MANAGEMENT OF ORAL COMPLICATIONS OF DISEASE-MODIFYING DRUGS IN RHEUMATOID-ARTHRITIS

Stomatitis is a troublesome adverse effect of disease-modifying anti-r heumatic drug (DMARD) therapy in rheumatoid arthritis (RA) patients. T his review presents data to examine the incidence, clinical features a nd consequences of DMARD-related stomatitis. and suggests an algorithm for its clinical management. The specific objectives of the two studi es presented here were to determine the incidence of DMARD related sto matitis and its effect on DMARD continuation, and secondly to identify the clinical and laboratory risk factors. We investigated two cohorts of patients: (i) a retrospective survey of data collected from drug m onitoring clinics run for patients on DMARDs from 1987 to 1994 involvi ng 1539 patients and 2394 drug exposures; (ii) a prospective study of 25 consecutive RA patients presenting with DMARD-related stomatitis co mpared to 29 RA controls with no history of DMARD stomatitis. The retr ospective survey showed that 2% of DMARD patients stopped therapy beca use of stomatitis, but 55% of these were able to resume the same thera py. In the case-control study, 24% of patients discontinued temporaril y and 8% permanently. Cases of DMARD-related stomatitis differed from controls in that they had a higher incidence of previous mouth ulcers (40% vs 14%); they smoked less (8% vs 31%) and Schirmer's test was mor e often abnormal (44% vs 21%). There were no differences in RA severit y, disease activity or oral hygiene. Haematinic deficiencies were equa lly common in cases and controls: 30% for iron, 8% for vitamin B12 and 24% for folic acid. Herpes simplex virus was involved in a minority ( 8%) of cases. In conclusion, the occurrence of stomatitis in RA patien ts on DMARD should not lead to cessation of drug therapy, but to a car eful evaluation so that patients may be maintained on effective treatm ent.