Management of osteoarthritis and rheumatoid arthritis: prospects and possibilities

Conventional drug therapy in rheumatoid arthritis (RA) has failed to control the longterm morbidity and mortality associated with RA. Similarly, drug therapy for osteoarthritis (OA) can relieve symptoms, but it is not clear that it alters progression of disease. Three classes of drugs are widely used for treatment of RA: nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and the slow-acting agents. In most patients, pharmacologic therapy is initiated with NSAIDs. These drugs can relieve symptoms but do not alter the course of the disease. The gastrointestinal and other side effects attributed to these compounds are well known. Similarly, use of corticosteroids can provide rapid pain relief to patients with RA and, if used in low doses, pose limited risk of toxicity. Slow-acting agents, including gold, d-penicillamine, and methotrexate, appear to decrease radiographic progression and improve clinical and biochemical indicators of RA. Therefore, newer treatment philosophies encourage use of slow-acting agents earlier in the course of the disease in order to prevent or diminish bone and joint erosions and destruction and other manifestations of disease progression. Drugs under investigation for the treatment of arthritis appear to exhibit disease-modifying or immunomodulating properties. Tenidap is a novel agent that possesses a dual mechanism of action: cyclooxygenase inhibition and modulation of cytokine activity. In addition, several biologic agents, including antibodies to tumor necrosis factor-alpha (TNF-alpha) and to intercellular adhesion molecule-1, may prove useful. These immunotherapeutic strategies are based on knowledge of the role of cytokines in the inflammatory process in arthritis. Osteoarthritis may be managed using drug and nondrug modalities. Weight loss is especially important when OA is in the weight-bearing joints. Biopsies of synovium from patients with OA show evidence of inflammation, but whether this disease should be treated with analgesics alone or with anti-inflammatory drugs remains controversial. Other treatment modalities, including tissue transplants and cytokine-modulating drugs, are emerging for the potential therapy of OA. Surgery may also be appropriate if drug treatment fails to control symptoms.