Treatment of severe rheumatoid arthritis

The basis for the application of remittive agents in rheumatoid arthritis is still hypothetical and empirical. Immunoreactions may be of pathogenetic significance in rheumatoid arthritis but definite evidence is lacking. Similarly the rheumatoid inflammation may be 'non-specific' or immune mediated. Therefore at present there is no basis for 'guidelines' for immunotherapy. Controlled trials have provided little or no information on the mechanism of action of the remittive agents. Furthermore classical controlled trials have severe limitations and require great resources. Therefore we need a new strategy for controlled trials. The emphasis should be on elucidation of the mechanism of actions of remittive agents with already established clinical efficacy. It is now possible in controlled trials to analyse immunological factors of possible pathogenetic significance, factors in the processes of inflammation and the interaction between the immune system, inflammation and connective tissue. Thereby a proper evaluation of the mechanism of action of remittive agents as well as of pathogenetic factors in rheumatoid arthritis seems possible.