেবে শুরু হয়, বিশেষ করে MCP, PIP, wrist, MTP joints। ACR/EULAR classification অনুযায়ী RA মূল্যায়নে joint involvement, RF/anti-CCP serology, ESR/CRP এবং symptom duration ব্যবহার করা হয়।

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2. Cause / Etiology & Pathophysiology — কারণগুলো

A. Autoimmune cause

• শরীরের immune system ভুল করে synovial membrane-কে foreign tissue মনে করে attack করে।
• T-cell, B-cell, macrophage activate হয়।
• Cytokines যেমন TNF-α, IL-6, IL-1 বৃদ্ধি পায়।
• Synovium thick হয়ে pannus তৈরি করে, যা cartilage ও bone destroy করে।

B. Genetic factor

• HLA-DRB1 shared epitope RA risk বাড়ায়।
• Family history থাকলে risk বেশি।
• PTPN22 সহ কিছু immune-regulatory gene RA susceptibility বাড়াতে পারে।

C. Environmental trigger

• Smoking RA-এর সবচেয়ে established modifiable risk factor।
• Silica exposure, air pollution, chronic mucosal inflammation risk বাড়াতে পারে।
• Periodontal disease বিশেষ করে Porphyromonas gingivalis citrullination process বাড়িয়ে anti-CCP positive RA-এর সাথে সম্পর্কিত।

D. Autoantibody formation

• RA-তে anti-CCP/ACPA এবং rheumatoid factor বা RF তৈরি হতে পারে।
• Anti-CCP বেশি specific এবং erosive disease-এর risk predict করতে সাহায্য করে।

E. Hormonal / sex factor

• Female-দের RA বেশি হয়।
• Pregnancy/postpartum immune shift RA activity-তে প্রভাব ফেলতে পারে।

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3. Symptoms / Clinical Features — লক্ষণগুলো

Joint symptoms

• সকালে joint stiffness: সাধারণত ৩০–৬০ মিনিটের বেশি থাকে।
• Pain + swelling + warmth: inflammatory joint pain।
• Symmetrical involvement: দুই হাত/দুই wrist/দুই পা একসাথে আক্রান্ত হওয়া common।
• Small joints affected: MCP, PIP, wrist, MTP।
• DIP joint সাধারণত spared — DIP বেশি affected হলে OA/psoriatic arthritis ভাবতে হবে।
• Grip weakness: কাপ ধরা, বোতাম লাগানো, লেখা কঠিন হতে পারে।
• Reduced range of motion: chronic synovitis থেকে stiffness ও deformity হয়।

Systemic symptoms

• Fatigue
• Low-grade fever
• Weight loss
• Malaise
• Anemia-related weakness

Late deformities

• Ulnar deviation
• Swan-neck deformity
• Boutonnière deformity
• Z-thumb deformity
• Wrist subluxation
• MTP subluxation, hammer toe

Extra-articular features

• Rheumatoid nodule
• Dry eye/dry mouth — secondary Sjögren syndrome
• Scleritis/episcleritis
• Pleural effusion/interstitial lung disease
• Pericarditis
• Carpal tunnel syndrome
• Vasculitis

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4. Clinically Diagnosis — কীভাবে clinically diagnose করবেন

A. Clinical suspicion

RA strongly suspect করবেন যদি থাকে:

• ≥1 swollen joint, alternative diagnosis দিয়ে explain করা যাচ্ছে না।
• Symmetrical small-joint polyarthritis।
• Morning stiffness >৩০–৬০ মিনিট।
• Symptoms ≥৬ সপ্তাহ।
• MCP/PIP/wrist/MTP swelling।
• RF বা anti-CCP positive।
• ESR/CRP raised।

B. 2010 ACR/EULAR Classification Criteria

Prerequisite: অন্তত ১টি swollen joint থাকতে হবে এবং synovitis-এর better alternative diagnosis না থাকতে হবে। Score ≥6/10 হলে RA classification strongly supported।

Component	Score
1 large joint	0
2–10 large joints	1
1–3 small joints	2
4–10 small joints	3
>10 joints, at least 1 small joint	5
RF negative + anti-CCP negative	0
Low-positive RF or anti-CCP	2
High-positive RF or anti-CCP	3
Normal ESR + normal CRP	0
Abnormal ESR or CRP	1
Symptoms <6 weeks	0
Symptoms ≥6 weeks	1

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5. Investigations — specific list

A. Diagnostic investigations

• CBC: anemia of chronic disease, thrombocytosis, leukopenia।
• ESR, CRP: disease activity/inflammation marker।
• RF: supportive, but not fully specific।
• Anti-CCP/ACPA: highly specific; erosive disease risk বেশি।
• LFT, serum creatinine/eGFR: DMARD শুরু করার আগে baseline।
• Urine R/M/E: renal involvement/differential।
• X-ray both hands/wrists/feet: periarticular osteopenia, marginal erosion, joint-space narrowing।
• MSK ultrasound with Doppler: early synovitis/tenosynovitis detect করতে helpful।
• MRI: early erosions/synovitis when diagnosis uncertain।

B. Before DMARD / biologic / JAK inhibitor

• CBC with differential
• ALT/AST, bilirubin, albumin
• Creatinine/eGFR
• Hepatitis B surface antigen, anti-HBc, anti-HCV
• TB screening: CXR ± IGRA/Mantoux
• HIV if clinically indicated
• Pregnancy test where relevant
• Vaccination review: influenza, pneumococcal, hepatitis B, COVID, varicella/zoster where appropriate
• Baseline lipid profile especially before JAK inhibitors/tocilizumab
• Baseline eye exam for hydroxychloroquine; then periodic ophthalmologic monitoring। Hydroxychloroquine MedEx monograph also mentions ophthalmologic examination requirement.

C. Disease activity monitoring

• DAS28-ESR/CRP, CDAI, SDAI
• Tender joint count, swollen joint count
• Patient global assessment
• Functional assessment: HAQ
• EULAR 2025 update recommends active disease monitoring every 1–3 months and treatment adjustment if no improvement by 3 months or target not reached by 6 months.

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6. Differential Diagnosis

• Osteoarthritis
• Psoriatic arthritis
• SLE arthritis
• Viral arthritis — chikungunya, parvovirus B19, hepatitis B/C
• Gout / pseudogout
• Reactive arthritis
• Ankylosing spondylitis / peripheral spondyloarthritis
• Polymyalgia rheumatica
• Septic arthritis
• Tuberculous arthritis
• Sarcoidosis
• Hypothyroid arthropathy

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7. Complications — রোগের জটিলতা বাংলায়

Joint complications

• Permanent joint damage: untreated RA cartilage ও bone erosion করে।
• Deformity: ulnar deviation, swan neck, boutonnière deformity।
• Tendon rupture: chronic tenosynovitis থেকে tendon দুর্বল হয়ে ছিঁড়ে যেতে পারে।
• Carpal tunnel syndrome: wrist synovitis median nerve compress করে।
• Cervical spine involvement: atlanto-axial subluxation হতে পারে; neck pain, myelopathy risk।

Systemic complications

• RA lung disease: interstitial lung disease, pleural effusion, pulmonary nodule।
• Cardiovascular disease: chronic inflammation MI/stroke risk বাড়ায়।
• Anemia: chronic inflammation বা drug toxicity থেকে।
• Osteoporosis: inflammation + steroid use।
• Eye: scleritis/episcleritis, dry eye।
• Felty syndrome: RA + splenomegaly + neutropenia।
• Vasculitis: severe longstanding seropositive RA-তে skin ulcer, neuropathy।
• Secondary amyloidosis: long uncontrolled inflammation।
• Disability/depression: pain, deformity, work loss।

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8. Treatment Management — Guideline-based framework

EULAR 2025 update অনুযায়ী RA diagnosis হলেই DMARD শুরু করা উচিত; treatment target হবে sustained remission বা low disease activity; methotrexate first strategy, intolerance/contraindication থাকলে leflunomide বা sulfasalazine; short-term glucocorticoid bridging ব্যবহার করা যায় কিন্তু দ্রুত taper/discontinue করতে হবে; csDMARD failure হলে bDMARD add, JAK inhibitor risk assessment করে consider করা যায়। ACR guideline page-এ 2021 RA treatment guideline এখনো listed আছে।

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9. Bangladesh doctors commonly use — prescription drug list with purpose

1) Pain & inflammation control — symptom relief, disease progression stop করে না

• Paracetamol — pain relief।
• NSAID: Naproxen, Diclofenac, Etoricoxib, Celecoxib — pain, swelling, stiffness কমাতে।
• PPI cover: Omeprazole/Esomeprazole/Pantoprazole — NSAID-induced gastritis/ulcer risk কমাতে।

2) Short-term bridging steroid

• Prednisolone low dose — DMARD onset হতে ৬–১২ সপ্তাহ লাগে, এই সময় inflammation control।
• Intra-articular steroid — ১–২ joint flare হলে local control।

3) csDMARD — disease-modifying core treatment

• Methotrexate + folic acid — first-line anchor drug।
• Hydroxychloroquine — mild RA/combination therapy।
• Sulfasalazine — MTX intolerance বা triple therapy।
• Leflunomide — MTX intolerance/contraindication বা inadequate response।

4) Combination csDMARD

• Methotrexate + Hydroxychloroquine + Sulfasalazine — “triple therapy”, moderate disease বা biologic access limited হলে।

5) Biologic / targeted synthetic DMARD

• Adalimumab / Etanercept — TNF-α inhibitor।
• Tocilizumab — IL-6 receptor antagonist।
• Rituximab — anti-CD20, especially seropositive RA, some refractory cases।
• Tofacitinib / Baricitinib / Upadacitinib — JAK inhibitor; infection, thrombosis, MACE, malignancy risk assess করে।

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10. Pharmacological drugs — generic, class, dose, duration, side effects, interactions, Bangladesh brands

A. Methotrexate — first-line anchor csDMARD

• Generic name: Methotrexate
• Therapeutic category: DMARD; drugs used for rheumatoid arthritis
• Pharmacological class: Antimetabolite; folate antagonist; immunomodulatory csDMARD
• Why used: RA disease activity, synovitis, erosion progression কমাতে first-line anchor drug।
• Adult dose: commonly 7.5–15 mg once weekly, titrate 20–25 mg/week as tolerated; MedEx lists adult RA dose 7.5 mg once weekly, max 20 mg/week.
• Duration: long-term; response usually 6–12 weeks; remission/low disease activity হলে maintain, abrupt stop নয়।
• Must add: Folic acid 5 mg once weekly 24–48 h after MTX অথবা 1 mg daily except MTX day.
• Side effects: nausea, stomatitis/oral ulcer, leukopenia, hepatotoxicity, pneumonitis, infection risk, alopecia, teratogenicity। MedEx lists stomatitis, leukopenia, nausea, abdominal distress, fatigue, fever, infection tendency.
• Interactions: alcohol/hepatotoxic drugs ↑ liver toxicity; TMP-SMX ↑ marrow suppression; NSAID with high-dose MTX ↑ toxicity; phenytoin/sulfonamide/probenecid interactions; folic acid preparations may reduce response if incorrectly timed. MedEx lists these interactions.
• Avoid/contraindicated: pregnancy, breastfeeding, severe liver disease, significant cytopenia, severe renal impairment, active serious infection.

Bangladesh available brand names — MedEx listed: Meth 2.5/10 mg, Methotrax 2.5/10/15 mg, Methox 2.5/10 mg, Metorax 10 mg & 50 mg/2 ml, Mtrex 2.5/10 mg & 50 mg/2 ml, MTX 2.5 mg & 50 mg/2 ml, Trexall 2.5/10 mg & 50 mg/2 ml, Trexonate 2.5/10 mg & 50 mg/2 ml.

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B. Hydroxychloroquine

• Generic name: Hydroxychloroquine sulphate
• Therapeutic category: DMARD; anti-malarial; drugs used for RA
• Pharmacological class: 4-aminoquinoline immunomodulator
• Why used: mild RA, palindromic rheumatism-like symptoms, combination DMARD/triple therapy; less erosive prevention than MTX but safer profile।
• Adult dose: 200–400 mg/day usual; MedEx RA dose 400–600 mg daily initially, response হলে 50% reduce.
• Duration: long-term; onset 8–12 weeks; eye monitoring needed।
• Side effects: nausea, vomiting, abdominal upset, diarrhea, headache, rash, hyperpigmentation, QT prolongation rare, retinopathy। MedEx mentions GI upset, weakness/headache and visual problem.
• Interactions: QT-prolonging drugs caution; digoxin level may increase; antacids reduce absorption; avoid overdose.
• Monitoring: baseline eye exam, then periodic screening; dose generally ≤5 mg/kg/day actual body weight.

Bangladesh available brand names — MedEx listed: Avloquin-H 200 mg, Bioquin 200 mg, Corofree 200 mg, Coroquin 200 mg, Covikil 200 mg, H-Quin 200 mg, HCQ 200 mg, Hydroquin 200 mg, Kovicin 200 mg, Oxiquin 200/400 mg, Quinivir 200 mg, Reconil 200 mg, Reumaflex 200 mg, Roquin 200 mg, Roxiquin 200 mg.

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C. Sulfasalazine

• Generic name: Sulfasalazine
• Therapeutic category: Drugs used for RA; ulcerative colitis drug
• Pharmacological class: Aminosalicylate/sulfonamide; csDMARD
• Why used: MTX intolerance, pregnancy-compatible option in selected cases, triple therapy component।
• Adult dose: start 500 mg daily → gradually titrate; usual RA dose 1 g BD = 2 g/day. MedEx lists adult RA 2 g/day in two divided doses with gradual weekly escalation.
• Duration: long-term; response 6–12 weeks।
• Side effects: nausea, dyspepsia, headache, rash, reversible oligospermia, leukopenia, hepatotoxicity, hemolysis in G6PD deficiency। MedEx lists anorexia, headache, nausea, vomiting, gastric distress, dyspepsia, abdominal pain, dizziness, reversible oligospermia.
• Interactions: reduces folic acid and digoxin absorption; caution with warfarin, sulfonamide allergy, G6PD deficiency। MedEx notes reduced folic acid and digoxin absorption.

Bangladesh available brand names — MedEx listed: Reumazin 500 mg, Salazine 500 mg tablet/suppository, Sulfaben 500 mg, Sulfacol 500 mg, Sulfazin 500 mg, Zulfidin 500 mg.

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D. Leflunomide

• Generic name: Leflunomide
• Therapeutic category: Drugs used for RA
• Pharmacological class: Pyrimidine synthesis inhibitor; csDMARD
• Why used: MTX intolerance/contraindication বা inadequate response; erosive RA-তে disease modification।
• Adult dose: 20 mg once daily; tolerability issue হলে 10 mg daily. MedEx lists loading 100 mg daily ×3 days then 20 mg daily, but many clinicians avoid loading due to GI/LFT toxicity.
• Duration: long-term; response 4–12 weeks।
• Side effects: diarrhea, nausea, hypertension, alopecia, rash, hepatotoxicity, cytopenia, teratogenicity। MedEx lists diarrhea, nausea, vomiting, abdominal pain, headache, respiratory infection/bronchitis, elevated liver enzymes, hypertension aggravation, alopecia, rash.
• Interactions: MTX/other hepatotoxic drugs ↑ hepatotoxicity; rifampicin ↑ active metabolite; cholestyramine/activated charcoal reduce level.
• Pregnancy: contraindicated; washout with cholestyramine needed before conception.

Bangladesh available brand names — MedEx listed: Nodia 10 mg tablet.

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E. Folic acid — MTX toxicity reduction

• Generic name: Folic acid
• Therapeutic category: Vitamin; hematinic
• Pharmacological class: Water-soluble vitamin B9
• Why used: Methotrexate-induced stomatitis, GI upset, liver enzyme rise, cytopenia risk কমাতে।
• Dose: 5 mg once weekly 24–48 h after MTX, or 1 mg daily except MTX day।
• Side effects: usually minimal; nausea/bloating rare।
• Interaction: same day high-dose folic acid may reduce MTX efficacy in some regimens; timing ঠিক রাখতে হয়।

Bangladesh available brand examples — MedEx listed: Folac 5 mg, Folate 5 mg, Folcid 5 mg, Folic Acid 5 mg, Folic-Son 5 mg, Folison 5 mg, Folus 5 mg; oral solution B-9 2.5 mg/5 ml, Foli Kidz 2.5 mg/5 ml, Folic OS 2.5 mg/5 ml.

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F. Prednisolone — bridging steroid

• Generic name: Prednisolone
• Therapeutic category: Glucocorticoid
• Pharmacological class: Systemic corticosteroid
• Why used: acute flare/bridging therapy; DMARD কাজ শুরু করা পর্যন্ত inflammation control।
• Dose: 5–10 mg daily short-term; severe flare-এ clinician may use 15–20 mg then taper. Morning after breakfast.
• Duration: shortest possible; ideally taper within weeks to ≤3 months where feasible; EULAR recommends short-term glucocorticoids when initiating/changing csDMARDs but taper/discontinue rapidly.
• Side effects: hyperglycemia, hypertension, gastritis, mood change, insomnia, weight gain, infection risk, osteoporosis, cataract, adrenal suppression।
• Interactions: NSAID ↑ GI bleed; warfarin effect variable; diabetes drugs need adjustment; live vaccine caution।

Bangladesh available brand examples — MedEx listed: Solone 5/10/20 mg, Pred 5/10/20 mg, Predimax 5/10/20 mg, Pednisol 5/10/20 mg, Precodil 2/5/10/20 mg and oral solution, Rayox 20 mg, Rednisone 5 mg, Peron 5/10/20 mg, Pednil 5/10 mg and oral solution.

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G. NSAIDs — symptomatic relief only

Naproxen / Naproxen sodium

• Generic name: Naproxen / Naproxen sodium
• Therapeutic category: Drugs used for RA; NSAID
• Pharmacological class: Non-selective COX inhibitor
• Why used: joint pain, morning stiffness, swelling symptom relief; disease progression stop করে না।
• Dose: Naproxen 250–500 mg BD after meal; Naproxen sodium 500–1000 mg/day divided 12-hourly; MedEx lists adult RA/OA/AS 500–1000 mg/day divided.
• Side effects: dyspepsia, ulcer/GI bleed, renal impairment, fluid retention, BP rise, CV risk।
• Interactions: anticoagulant/antiplatelet ↑ bleed; ACEi/ARB/diuretic ↑ AKI risk; steroid ↑ GI bleed; MTX toxicity caution।

Bangladesh brand examples: Naproxen 500 mg, Naproxen Plus 500 mg + esomeprazole 20 mg; MedEx lists naproxen for RA symptom relief.

Etoricoxib

• Generic name: Etoricoxib
• Therapeutic category: NSAID; drugs for OA/RA/AS pain
• Pharmacological class: Selective COX-2 inhibitor
• Why used: RA pain/stiffness with lower GI toxicity than nonselective NSAID, but CV risk consider।
• Dose: 60–90 mg once daily; MedEx RA dose 90 mg once daily.
• Side effects: hypertension, edema, dyspepsia, renal impairment, CV thrombotic risk।
• Interactions: warfarin, ACEi/ARB/diuretic, lithium, methotrexate caution।

Bangladesh brand examples: Etorix 90 mg, Rito 90/120 mg, Torcox 90/120 mg, E-coxib 120 mg, CoxTop 60/90 mg, Etoshine 60/90 mg.

Diclofenac

• Generic name: Diclofenac sodium/potassium
• Therapeutic category: NSAID
• Pharmacological class: Nonselective COX inhibitor, relatively COX-2 preference
• Why used: short-term pain/inflammation relief।
• Dose: 50 mg BD/TDS or SR 100 mg daily; use lowest effective dose shortest duration।
• Side effects/interactions: GI bleed, renal injury, hepatic enzyme rise, CV risk; avoid with anticoagulants/steroid where possible।
• Bangladesh brand examples: Diclofen 50 mg, A-Fenac 50 mg, Penac 50 mg, Proflam 50 mg, plus SR/TR/gel/injection forms listed in MedEx.

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H. Adalimumab — biologic DMARD

• Generic name: Adalimumab
• Therapeutic category: Biologic DMARD; immunosuppressant
• Pharmacological class: TNF-α inhibitor, monoclonal antibody
• Why used: moderate–severe RA with inadequate response to csDMARD/MTX।
• Dose: 40 mg SC every other week; without MTX, some patients may need weekly. MedEx lists 40 mg every other week for RA.
• Duration: long-term if effective; assess response at 3–6 months।
• Side effects: injection-site reaction, serious infection, TB/HBV reactivation, rash, pneumonia; MedEx lists injection-site reactions and pneumonia/rash among discontinuation causes.
• Interactions: avoid live vaccines; avoid combination with abatacept/anakinra due to serious infection risk. MedEx lists abatacept/anakinra/live vaccine interactions.

Bangladesh available brand names — MedEx listed: Adali 40 mg/0.8 ml, Adalimab 40 mg/0.8 ml, Adimab 40 mg/0.8 ml, Advixa 40 mg/0.8 ml, Hyrimoz 40 mg/0.8 ml, Yuflyma 40 mg/0.4 ml.

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I. Etanercept — biologic DMARD

• Generic name: Etanercept
• Therapeutic category: Immunosuppressant; biologic DMARD
• Pharmacological class: TNF receptor fusion protein; TNF blocker
• Why used: moderate–severe RA after inadequate DMARD response; with MTX or monotherapy।
• Dose: 50 mg SC weekly or 25 mg SC twice weekly; MedEx lists exactly this adult RA dosing.
• Side effects: infection, injection-site reaction, serious infection, thrombocytopenia, skin cancer rare, ILD worsening rare; MedEx lists infections and injection-site reactions as very common.
• Interactions/cautions: active infection, TB, HBV/HCV, CHF, malignancy, live vaccines.

Bangladesh available brand names — MedEx listed: Enbrel 50 mg/ml, Etacept 25 mg/0.5 ml, Etacept 50 mg/ml.

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J. Tocilizumab — biologic DMARD

• Generic name: Tocilizumab
• Therapeutic category: Biologic DMARD; immunosuppressant
• Pharmacological class: IL-6 receptor antagonist monoclonal antibody
• Why used: moderate–severe RA after inadequate response to one or more DMARDs; especially high inflammatory markers, systemic features; can be monotherapy if MTX intolerant। MedEx lists RA indication after inadequate DMARD response.
• Dose: IV 4 mg/kg every 4 weeks, increase to 8 mg/kg based on response; MedEx lists this IV regimen. SC usual 162 mg weekly/alternate weekly depending context.
• Side effects: infection, neutropenia, thrombocytopenia, elevated ALT/AST, lipid rise, GI perforation risk।
• Interactions: CYP450 substrates may need review as inflammation suppression alters metabolism; avoid live vaccines; caution with diverticulitis/GI perforation risk।

Bangladesh available brand names — MedEx listed: Actemra 80 mg/4 ml IV, Actemra 200 mg/10 ml IV, Actemra 162 mg/0.9 ml SC, Tocimab 200 mg/10 ml IV, Tolosa 80 mg/4 ml IV.

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K. Rituximab — biologic DMARD

• Generic name: Rituximab
• Therapeutic category: Biologic DMARD; immunosuppressant
• Pharmacological class: Anti-CD20 monoclonal antibody; B-cell depleting agent
• Why used: refractory RA, especially RF/anti-CCP positive RA; often after TNF inhibitor failure or where preferred due to comorbidity।
• Dose: 1000 mg IV ×2 doses separated by 2 weeks; repeat usually every 24 weeks based on response, not sooner than 16 weeks. MedEx lists this RA dose and MTX combination.
• Premedication: methylprednisolone 100 mg IV 30 min before infusion ± antihistamine/paracetamol।
• Side effects: infusion reaction, HBV reactivation, serious infection, hypogammaglobulinemia, cytopenia, rare PML। MedEx lists HBV reactivation, fever/rigors, bronchospasm, hypotension, cytopenias, interstitial pneumonia/fibrosis.
• Interactions/cautions: live vaccines avoid; screen HBV; caution recurrent infection/low IgG।

Bangladesh available brand names — MedEx listed: Mabrix 10 mg/ml 100/500 mg vial, Mabthera 10 mg/ml 100/500 mg vial, Recelbia 10 mg/ml 100/500 mg vial, Relyto 10 mg/ml 100/500 mg vial, Ritumab 10 mg/ml 100/500 mg vial, Rituris 10 mg/ml 100/500 mg vial, Rituxim 10 mg/ml 100/500 mg vial, Truxima 10 mg/ml 100/500 mg vial.

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L. Tofacitinib — targeted synthetic DMARD

• Generic name: Tofacitinib
• Therapeutic category: Immunosuppressant; tsDMARD
• Pharmacological class: JAK inhibitor
• Why used: moderate–severe RA with MTX inadequate response/intolerance; MedEx lists RA indication after inadequate response/intolerance to MTX.
• Dose: 5 mg BD or XR 11 mg once daily; renal/hepatic impairmentে 5 mg daily may be needed. MedEx lists same.
• Duration: long-term if effective; assess 3 months improvement/6 months target।
• Side effects: URTI, herpes zoster, serious infection, TB, lipid rise, cytopenia, liver enzyme rise, thrombosis/MACE/malignancy warning।
• Interactions: strong CYP3A4 inhibitors ↑ level; rifampicin ↓ level; avoid biologic DMARD/other JAK inhibitor/live vaccine।

Bangladesh available brand names — MedEx listed: Arthanib 5 mg, Arthanib XR 11 mg, Jakloc 5 mg, Jakloc XR 11 mg, Jaknib 5 mg, Jakrif 5 mg, Jaktor 5 mg, Jaktor XR 11 mg, Tocit 5 mg, Tocit XR 11 mg, Tofacent 5/10 mg and oral solution 1 mg/ml, Tofacent XR 11 mg, Tofacinix XR 11 mg, Tofacit 5 mg, Tofacit XR 11 mg, Tofanib 5 mg, Tofanib XR 11 mg, Tofara 5 mg, Tofatin 5 mg, Tofatin XR 11 mg, Tofator 5 mg, Tofaxen 5 mg, Tojak 5 mg, Xelnib 5 mg and oral solution 1 mg/ml, Xelnib XR 11 mg.

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M. Baricitinib — targeted synthetic DMARD

• Generic name: Baricitinib
• Therapeutic category: Immunosuppressant; tsDMARD
• Pharmacological class: JAK1/JAK2 inhibitor
• Why used: moderate–severe RA after TNF antagonist inadequate response; MedEx lists this indication.
• Dose: 2 mg once daily; MedEx lists 2 mg once daily and combination with MTX/other DMARDs.
• Side effects: LDL rise, URTI, nausea; serious infection, TB, thrombosis, GI perforation risk.
• Interactions: probenecid/strong OAT3 inhibitors ↑ exposure; avoid other JAK inhibitors/biologic DMARDs.

Bangladesh available brand names — MedEx listed: Baricent 2/4 mg, Baricit 2/4 mg, Barinez 2 mg, Barinib 2/4 mg, Barinix 2 mg, Baritab 2 mg, Baritinib 2 mg, Baritor 2 mg, Barixen 2 mg, Barri 2/4 mg.

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N. Upadacitinib — targeted synthetic DMARD

• Generic name: Upadacitinib
• Therapeutic category: Drugs used for RA; tsDMARD
• Pharmacological class: Selective JAK inhibitor
• Why used: moderate–severe RA after inadequate response/intolerance to TNF blocker; MedEx lists this indication.
• Dose: 15 mg once daily; MedEx lists RA 15 mg once daily.
• Side effects: URTI, nausea, cough, fever; serious infection, malignancy, thrombosis, GI perforation, lab abnormalities.
• Interactions: strong CYP3A4 inhibitors e.g., ketoconazole ↑ exposure; rifampicin/strong CYP3A4 inducer ↓ effect; avoid live vaccines.

Bangladesh available brand names — MedEx listed: Coltinib 15 mg, Rematib 15 mg, Reucent XR 15 mg, Rinva 15 mg, Upacit XR 15 mg, Upanib 15/30 mg, Uparen 15 mg.

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11. Non-pharmacological Management

• Patient education: RA chronic disease; early DMARD disease outcome improve করে।
• Smoking cessation: mandatory advice।
• Physiotherapy: ROM exercise, strengthening, posture, hand function।
• Occupational therapy: splint, joint protection, adaptive devices।
• Exercise: low-impact aerobic + resistance exercise।
• Weight control: obesity disease activity and treatment response খারাপ করতে পারে।
• Diet: Mediterranean-style diet, adequate protein, omega-3-rich fish; fad diet avoid।
• Vaccination: biologic/JAK/MTX before non-live vaccines update; live vaccine immunosuppression চলাকালে avoid।
• Bone protection: steroid use হলে calcium/vitamin D, DEXA, bisphosphonate if indicated।
• Comorbidity control: HTN, diabetes, dyslipidemia, CVD risk, depression।

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12. Prevention — কীভাবে প্রতিরোধ/ক্ষতি কমাবেন

RA সম্পূর্ণভাবে prevent করার proven method নেই, কিন্তু risk ও complications কমানো যায়:

• Smoking পুরোপুরি বন্ধ।
• Gum disease/periodontitis treat করা।
• Obesity control।
• Occupational silica exposure কমানো।
• Early symptoms হলে দ্রুত rheumatology referral।
• Diagnosis হলে ৩ মাসের মধ্যে DMARD শুরু করা।
• Treat-to-target follow: remission/low disease activity।
• Regular monitoring: CBC, LFT, creatinine, ESR/CRP, DAS28/CDAI।
• Eye check with hydroxychloroquine।
• TB/HBV/HCV screening before biologic/JAK।
• Vaccination update before immunosuppression।
• Pregnancy planning: MTX/leflunomide stop and proper washout; safe alternatives plan।

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1. Overview / Summary

• RA হলো chronic autoimmune inflammatory arthritis, mainly symmetrical small joints affected।
• Cause: genetic susceptibility + environmental triggers + autoantibody-mediated synovitis।
• Diagnosis mainly clinical; RF/anti-CCP, ESR/CRP, X-ray/US support করে।
• ACR/EULAR score ≥6/10 classification strongly supports RA।
• Main treatment: early DMARD, especially methotrexate; steroid/NSAID শুধু symptomatic/bridging।
• Uncontrolled RA joint deformity, lung disease, CVD, anemia, osteoporosis, disability করতে পারে।
• Bangladesh practice-এ MTX + folic acid, HCQ, sulfasalazine, leflunomide, steroid/NSAID, and refractory disease-এ biologic/JAK inhibitors commonly used.

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2. Actionable Plan / Steps

1. Confirm inflammatory arthritis: ≥1 swollen joint, symmetrical MCP/PIP/wrist/MTP, morning stiffness, duration ≥6 weeks।
2. Order baseline tests: CBC, ESR, CRP, RF, anti-CCP, ALT/AST, creatinine/eGFR, urine R/M/E, X-ray hands/feet।
3. Apply ACR/EULAR criteria: score ≥6/10 হলে RA classification supported।
4. Start csDMARD early: MTX weekly + folic acid unless contraindicated।
5. Bridge symptoms: short-course low-dose prednisolone ± NSAID/PPI only when indicated।
6. Monitor 1–3 monthly: joint count, ESR/CRP, DAS28/CDAI, CBC/LFT/creatinine।
7. Escalate if needed: 3 months no improvement or 6 months target not achieved → combination csDMARD or bDMARD/JAK after screening।
8. Prevent toxicity: pregnancy avoidance with MTX/leflunomide/JAK; TB/HBV/HCV screening before biologic/JAK; eye exam for HCQ।
9. Long-term prevention: smoking cessation, exercise, vaccination, CVD/bone health management।

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3. Reference List — Textbook + Guideline + DOI

Textbooks

1. Harrison’s Principles of Internal Medicine, 21st ed. Chapter: Rheumatoid Arthritis. McGraw Hill.
2. Davidson’s Principles and Practice of Medicine, 24th ed. Chapter: Rheumatology and Bone Disease—Rheumatoid Arthritis. Elsevier.
3. Kelley and Firestein’s Textbook of Rheumatology, 11th ed. Chapters: Pathogenesis and Treatment of Rheumatoid Arthritis. Elsevier.
4. Robbins & Cotran Pathologic Basis of Disease, 10th ed. Chapter: Diseases of the Immune System / Joints—Rheumatoid Arthritis. Elsevier.
5. Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 14th ed. Chapters: Immunomodulators, DMARDs, NSAIDs, glucocorticoids. McGraw Hill.
6. Katzung BG. Basic & Clinical Pharmacology, 16th ed. Chapters: NSAIDs, DMARDs, glucocorticoids, immunopharmacology. McGraw Hill.

Guidelines / Classification

1. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biologic DMARDs: 2025 update, Annals of the Rheumatic Diseases, published online 12 March 2026. DOI: 10.1016/j.ard.2026.01.023.
2. EULAR recommendations for RA management with synthetic and biological DMARDs: 2022 update. DOI: 10.1136/ard-2022-223356.
3. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care & Research. DOI: 10.1002/acr.24596.
4. Aletaha D, Neogi T, Silman AJ, et al. 2010 Rheumatoid Arthritis Classification Criteria: An ACR/EULAR Collaborative Initiative. Arthritis & Rheumatism. DOI: 10.1002/art.27584.
5. Funovits J, Aletaha D, Bykerk V, et al. 2010 ACR/EULAR Classification Criteria for RA: Methodological Report Phase I. Ann Rheum Dis. DOI: 10.1136/ard.2010.130310.

Drug/Brand source

• MedEx Bangladesh medicine index pages for methotrexate, hydroxychloroquine, sulfasalazine, leflunomide, prednisolone, tofacitinib, baricitinib, upadacitinib, adalimumab, etanercept, tocilizumab, rituximab brand availability and monograph details.

Md.Rafiqul Islam Lipu,Date:-17-06-2026 Wednesday,Time:-09-49-12 Pm