Evaluation of pathophysiology and drug effects on rheumatoid arthritis

The treatment of rheumatoid arthritis has been divided into symptomatic or anti-inflammatory drug therapy, and disease-modifying or remission-inducing drug therapy. A more useful classification may be one that correlates the therapy with the component of the disease process that it affects. In general, nonsteroidal drugs do not affect cells as much as they do some of the mediators that cells produce. The effects of gold and D-penicillamine, although used later in the disease because of their toxicity, probably act early in the cascade of development of the disease by affecting the macrophages and lymphocytes. Prednisone may be effective in inhibiting synthesis by macrophages and fibroblasts of proteinases as well as arachidonic acid metabolites. Retinoids may be prototypes of drugs that selectively inhibit collagenase/proteinase production but do not affect production of normal connective tissue components.