Modifying Antirheumatic Drugs

Disease-modifying agents currently used in treating rheumatoid arthritis are listed in Table 16-3. As the name implies, DMARDs attempt to induce remission by modifying the pathologic process inherent to rheumatoid arthritis. In general, DMARDs inhibit certain aspects of the immune response thought to 

Originally used in the treatment of malaria, the drugs chloroquine (Aralen) and hydroxychloroquine (Pla-quenil) have also been used to treat rheumatoid arthritis. In the past, these drugs have been used reluctantly because of the fear of retinal toxicity (see Adverse Side Effects ).25 There is now evidence, however, that these agents can be used safely, but they are only marginally effective when compared to other DMARDs. These drugs are therefore not usually the first choice, but they can be used in patients who cannot tolerate other DMARDs, or in combination with another DMARD (e.g., methotrexate) for more comprehensive treatment. 

Drug Anakinra Trade Name Kineret Usual Dosage Subcutaneous injection 100 mg/d. Special Considerations Can be used alone or with other antiarthritic agents, but should not be used with tumor necrosis factor inhibitors. 

Chloroquine Aralen Oral Up to 4 mg/kg of lean body weight per day. Periodic ophthalmic exams recommended to check for retinal toxicity. 

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DL-CFU Dendritic cell/Langerhans cell colony forming DLE Discoid lupus erythematosus DMARD Disease-modifying antirheumatic drug... 

It is imperative that the initiation of one or more disease-modifying antirheumatic drugs occurs in all patients within the first 3 months of diagnosis to reduce joint erosion. 

Methotrexate is the disease-modifying antirheumatic drug of choice because of its documented efficacy and safety profile when monitored appropriately. 

FIGURE 54-2. Outl ine of the management of rheumatoid arthritis. (From Guidelines for the management of rheumatoid arthritis 2002 update. Arthritis Rheum 2002 46(2) 328-346, with permission.) DMARD, disease-modifying antirheumatic drug NSAID, nonsteroidal antiinflammatory drug ... 

DMARD disease-modifying antirheumatic drug ESR erythrocyte sedimentation rate... 

Cush JJ. Safety overview of new disease-modifying antirheumatic drugs. Rheum Dis Clin North Am 2004 30 237-255. 

A disease-modifying antirheumatic drug (DMARD) should be started within the first 3 months of symptom onset (Fig. 4-1). DMARDs should be used in all patients except those with limited disease. Early use of DMARDs results in a more favorable outcome and can reduce mortality. 

Methotrexate is one of the disease-modifying antirheumatic drugs, which are administered once a week. The initial dose is 7.5 mg administered once a week and the maximum dose is 15-20 mg administered once a week. 

The first-line agents in the treatment of rheumatoid arthritis are non-steroidal anti-inflammatory drugs such as diclofenac. Diclofenac and indometacin, another NSAID, tend to have similar activity hov/ever, indometacin has a higher incidence of side-effects and therefore diclofenac is more appropriate for initial treatment. Sodium aurothiomalate is classified as a disease-modifying antirheumatic drug and is used as a second-line treatment in rheumatoid arthritis, but has been superseded by methotrexate, administered v/eekly. Paracetamol is often indicated in the management of osteoarthritis. Local intra-articular injections of dexamethasone may be administered for the relief of soft-tissue inflammatory conditions. 

Polyarticular-course juvenile rheumatoid arthritis (JRA) For reducing signs and symptoms of moderately to severely active polyarticular-course JRA in patients who have had an inadequate response to at least 1 disease-modifying antirheumatic drug (DMARD). 

B. Indications and use Kineret is indicated for the reduction in signs and symptoms of moderately to severely active rheumatoid arthritis in patients 18 years of age or older who have failed one or more disease-modifying antirheumatic drugs (DMARDs). Kineret can be used alone or in combination with DMARDs other than tumor necrosis factor (TNF) blocking agents. 

Chapter 36 Nonsteroidal Anti-Inflammatory Drugs, Disease-Modifying Antirheumatic Drugs, Nonopioid Analgesics, Drugs Used in Gout... 

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS, DISEASE-MODIFYING ANTIRHEUMATIC DRUGS, NONOPIOID ANALGESICS, DRUGS USED IN GOUT INTRODUCTION THE IMMUNE RESPONSE... 

Another important group of agents is characterized as disease-modifying antirheumatic drugs (DMARDs). They decrease inflammation, usually improve symptoms, and slow the bone damage associated with rheumatoid arthritis. They are thought to affect more basic inflammatory mechanisms than do glucocorticoids or the NSAIDs. They may also be more toxic than those alternative medications. 

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