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Step-Wise Administration of Disease-Modifying Antirheumatic Drug Therapy Effective for Long-Term Inflammation Control in Rheumatoid Arthritis
Een DGReview van"Outcome of patients with rheumatoid arthritis treated by step-wise administration of disease-modifying antirheumatic drugs over a 10-year period"
Modern Rheumatology
06/09/2003
By Jill Taylor
Step-wise administration of disease-modifying antirheumatic drugs (DMARDs) controls rheumatoid arthritis inflammation over an extended period, as well as allows the clinician to predict the prognosis of each case over the course of treatment.
Patient response to DMARDs, commonly used to slow the progression of joint destruction in rheumatoid arthritis (RA) cases, varies widely and unpredictably. Additionally, adverse reactions to DMARD therapy are not uncommon.
Yoshiaki Hamada and colleagues of the Department of Orthopaedic Surgery and Rheumatology, Tokushima Kensi Hospital, Japan, performed a retrospective review of RA patients administered DMARDs to evaluate long-term efficacy of DMARDs in RA treatment and therapeutic response to a step-wise treatment regimen.
The study included 200 RA patients, 31 males and 169 females, average age at initial treatment was 50.9 years. All patients received follow up for 10 or more years.
Measurements included changes to DMARDs used, the Lansbury activity index (LAI), C-reactive protein (CRP), rheumatoid factor (RF), and radiological Larsen grade for the wrists, knee, and hip joints.
Step-wise administration consisted of auranofin (AF), gold sodium thiomalate (GST), D-penicillamine (DP), bucillamine (BCL), sulfasalazine (SASP), and methotrexate (MTX), singly or in combination. All drugs were administered in low doses.
Drugs were altered in cases where no decrease in LAI or CRP was observed after 3 to 6 months, and for adverse reactions.
While no renal dysfunction or drug-induced pulmonary disorder occurred in patients, researchers noted other adverse events, most commonly gastrointestinal complications (AF and SASP), mucocutaneous symptoms (GST, DP, BCL), and liver injury (MTX). Serious, but less common, reactions included proteinuria (GST, BCL) and bone marrow suppression (DP, BCL).
The researchers found that step-wise administration of DMARDs resulted in significant, sustained decreases in LAI scores and CRP levels. RF decreased as well, however, the decrease was not significant.
Substantial control of disease activity occurred for patients with LAI scores of 30% or less, and CRP values not more than 1.5mg/dl (71.5% of the population).
Hip and knee joint destruction significantly diminished for the majority of patients (96% and 80%, respectively, after 10 years). Alternatively, wrist deterioration did not diminish in the majority of patients. X-ray findings indicated joint destruction in the wrist to a Larsen grade III or higher in 80% of patients after 10 years.
"Because it is difficult to inhibit the progression of joint destruction in RA with the use of currently available DMARDs alone, the development of effective new biological products or genetic therapy is anticipated," the researchers conclude.
Modern Rheumatology Volume 13 Issue 1 (2003) pp 27-34.
"Outcome of patients with rheumatoid arthritis treated by step-wise administration of disease-modifying antirheumatic drugs over a 10-year period"
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