Treatment of rheumatoid arthritis. Evolution of concepts and strategies

Introduction. - The treatment of rheumatoid arthritis includes non-steroid anti-inflammatory drugs (NSAID), low-dose steroids and drugs which modify t he evolution of the disease (disease modifying anti-rheumatic drugs, [DMARD ]). In the last few years, the long-term efficiency of the recommended trea tment strategies in rheumatoid arthritis has been a matter of debate and th eir basic assumptions have been challenged. Numerous studies were undertake n to settle the question. They tried to delineate the rules for an optimal use of current drugs and other therapeutic means. Current knowledge and key points, - Rheumatoid arthritis is a crippling dis ease. It decreases life expectancy and irreversible bone and joint damage m ay develop even in the first months of evolution. The sooner the prescripti on of DMARD, the higher the frequency and quality of rheumatoid arthritis i mprovement and, in the long-ten, the lesser the functional impairment. Low dose steroids, when administered early, can slow down the development of ra diologic lesions. Some of their effects are thus closer to those of DMARD t han to those of symptomatic treatment. NSAID are at least as equally danger ous as DMARD and possibly more so in terms of the potential number of sever e side effects. The combination of several DMARD does not increase their ov erall toxicity. An evaluation of the most efficient combinations and of the clinical situations in which combinations show promise of improved results is in progress. Future prospects and projects, - At present, the tendency is to treat early and intensively, in order to obtain complete remission, improve evolution and reduce functional impairment. This strategy requires early diagnosis an d early evaluation of prognosis of rheumatoid arthritis. Rheumatoid arthrit is with benign evolution would not warrant intensive treatment. Studies are in progress to evaluate the prognostic factors in early rheumatoid arthrit is that would enable us to adapt the strength of initial treatment to the d isease's putative severity. (C) 1999 Elsevier, Paris.