THE USE OF SLOWER-ACTING (CLASS-III) SYMPTOM-MODIFYING ANTIRHEUMATIC DRUGS IN RHEUMATOID-ARTHRITIS

Slower-acting (class III) symptom-modifying drugs are given in rheumat oid arthritis to control acute signs and symptoms of the disease, with the hope of favourably modifying long term outcome. Among these agent s, methotrexate, sulfasalazine and hydroxychloroquine offer the best e fficacy/toxicity ratio. Unfortunately, sustained remission with treatm ent is rare, and most analyses demonstrate long term progressive disab ility. Clearly, strategies that initiate single-agent therapy with the currently available class III symptom-modifying drugs only after fail ure of physical therapy and treatment with nonsteroidal anti-inflammat ory drugs are successful in only a small proportion of patients. For m ost patients with moderate to severe disease at the time of diagnosis, this approach should probably be abandoned. New agents and/or new str ategies are needed. Newer biological agents have not proven superior t o existing therapies, nor are they readily available to most practisin g clinicians. However, novel strategies using existing agents can ofte n control disease in the short term and might also offer improved long term outcome. There is reason to believe that both of these goals can be met by using a strategy in which sufficiently aggressive treatment is given to decrease the number of swollen joints to less than or equ al to 5 and to normalise acute phase reactant levels. If combinations of class III symptom-modifying drugs are necessary to achieve these go als, methotrexate combined with hydroxychloroquine, sulfasalazine or c yclosporin seem the best choices today.