Rheumatoid arthritis disease-modifying antirheumatic drugs

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 ... 

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as a disease-modifying antirheumatic drug and is used as a second-line treatment in rheumatoid arthritis, but has been superseded by methotrexate, administered v/eekly.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. 

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. 

Fishman P (2008) Clinical evidence for utilization of the A3 adenosine receptor as a target to treat rheumatoid arthritis data from a phase II clinical trial. J Rheumatol 35(1 ) 41—48 Sizova L (2008) Approaches to the treatment of early rheumatoid arthritis with disease-modifying antirheumatic drugs. Br J Clin Pharmacol 66(2) 173-178 Spargo LD, Cleland LG, Cockshell MP, Mayrhofer G (2006) Recruitment and proliferation of CD4+ T cells in synovium following adoptive transfer of adjuvant-induced arthritis. Int Immunol 18(6) 897-910... 

Methotrexate is also used in the treatment of rheumatoid arthritis (Chapter 36 Nonsteroidal Anti-Inflammatory Drugs, Disease-Modifying Antirheumatic Drugs, Nonopioid Analgesics, Drugs Used in Gout) and psoriasis. 

J.F. Fries, et al., Reduction in long-term disability in patients with rheumatoid arthritis by disease modifying antirheumatic drug based treatment strategies. Arthritis Rheum. 39 616-622, 1996. 

Rau R, Schleusser B, Herborn G, Karger T. Longterm combination therapy of refractory and destructive rheumatoid arthritis with methotrexate (MTX) and intramuscular gold or other disease modifying antirheumatic drugs compared to MTX monotherapy. J Rheumatol 1998 25(8) 1485-92. 

Singh G, Fries JF, Williams CA, Zatarain E, Spitz P, Bloch DA. Toxicity profiles of disease modifying antirheumatic drugs in rheumatoid arthritis. J Rheumatol 1991 18(2) 188-94. 

However, the rate of adverse effects associated with leflunomide was significantly lower than with methotrexate and other disease-modifying antirheumatic drugs (DMARDs) in an analysis of 40 594 patients with rheumatoid arthritis (8,51). The incidences of adverse events per 1000 patient-years were as follows ... 

In a comprehensive study of 158 Japanese patients with rheumatoid arthritis, there was an obvious relation between membranous nephropathy and exposure to disease-modifying antirheumatic drugs (DMARDs) in 40 of 49 patients (231). In this study penicillamine (15%), bucillamine (67%), and gold compounds (17%) clearly predominated. 

Capell H, McCarey D, Madhok R, Hampson R. 5D outcome in 52 patients with rheumatoid arthritis surviving 20 years after initial disease modifying antirheumatic drug therapy. J Rheumatol 2002 29(10) 2099-105. 

Aletaha D, Smolen JS. Laboratory testing in rheumatoid arthritis patients taking disease-modifying antirheumatic drugs clinical evaluation and cost analysis. Arthritis Rheum 2002 47(2) 181-8. 

De La Mata J, Blanco FJ, Gomez-Reino JJ. Survival analysis of disease modifying antirheumatic drugs in Spanish rheumatoid arthritis patients. Ann Rheum Dis 1995 54(ll) 881-5. 

Sokka T, Hannonen P. Utility of disease modifying antirheumatic drugs in sawtooth strategy. A prospective study of early rheumatoid arthritis patients up to 15 years. Ann Rheum Dis 1999 58(10) 618-22. 

SchiffMH,Whelton A. Renal toxicity associated with disease-modifying antirheumatic drugs used forthe treatment of rheumatoid arthritis. Semin Arthritis Rheum 2000 30 196-208. 

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