Clinical Review

Science, medicine, and the future: Treatment of rheumatoid arthritis

BMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7102.236 (Published 26 July 1997) Cite this as: BMJ 1997;315:236
  1. C D Buckley, Wellcome clinician scientist, (c.d.buckley@bham.ac.uk)a
  1. a Department of Rheumatology, University of Birmingham, Birmingham B15 2TT,

    Introduction

    Rheumatoid arthritis is the commonest form of inflammatory arthritis and affects about 1% of the population. The clinical presentation is heterogeneous with a wide variation in age at onset, degree of joint involvement, and severity. In addition, it is difficult to predict at diagnosis which patients will develop severe disease. Nearly 90% of patients with aggressive disease will become clinically disabled within 20 years. Furthermore, in patients with severe disease or extra-articular symptoms mortality is equal to that for patients with triple artery coronary artery disease or stage IV Hodgkin's lymphoma. Thus the view that rheumatoid arthritis is a benign disease has been discredited.

    Fig 1

    Cellular components and sites of destruction in rheumatoid joint7

    For the past 20 years the treatment of rheumatoid arthritis has been developed on the premise that the prognosis of the disease is generally good. Treatment has been based on the sequential use of drugs starting with non-steroidal anti-inflammatory drugs progressing to disease modifying agents such as gold, sulphasalazine, and methotrexate. This pyramid approach has had limited success at preventing joint destruction or improving long term outcome. In fact, up to 90% of patients with aggressive synovitis have evidence of bone erosions within two years of diagnosis despite treatment.1 This has led to a move towards using disease modifying drugs early in the disease.2 The future of rheumatoid arthritis is currently at an exciting cross roads with management focusing on early diagnosis, intensive induction therapy, and intensification of treatment for resistant disease. This review highlights how recent developments in our understanding of the pathogenesis of rheumatoid arthritis have led to the discovery of new targets for treatment.

    Possible future developments

    • Early identification and treatment of patients at risk of aggressive disease from clinical and genetic characteristics

    • Development of more selective non-steroidal anti-inflammatory drugs and cyclo-oxygenase 2 inhibitors …

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