Office management of rheumatic disease. Pharmacology and laboratory evaluation

Nonsteroidal anti-inflammatory drugs are the primary therapy in most of the rheumatic diseases. After an adequate trial of NSAIDs in a patient with rheumatoid arthritis, the physician would usually add either a slow-acting remittive drug or an antimalarial. If the response to these drugs is unsatisfactory, or they have lost their effectiveness, then a cytotoxic drug would be considered for RA. With major organ involvement in systemic lupus erythematosus or with vasculitis (polymyalgia rheumatica/temporal arteritis and polyarteritis nodosa), corticosteroids would play an important role. Cytotoxic drugs are being used with increased frequency in conditions that may be refractory to steroids, such as polyarteritis or Wegener's granulomatosis, and when the side effects of high dose steroids are becoming intolerable. Whichever drug is chosen, careful instruction to the patient and follow-up of that patient for side effects are essential.