Up until the mid 1990’s the best we, as rheumatologists could do with patients with rheumatic arthritis (RA), was to relieve their pain, suppress their disease a bit, and perhaps slow it down some.
With the advent of biological therapies, specifically tumor necrosis inhibitors (anti-TNF drugs), it is now possible to have the disease into complete remission. And, it isn’t out of the area of possibility that if treated early enough and aggressively enough, some patients with RA can actually be cured.
And Now For More Dmards Withdrawal
We know from multiple studies that early aggressive treatment of rheumatoid arthritis is associated with improved disease control, slower x-ray progression and improved functional outcomes.
Tumor necrosis factor blocking therapy is effective but there remain concerns in some circles about long-term risks.
Combining disease-modifying antirheumatic drugs (DMARDs) is a widely used therapeutic alternative; however, there is uncertainty surrounding the most effective regimen. Advocates claim a fairly impressive response rate.
It is felt by some practitioners that triple DMARD therapy is better than DMARD monotherapy or using two DMARDS. Some advocates point out that the combination of methotrexate with hydroxychloroquine has synergistic anti-inflammatory properties.
Among rheumatologists who tout the use of combination DMARDS, various approaches are used. These include: a step-up (addition of new DMARDs to an existing treatment), a step-down (initial use of multiple DMARDs with subsequent withdrawal once remission is achieved) or a parallel approach (simultaneous use of two or more DMARDs).
To date though, there’s no consensus regarding either the most effective strategy, or the combination of DMARDs for the treatment of RA. Most rheumatologists who do use combinations though feel that any combination should use methotrexate and that combinations not using methotrexate aren’t as effective.
There still is uncertainty regarding the longer term use of anti-TNF drugs. No question about it. However, there is some new interesting information that supports their use in regards to lessening of both lymphoma risk as well as cardiovascular risk is patients with RA.