REVIEW - Benefit/risk of therapies for RA: underestimation of the side effects or risks of RA

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Clinical and Experimental Rheumatology Online

2004; 22

" Benefit/risk of therapies for rheumatoid arthritis: Underestimation of the

" side effects " or risks of RA leads to underestimation of the benefit/risk

of therapies " :

Conclusion:

The benefit/risk of traditional

DMARDs was considerably less

than currently available therapies

DMARDs available prior to the 1980s,

most notably injectable gold and penicillamine,

had considerable toxicity

and were poorly tolerated. Fewer than

50% of treatment courses of these drugs

were continued for longer than 2 years,

and fewer than 20% after 5 years (19,

20). Therefore, any reference to these

drugs as " remission inducing " was incorrect,

as fewer than 2% of patients

experienced long-term remission (155).

A most fortunate development in the

treatment of RA is that methotrexate

not only is much more likely to be associated

with an improvement in the

patient status compared to gold or penicillamine,

albeit rarely leading to actual

remission, but is much better tolerated

(156). Furthermore, methotrexate does

not appear be associated with a loss of

efficacy over months to years, as was

frequently seen with gold and penicillamine.

More than 50% of courses were

continued for longer than 5 years (20).

The newer DMARDs, leflunomide, and

biological agents also appear to have

more favorable tolerability and safety

profiles compared to gold salts and penicillamine.

Nonetheless, when patients

read about anti-rheumatic drugs on the

Internet or fill prescriptions for these

drugs, they are warned of the extensive

possible complications and adverse

events (Table I), but not of the potential

" side effects " of RA if left untreated (Table II).

Conclusion

In summary, the risks of RA indicate a

progressive disease, with a natural history

of radiographic damage, functional

declines, work disability, and premature

mortality in most patients. In view

of these findings, a new approach to

therapy involving " tight control " of RA,

analogous to the modern treatment of

hypertension and diabetes, is recommended.

Aggressive treatment is possible

because of the favorable benefit/

risk of methotrexate, leflunomide and

biological agents, particularly if full recognition

is given to the risks of RA.

However, to obtain maximum efficacy,

these therapies must be administered

prior to the development of joint damage.

The need for two, three, or more

drugs to achieve maximum control of

inflammatory activity can usually be

recognized within one year. With effective

therapies available, RA should be

viewed as an urgent medical problem -

a " medical emergency " - in order to

control the long-term consequences of

the disease process.

Full article:

http://www.clinexprheumatol.org/pdf/vol22/s35/s35_pdf/2pincus.pdf

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