Disease-modifying agents and experimental treatments of rheumatoid arthritis

The pharmacologic management of the rheumatoid arthritis (RA) patient involves the use of various classes of therapeutic agents to induce symptomatic relief and reduce disease activity. Aspirin and nonsteroidal antiinflammatory drugs are used initially to lessen the degree of pain and swelling associated with the inflammatory disease process. The addition of a heterogeneous class of compounds, "second-line" therapy (previously known as disease-modifying antiinflammatory rheumatic drugs), is advocated to modify the disease course itself. Second-line treatments include antimalarials, gold salts, D-penicillamine, azathioprine, and methotrexate. Randomized placebo-controlled trials ahve demonstrated the efficacy of these compounds in RA. Improvement in standard parameters of disease activity including the number of painful and swollen joints, duration of morning stiffness, and erythrocyte sedimentation rate has been noted with these second-line drugs. Whether they modify roentgenographic progression is under rigorous study. These agents alone or in combination rarely induce complete disease remission. Therefore, newer therapies are under intensive investigation and include sulfasalazine, cyclosporin A, and combination therapy.