Diseasemodifying antirheumatic drugs

All patients whose RA remains active despite adequate treatment with NSAIDs should be considered for disease-modifying antirheumatic drugs (DMARDs) (see Table 38.2). In broad terms, DMARDs are slow acting drugs with a delay of one to six months before a clinical response becomes evident. Efficacy cannot be predicted for an individual patient, but two-thirds of patients may respond. It should be noted that each drug has specific toxicity that requires monitoring.59,60

The decision as to when to introduce DMARDs remains controversial. One randomized controlled trial (RCT) of 238 patients with recently diagnosed RA compared early (within one year of onset of symptoms) with delayed DMARD treatment.61[II] Patients who received early treatment had significantly better outcome measures at 12 months although no differences were observed in radiologic progression between the early and delayed groups. In another prospective three-year follow-up study of 119 patients with early disease, a nine-month delay in starting hydroxychloroquine resulted in a detrimental effect on pain intensity and patient global well-being.62 [II] Combination therapy with up to three DMARDs is currently proposed as best practice for the initial management of RA compared with monotherapy or step-therapy, with studies suggesting that the response is superior in regimens that include methotrexate therapy.63

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