Rheumatoid arthritis: current concepts and management, Part 2

Rheumatoid arthritis is a systemic disorder, but primarily involves chronic polyarticular inflammation. Conservative nondrug therapy and NSAIDs are indicated initially and are effective treatment for many RA patients. For those individuals with progressive unresponsive disease an SAARD should be used. All SAARDs exhibit severe and frequent adverse effects with the risk-to-benefit ratio being the determining factor in deciding which agent to use. The first to be used is usually a gold compound; antimalarials and penicillamine provide alternatives to gold therapy. Sulfasalazine may gain a role in the therapy of early progressive RA. Methotrexate has recently been given FDA approval for use in RA and can be used, if the first three agents fail. Azathioprine and cyclophosphamide are cytotoxic agents with an increased risk of producing malignancies, but their use is sometimes required to halt serious progressive RA. Chlorambucil or cyclosporin A are relatively toxic agents that may play a role in treating refractory RA. Corticosteroids should be used for short-term adjunctive therapy as intra-articular injections or oral therapy in individuals refractory to all other therapies. The use of SAARDs early in RA or in combination with one another is controversial.