Disease-modifying antirheumatic drugs: gold, penicillamine, antimalarials, and sulfasalazine

Safety of long-term use of four common conventional disease modifying anti-rheumatic drugs in rheumatoid arthritis

Conventional disease-modifying antirheumatic drugs (DMARDs) have been used in the management of rheumatoid arthritis for a long time. Whereas methotrexate (MTX) is the anchor drug, leflunomide, hydroxychloroquine and sulfasalazine are used along with MTX either in combination or sequentially. Together these four drugs are the most commonly used DMARDs. They are also used in combination with biological DMARDs (bDMARDs) to enhance their efficacy and MTX in particular to reduce antibodies against anti-tumour necrosis factor. Despite their widespread use, concerns regarding their safety especially when used long-term hinder their optimum use in clinical medicine. In this narrative review we have critically appraised the available literature regarding the safety of these four DMARDs when used long-term.

Update on treatment of rheumatoid arthritis

OBJECTIVE

To review current treatment of rheumatoid arthritis (RA), as well as recent advances.

DATA SOURCES

MEDLINE search from 1990 to 1998 for human studies using search terms "rheumatoid arthritis"; "cyclooxygenase inhibitors" combined with "anti-inflammatory agents, nonsteroidal"; "tumor necrosis factor" limited to "antagonists and inhibitors"; "isoxazoles."

DATA SYNTHESIS

RA is a chronic inflammatory disease characterized by symmetrical joint involvement, usually of the small joints of the hands and feet. Although the hallmark of the disease is inflammation of joints, other organ systems--including the eyes, blood vessels, lungs, and cardiopulmonary system--may also be involved. Treatment of RA requires both drug and non-drug approaches. Current drug therapy consists of combinations of nonsteroidal anti-inflammatory drugs (NSAIDs) and disease-modifying antirheumatic drugs (DMARDs). Corticosteroids are also used either for short-term treatment during initiation of therapy, in bursts during acute disease flares, or chronically in low doses. A number of promising new agents are in development. NSAIDs with preferential inhibition of cyclooxygenase II may offer a better safety profile than existing agents. Leflunomide and biological agents such as etanercept may provide benefit for patients who fail to achieve adequate response from conventional therapy.

CONCLUSION

Traditional approaches to treatment of RA include NSAIDs combined with DMARDs. New agents just reaching the market represent important advances and have the potential to make a positive impact on treatment of RA.

Obstructive sialadenitis caused by intraparotid deposits of gold salts: a case report

A case of obstructive sialadenitis caused by deposits of gold salt compound in the intraparotid lymphoid tissues in a woman with classic rheumatoid arthritis is presented. The patient had been treated with a parenteral gold salt compound (sodium aurothiomalate) for 10 years with chrysotherapy balance of 7525 mg. She presented with swelling of both parotid glands on eating, and computed tomography images showed accumulation of high density spots. Obstructive sialadenitis most probably was caused by local compression on the excretory ducts of the parotids. This clinical disorder should be classified as a case of mechanical, nontumoral, obstructive sialadenitis caused by gold salt compound.