DISEASE MODIFYING ANTI-RHEUMATIC DRUGS
In the last communication it was made clear that treatment of RA with NSAIDs alone is not enough. Therapy with drugs that have the potential to halt or retard disease progression (joint damage) is absolutely essential.
What do DMARDs do ?
DMARDs control the disease process. The inflammation subsides. As a result joint damage is retarded in most or halted in some. Healing of erosions may take place. The total effect is reduction of pain, improved joint function, improved quality of life, less loss of working capacity and earnings and ultimately less money spent on medical and surgical treatment.
What is the best time to start DMARD therapy ?
| It has been pointed out (see 1st communication) that |
| i. |
Joint damage starts early in the course of the disease. Joint damage can be evident within a few months of disease onset and reaches its peak by 2 – 3 years of disease duration. |
| ii. |
Once damage starts the efficacy and benefit of DMARD therapy is reduced as the damage is self perpetuating. Therefore, for maximum benefit, DMARD therapy should ideally be initiated between 3 – 6 months of disease onset. DMARDs when started early improve disease outcome and quality of life. |
Which are the commonly prescribed DMARD’s ?
In the past gold salts and d-Penicillamine (d-Pen) were the most commonly used DMARDs. With the introduction of methotrexate (MTX) and sulfasalazine (SSZ), gold and d-Pen are now rarely used to treat RA. The reasons are better efficacy, less cost and less toxicity of MTX and SSZ. Chloroquine or hydroxychloroquine is another useful DMARD. Lately leflu nomide, an effective DMARD, has been introduced. Today with the availability of these agents, RA can rightly be considered a treatable disease.
Are not DMARDs very toxic ?
There is no drug that does not have some toxicity or the other. The important question is – “Is uncontrolled disease with almost certain dysfunction and disability a better choice than DMARD that has 70 – 80% chance of controlling the disease process and 10% or so chances of side-effects ?”. Further only a small % of these side-effects are of serious nature. The choice and decision therefore are clear. One should not be afraid of a mouse and close eyes to a tiger.
How long should DMARD be taken ? Do we change a DMARD after some time?
Since RA is not curable, the treatment has to be indefinite, that is it has to be prolonged.
If a DMARD singly or in combination is effective and well tolerated there is no need to change the same.
How do we know that there are no side-effects ?
Your doctor will explain to you in detail the likely side-effects their identification and prevention. He will also advise blood or other tests that need to be carried out to monitor toxicity. What is important is to be vigilant and careful and not be afraid.
What tests are advised ?
Briefly for chloroquine and hydroxychloroquine an eye check before the start of therapy and once every 3 – 6 months is necessary.
For methotrexate, sulfasalazine and leflunomide blood tests are needed every 4 – 6 weeks.
But you must get these instructions clearly from your doctor.
Can we use more than one DMARD at one time ?
Yes. In fact today there is more and more tendency to start a patient on 2 or 3 DMARD simultaneously especially if the disease is very active and aggressive.
Are there any other benefits of DMARDs ?
It has been shown that methotrexate improves life expectancy. Chloroquine diminishes serum lipids and reduces thrombotic tendency (clot formation in blood vessels). Further with disease control need for NSAIDs goes down, an added benefit.
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