It is now agreed that Disease modifying anti rheumatic drugs (DMARDS) should be started early in disease i.e. within 3-6 months of onset of symptoms when patient has persistent polyarticular synovitis, joint deformity and reduction in functional capacity.
Traditionally patients are put on Disease modifying anti rheumatic drugs (DMARDS) when they fail to respond to NSAIDs. Now it is believed that these drugs should be started before there is evidence of joint damage radiologically. These agent act by controlling T-cell mediated immuno inflammation and give better control ofjoint pain and stiffness and slow progress of the disease.
Choice of DMARDs depends on prescriber’s choice and evaluation of activity of disease process. Because of delayed onset of action and lack of analgesic effect, drug compliance may be poor.
The members of this group (SAARDs) are chloroquine phosphate, sulfasalazine, D-penicillamiae, gold (Auranofin), immunomodulatory drugs like methotrexate, cyclophosphamide and cyclosporine-A.
Chioroquine phasphate and other analogues are less effective as compared to other members of this group. Dose (chloroquine phosphate 4 mg/kg body weight. Choroquine Hydroxychloroquin 6-5 mg/kg body weight).
Long term use produces nausea, vomiting, headache, loss of vision due to retinal damage and corneal deposits, loss of hearing, rashes, photo allergy and rarely myopathy. Regular ophthalmic examination during course of treatment is essential.
It is an effective drug and produces remission in 60% of patients in 4-6 weeks. Dose 500mg once a day with meals and be increased weekly to 1.5-2 gm/day. Side-effects include nausea, vomiting, hepatitis, dizziness, bone marrow toxicity and hypersensitivity pneumonitis.
D-Penicillamine is given in a dose of 125 mg/ day till a maximal allowable dose of 750 mg/day is achieved. It is to be taken on empty stomach. Toxicity includes skin rash, metallic taste, fever, bone marrow depression, nephrotoxicity and autoimmune diseases like myasthenia gravis, SLE and Goodpasture’s syndrome. Regular monitoring of blood count and proteinuria is essential.
Both oral and injectable preparations of gold are available. Gold is considered to be an effective agent for arresting the rheumatoid process. It reduces macrophage and lyosomal activity of inflammatory cells and has an effect on synovial membrane and collagen to prevent joint destruction. It may induce healing of bony erosions.
Oral gold (auranofin) is rapidly but incompletely absorbed and excreted slowly. Dose 6 mg daily in 2 divided doses for minimum 3-6 months. Side effects include diarrhea, nausea, abdominal pain rashes, pruritis, pulmonary fibrosis and nephrotic syndrome.
Parenteral preparations of gold (Sodium aurothiomalate and sodium aurothioglucose) are rapidly absorbed and slowly excreted. Usual schedule is 10mg test dose followed by 50 mg intramuscularly over a week till total of 1 gm has been given.
It generally takes 20 weeks to complete the course. Side effects of Disease modifying anti rheumatic drugs (DMARDS) include stomatitis, bone marrow depression, skin rash, nephropathy and colitis. Regular blood counts and urine analysis are essential and be done every fortnightly.