Therapeutic progress--review VI. Treatment of rheumatoid arthritis.

Anti-rheumatic drugs used in rheumatoid arthritis fall into two distinct groups: non-steroidal anti-inflammatory and second-line drugs. Non-steroidal anti-inflammatory drugs give early symptomatic improvement and reduce the degree of acute inflammatory synovitis. Second-line drugs such as gold or D penicillamine exert an anti-inflammatory effect only after two to three months and act by suppressing disease activity: these reduce the ESR and other acute phase responses. However, the evidence that any of these drugs halt the progression of radiological changes or can be used as long-term agents to control the disease over a period of years is weak. The current use of anti-rheumatic drugs follows a general pattern with non-steroidal anti-inflammatory drugs used alone in patients with mild disease, whereas patients with severe disease also receive second-line drugs. As yet the long-term effect of this policy is not known. Cytotoxic drugs should be restricted to patients with severe disease who either fail to respond to conventional second-line drugs or have active extra-articular disease, particularly those with vasculitis.