History of the development of drug treatment in Rheumatoid Arthritis, Part 2

Editor's Note: This article was originally written by patient expert Michael Makover.

Read History of the development of drug treatment in Rheumatoid Arthritis, Part 1

DMARDs, (for Disease Modifying AntiRheumatic Drugs) go beyond just relief of symptoms. To varying degrees, they actually stop and sometimes even reverse the disease process. There are many kinds of DMARDs, most of which are still used. Some are based on gold salts. Others are adapted from other diseases, such as one originally developed for malaria, another for inflammatory bowel disease and some from anti-cancer drugs. Each drug has a unique profile, mode of use, degree of effectiveness and types of risks.

Patients vary quite considerably in the benefits and tolerance of each and they can be used in combination with each other and with the newer biologic agents. Rheumatologists are very expert with these drugs because they are the mainstay of care of Rheumatoid Arthritis. Used incorrectly, these drugs can be quite harmful. Though each drug has potentially serious risks and adverse effects, those risks are small when employed carefully and thoughtfully and most patients choose to take such risks to alleviate the suffering untreated Rheumatoid Arthritis can impose.

The most effective of these DMARDs has been methotrexate. It was one of the very first cancer chemotherapy agents and was used for acute leukemia over sixty years ago. In recent times it has found numerous other uses, especially in autoimmune diseases. Much lower doses are needed when used this way than for cancer, so that the risks are lower. Methotrexate benefits most RA patients and gives dramatic improvement for many. However, good as it has been for most, it does not give as much relief as would be desired and not all can tolerate it.

Fortunately the new biologic agents have come along that, often given in addition, provide even greater benefit. Methotrexate is usually tried sooner and the biologic agents added later as needed.

One of the most exciting developments in rheumatology has been the introduction of the biologic agents in 1998. They have brought greater relief to more patients than any other treatment. They are called biologics because they mimic the action of proteins involved in the immune system. They are made by genetic engineering in tissue cultures of various kinds. Research has learned a great deal about how the immune system works and how it affects the joints in RA. There is much, much more to learn, but the knowledge acquired by very smart and dedicated people doing very hard work has laid the groundwork to tailor drugs to target the disease process in very specific ways.

Besides the newer treatments, the other major advance in RA treatment since I began my career is to treat with DMARDs and biologic agents very early in the onset of the disease in cases that look likely to be severe. It took many years of research by rheumatologists to establish that doing so was safe and effective and when to do so, but now we know to attack the disease at the earliest practical point to forestall the damage and complications from occurring, if possible. As we shall discover in later postings, that promise is being realized to at least some extent and the dream is to reach the point of complete control for every patient. That goal is now within view, though not as close as we all would wish.

Biologic medications are far from perfect: they are very expensive and entail serious risks, though fortunately most patients do not suffer the most ominous side effects. New generations of biologic drugs are in the works. The dream of all treatment research is to find what Paul Ehrlich, one of the greatest of early medical researchers, termed The Magic Bullet. It means a treatment so perfectly focused that it would accomplish its benefit with no damage to healthy parts of the body. Hopefully newer treatments for Rheumatoid Arthritis will come ever closer to that goal.

Drug treatment alone is never enough in Rheumatoid Arthritis. Advanced disease often takes a powerful emotional, social and economic toll and can also affect many other parts of the body. Equally important, no matter how consuming may be the effort needed to control RA, it is important to remember that the patient with RA is still a whole person and needs to attend to all the good preventive measures that everyone need do.

The care of RA works well only if it is a team effort, never losing sight of the fact that the patient is the most important player We will discuss that in the next post.
I will discuss in future posts how to make the diagnosis of Rheumatoid Arthritis, judge the severity and decide who needs aggressive early treatment.

Read History of the development of drug treatment in Rheumatoid Arthritis, Part 1

Please feel free to post comments, suggest topics and ask questions, but I cannot respond to them directly. At times I will address a reader's question or comment within a posting. As with all such sites as this, it is not intended to give individual advice, to advise on your treatment or to substitute for your own doctors. It is intended to give you some insight and background that I hope will help you understand the disease better.