Drug treatment of progressive rheumatoid arthritis

The drug treatment of progressive rheumatoid arthritis (RA) is discussed with emphasis on second line agents used both singly and in combination. NSAIDS play a supportive role in the management of RA. Low dose prednisolone is acceptably safe and effective in long term use whereas pulsed steroids and intra-articular use is reserved for short term control of disease. Antimalarials are rarely valuable as sole agents in progressive arthritis. The use of sulphasalazine, gold thiomalate, d-penicillamine, auranofin, methotrexate, azathioprine and cyclophosphamide in rheumatoid arthritis and their place in the therapeutic strategy are discussed. The reported use of combination chemotherapy has not shown the expected additive benefits although azathioprine, methotrexate and hydroxychloroquine combination may prove to be better than single agents. Recently cyclosporine and gamma interferon have not been shown to be highly efficacious. Of the new therapies monoclonal antibodies to CD4 and CD5 positive lymphocytes are showing promise of marked efficacy in the short term. Sustained control of synovitis appears to improve the long term outcome but better strategies and better drugs are needed.