Disease-modifying antirheumatic drugs, including methotrexate, gold, sulfasalazine, antimalarials, and D-penicillamine.

The class of agents known as disease-modifying antirheumatic drugs remains the predominant treatment for rheumatoid arthritis. Methotrexate has again demonstrated efficacy in long-term studies, and more reports on its pharmacokinetics and possible mechanism of action have been published. Renal impairment has been highlighted again as a major risk factor for methotrexate toxicity, and studies have supported the American College of Rheumatology guidelines concerning elevated transaminases as a warning sign for liver toxicity. Although questions about the long-term efficacy of gold have again been raised, some interesting reports have focused on its mechanism of action. The sulfasalazine literature includes reports on possible immunomodulatory roles for the drug in the gastrointestinal tract. The usefulness of hydroxychloroquine has been confirmed in a large study of early rheumatoid arthritis. The minimal effective dose of D-penicillamine has been questioned in a clinical study. Combination therapy using existing disease-modifying antirheumatic drugs has not demonstrated major benefits over single-drug therapy.