The relative toxicity of alternative therapies for rheumatoid arthritis: implications for the therapeutic progression.
The traditional pyramid for the therapeutic progression in rheumatoid arthritis (RA) is based on assumptions that RA is a mild disease, that nonsteroidal antiinflammatory drugs (NSAIDs) have low toxicity, and that disease-modifying antirheumatic drugs (DMARDs) are extremely toxic. This article reviews data from ARAMIS (Arthritis, Rheumatism, and Aging Medical Information System), casting strong doubt on these assumptions. NSAIDs result in 1.3% excess gastrointestinal hospitalizations per year. Mortality rates in RA are far above those expected from age- and sex-matched populations. Individual NSAIDs show widely different overall quantitative toxicity indices, as do individual DMARDs. However, the ranges of toxicity of the two classes of drugs show nearly complete overlap. It is suggested that the new therapeutic progression in RA should emphasize initial use of DMARDs, beginning with the least toxic.
Fries
J F
JF
Department of Medicine, Stanford University School of Medicine, Palo Alto, CA 94304-1808.
Williams
C A
CA
Ramey
D R
DR
Bloch
D A
DA
D000893:Anti-Inflammatory Agents / Q000009:adverse effects*; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000009:adverse effects; D001172:Arthritis, Rheumatoid / Q000188:drug therapy* / Q000401:mortality; D006471:Gastrointestinal Hemorrhage / Q000139:chemically induced; D006801:Humans
D000893:Anti-Inflammatory Agents; D000894:Anti-Inflammatory Agents, Non-Steroidal