NEW APPROACHES
TO THE TREATMENT OF RHEUMATOID ARTHRITIS
In previous decades, a
pyramid model dominated the treatment of rheumatoid arthritis. Early in the
course of the disease, salicylates were used to control pain and stiffness. If
salicylates were poorly tolerated or began to lose efficacy, they were
discontinued and a different NSAID was used. As the efficacy of NSAID therapy
waned and joint deterioration progressed, treatment with a DMARD was added.
DMARDs were employed singly and sequentially for periods of up to 6 months
be-fore clinicians could determine their efficacy and switch to a new drug if
necessary.
The most recent treatment
paradigm calls for earlier, more aggressive treatment of rheumatoid arthritis.
DMARDs are frequently employed along with NSAIDs in the initial treatment of
the disease. The COX-2 in-hibitors are often used because they are less likely
to cause serious GI toxicity than are the nonspecific COX inhibitors. The usual
DMARD of choice for patients with mild rheumatoid arthritis is
hydroxychloroquine or sulfasalazine; methotrexate is used for those with
mod-erate to serious disease. Other DMARDs are used if these agents are poorly
tolerated or do not produce suf-ficient response. Combination therapy of
methotrexate and another agent is also used to treat disease that is not
responsive to individual DMARDs.
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