Treatment of rheumatoid arthritis: unknown long-term effects

(1) Rheumatoid arthritis, a chronic disease, is defined by a set of clinical, radiological and biochemical criteria. The diagnosis is initially uncertain. (2) Many patients have functional disability 10 years after onset, while others may have little or none. (3) The symptomatic and long-term efficacy of physical (nondrug, nonsurgical) therapies is poorly documented. (4) Various surgical approaches may restore a degree of functional capacity. (5) The use of paracetamol, possibly combined with codeine, can avoid recourse to nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs are the best-assessed analgesics in this setting but carry a risk of severe adverse effects. (6) All long term treatments for rheumatoid arthritis carry a risk of severe adverse effects, and their chronic effects are poorly documented. There is no firm evidence that long term treatments reduce the risk of serious disability or death. (7) Methotrexate is the best-tolerated slow-acting antirheumatic in the medium term, despite a risk of hepatic cirrhosis, pulmonary fibrosis and haematological disorders. (8) Hydroxychloroquine and sulfasalazine are less effective. Hydroxychloroquine carries a risk of retinal damage, while sulfasalazine can cause haematological disorders and skin problems. Chloroquine seems to be slightly more effective than hydroxychloroquine, but at the cost of more adverse effects. (9) The adverse effects of D-penicillamine and injectable gold salts often require treatment withdrawal. (10) The risks associated with immunosuppressants such as ciclosporin mean that these agents should not be used for first-line treatment. (11) The place of various combinations of slow-acting antirheumatics remains to be established. (12) Recourse to systemic steroids must be minimised but is sometimes unavoidable. Low doses are usually adequate. (13) Treatment risks in elderly subjects and patients with comorbidity must be taken into account. (14) Women and men of child-bearing potential who have rheumatoid arthritis must be warned about the toxicity of antirheumatic drugs for the fetus and the effects on fertility.