Pharmacotherapy: concepts of pathogenesis and emerging treatments. Optimising the strategy of care in early rheumatoid arthritis.
In rheumatoid arthritis (RA), early use of disease-modifying anti-rheumatic drugs (DMARDs), intensive follow-up and 'treating to target' to achieve low disease activity produce significant improvements in measures of disease activity, functional impairment and retard erosive radiographic progression. Step-up, parallel and step-down regimens are all significantly more effective than sequential monotherapy; although the most effective regimen has not been established. Minimising the period of exposure to synovitis, by including a rapidly acting agent (e.g., corticosteroids or tumour necrosis factor alpha (TNFalpha) inhibitor), may slow radiographic progression further. Biologic therapies, especially TNFalpha inhibitors, are effective in early RA; however, their exact role is unclear. Current measures may overestimate the number of patients in clinical remission; therefore, musculoskeletal ultrasound and/or novel biomarkers may also have a role. Pre-clinical immunological markers could possibly be used to trigger pre-emptive treatment in asymptomatic, 'at risk' individuals. Potential treatment developments include combining biologic agents or targeting alternative immunological pathways.
Dale
James
J
Division of Immunology, Infection and Inflammation, University of Glasgow, Glasgow, Scotland, UK. james.dale@ggc.scot.nhs.uk
Porter
Duncan
D
D018501:Antirheumatic Agents / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000209:etiology* / Q000503:physiopathology / Q000628:therapy*; D042241:Early Diagnosis; D006801:Humans; D056747:Immunomodulation; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D020127:Recovery of Function; D012074:Remission Induction; D012219:Rheumatology / Q000379:methods* / Q000639:trends; D013997:Time Factors
D018501:Antirheumatic Agents; D007166:Immunosuppressive Agents