Disease-modifying antirheumatic drugs are used to modify or alter the
rheumatoid arthritis disease process.
Disease-modifying antirheumatic drugs do not demonstrate the characteristic
analgesic,
antipyretic, and anti-inflammatory actions of the nonsteroidal anti-inflammatory drugs, since weeks or months of treatment are required before clinical benefit is observed. Although they have not been proved to delay, prevent, or reverse articular damage,
therapy with
disease-modifying antirheumatic drugs, when successful, is associated with decreased
pain and joint swelling and improved function.
Disease-modifying antirheumatic drugs and
cytotoxic agents should not be considered as routine treatment for patients with
rheumatoid arthritis. Before
disease-modifying antirheumatic drug therapy is implemented, an optimal basic program of
physical therapy, rest, and nonsteroidal anti-inflammatory drugs should be implemented, and it must be documented that the patient still has sufficient disease to justify the costs, risks, and benefits of these treatments. Drugs that are approved by the Food and Drug Administration (FDA) are preferred over nonapproved drugs.
Hydroxychloroquine, parenteral
gold salts, oral
gold,
D-penicillamine, and the cytotoxic
drug azathioprine are the FDA-approved
disease-modifying antirheumatic drugs for use in
rheumatoid arthritis. Many, not all, rheumatologists would employ
hydroxychloroquine as the first-choice
disease-modifying antirheumatic drug in patients who have early, mild, and nonerosive disease; treatment should be continued for six months before being abandoned for lack of efficacy, and appropriate ophthalmologic examination every four to six months is indicated. An alternative would be
auranofin, whose efficacy approaches that of parenteral
gold, yet may be safer. For patients who have severe active
rheumatoid arthritis, especially with erosive changes, parenteral
gold salts are usually a first choice.
D-penicillamine is also effective in controlling the signs and symptoms of
rheumatoid arthritis, but serious toxicity may occur.
Azathioprine might be considered a competitor to
D-penicillamine, although the FDA approval restricts its use to patients who have failed
gold therapy. Two cytotoxic drugs that are not FDA approved are
methotrexate and
cyclophosphamide.
Methotrexate can be very effective, but its side effects, particularly pulmonary and hepatic, must be carefully monitored.
Cyclophosphamide is generally considered too toxic for use in patients with
rheumatoid arthritis, although it may be helpful in patients with systemic
rheumatoid vasculitis or patients who have failed all other
therapies.(ABSTRACT TRUNCATED AT 400 WORDS)