The medical treatment of rheumatoid arthritis has been dramatically improved with the advances of newer disease-modifying antirheumatic drugs (DMARDs) and biologic agents during previous decades. To prevent joint damage, it is essential to start DMARD treatment early, especially within the first 3 months after diagnosis. Tight control of disease activity, and the thorough monitoring of the treatment's efficacy and the side effects of medications are also important. Nonsteroidal anti-inflammatory drugs (NSAIDs) are usually used to control pain and swelling of the joints. However, these drugs cannot alter the disease course of rheumatoid arthritis. It is therefore necessary to introduce DMARDs at the beginning of treatment, and, after achieving the effect of DMARDs, NSAIDs should be tapered as soon as possible. The main treatment should be DMARDs, which must be used wisely and appropriately. It is also important to adjust DMARD therapy during the course of treatment according to disease activity. Glucocorticoids have potent anti-inflammatory effects and can control inflammation dramatically. However, because of the diverse and serious side effects of glucocorticoids, the usage of glucocorticoids should be limited to low-dose oral therapy or intra-articular injection, unless otherwise indicated. Along with biologics, there are now various weapons available against rheumatoid arthritis, and it can be treated much more effectively than before.
Anti-Inflammatory Agents, Non-Steroidal ; Antirheumatic Agents ; Arthritis, Rheumatoid ; Biological Agents ; Glucocorticoids ; Inflammation ; Injections, Intra-Articular ; Joints

Authors introduced some classes of drugs for treating rheumatic arthritis. Basic drug group includes biological agents, anti TNF drugs such as Entanercept- Enbrel; Infliximab; Adalimumab- Humira. In non-steroidal anti-inflammatory drugs (NSAIDs) group, there are Meloxixam - Mobic; Nimesulide- B- Nalgesine; Nise, Celecoxib- Celebrex; Rofecoxib- Vioxx; Valdecoxib-Bextra; Parecoxib- Dynastat; Etoricoxib-arcoxia. Group of slow released antirheumatic drugs included diacetylrÐine or diacerhÐine (ART 50). A new therapy that gave rapid and long lasting pain relieve, more viscosity of articular fluid is administration of sodium hyaluronate (Hyalgan, Ostenil, Hyruan) intra-articular injection
Antirheumatic Agents ; Drugs, Investigational ; Pharmaceutical Preparations

Since the 1950's, methotrexatehas been the most widely used for the treatment of rheumatoid arthritis among various disease-modifying anti-rheumatic drugs (DMARDs). In this review, several hidden questions on methotrexate were discussed. First, so far, methotrexate has been considered to improve rheumatoid arthritis by inhibiting cell proliferation through the reduction of synthesis regarding purine and pyrimidine. Recently, a new concept was proposed that methotrexate could increase the release of adenosine, which subsequently decreases the inflammatory function of immune cells, and can finally quench the inflammation in affected joints of rheumatoid arthritis. Second, there were only three clinical trials done to directly compare the efficacy between methotrexate and biologics. With these results, methotrexate showed comparable therapeutic efficacy to biologics, but did not prevent radiological progression. In the future, clinical trials to directly compare the efficacy of methotrexate to biologics will be needed. Third, measuring the serum concentration of methotrexate is not appropriate, since circulating methotrexate is rapidly cleared by cellular uptake or renal excretion. Methotrexate polyglutamate is a more stable compound than methotrexate and it is more likely to relate to efficacy or adverse effects of methotrexate. Recently, the efforts to measure methotrexate polyglutamate in red blood cells have been done to increase therapeutic efficacy and reduce its adverse effects. Fourth, NSAIDs can decrease the excretion of methotrexate though renal tubular cells and it may increase the serum concentration of methotrexate and the risk of its toxicity, suggesting that physicians should pay close attention to dose adjustments concerning methotrexate combined with NSAIDs.
Adenosine ; Anti-Inflammatory Agents, Non-Steroidal ; Antirheumatic Agents ; Arthritis, Rheumatoid ; Biological Agents ; Cell Proliferation ; Erythrocytes ; Inflammation ; Joints ; Methotrexate ; Polyglutamic Acid ; Polymethacrylic Acids ; Purines ; Pyrimidines

Rheumatoid arthritis (RA) is a chronic inflammatory disease of the joint, for which treatment strategies have remained suboptimal for a long time. The treatment of RA has changed dramatically during the past decade due to the better understanding of its pathogenesis. Especially in early RA, early diagnosis and appropriate treatment is highlighted, with the treatment goal being clinical remission. In order to prevent joint damage and long-term disability, early use of disease-modifying anti-rheumatic drugs (DMARDs) is a key. Aggressive treatment such as combination of DMARDs and glucocorticoids or biological agents can induce a high rate of remission, suppression of joint damage and provide better outcome than DMARD monotherapy in early RA and should be considered in high-risk patients. Timely adjustment of therapy until patients have achieved low levels of disease activity is also crucial. On the other hand, treatment for osteoarthritis has mainly been focused on the alleviation of pain, while the goal of disease modification still remains elusive. Because the long-term use of non-steroidal anti-inflammatory agents poses significant risk of adverse events on the elderly, nonpharmacologic therapy including weight reduction, muscle strengthening, and exercise is recommended first. Recent advances in the understanding of the pathogenesis of osteoarthritis may provide a clue that will ultimately lead to disease modification.
Aged ; Anti-Inflammatory Agents, Non-Steroidal ; Antirheumatic Agents ; Arthritis* ; Arthritis, Rheumatoid ; Biological Factors ; Early Diagnosis ; Glucocorticoids ; Glucosamine ; Hand ; Humans ; Joints ; Osteoarthritis ; Weight Loss

BACKGROUND: Nonsteroidal anti-inflammatory drugs (NSAIDs) are used in nearly every patient with rheumatoid arthritis (RA) but their use can be associated with gastrointestinal (GI) side effects, which may be prevented with prophylactic prescription of misoprostol and omeprazole. Recently marketed COX-2 specific inhibitor (COX-2) affords protection against gastropathy. This study was performed to assess Korean cost-effectiveness of NSAIDs, NSAIDs with co-treatments to prevent GI toxicity, and COX-2 in the treatment of RA, and compare it with American cost-effectiveness analysis. METHODS: Markov (state-transition) models were used to simulate a cohort of RA patients with approximately 2.5:1 female to male ratio and 50 years, taking disease modifying antirheumatic drugs, low dose steroid (prednisone < or =10 mg/day) and one of the following strategies: 1) NSAIDs without prophylaxis, 2) NSAIDs with misoprostol, 3) NSAIDs with proton pump inhibitor (PPI), or 4) COX-2. Data on incidence, USA cost and consequences of adverse events from treatments were taken from the literature. Treatment costs of adverse events in Korea were calculated based on each disease code. Health effects were expressed as quality-adjusted life years (QALYs). Sensitivity analyses of probability of GI complication and cost were performed. Costs and health outcomes were discounted at a rate of 3% per year. RESULTS: Among the strategies to prevent GI toxicity, PPI was the most cost-effective strategy in Korea and COX-2 was in USA, respectively. The incremental C/E (cost/effectiveness) ratio between PPI and no prophylaxis was 38,068x103won/QALY (32,044$/QALY) in Korea. The incrementalC/E ratio between COX-2 and no prophylaxis was 53,228$/QALY in USA. The base case analysis results were sensitive to cost of NSAIDs and COX-2 in Korea, and cost of NSAIDs in USA, respectively, and adverse event rates of NSAIDs, misoprostol, and PPI in Korea. The medical cost of NSAID side effects in Korea is 11% of USA, but the sensitivity analyses varying medical costs were robust. The sensitivity analyses using age, discount rate and utility were robust. CONCLUSIONS: Although PPI in Korea and COX-2 in USA are the best option among the strategies to prevent GI toxicity, the incremental C/E ratios between PPI versus no prophylaxis in Korea and COX-2 versus no prophylaxis in USA are over 30,000 and 50,000$/QALY, respectively. However, it appears that the prescription of COX-2 in the group of higher cost NSAIDs users in Korea was the best option.
Anti-Inflammatory Agents, Non-Steroidal* ; Antirheumatic Agents ; Arthritis, Rheumatoid* ; Cohort Studies ; Female ; Health Care Costs ; Humans ; Incidence ; Korea ; Male ; Misoprostol ; Omeprazole ; Prescriptions ; Proton Pumps ; Quality-Adjusted Life Years

The systematic approach to pharmacologic treatment is typically to begin with the safest, simplest, and most conservative measures. It has been realized that the more rapidly inflammation is under control, the less likely it is that there will be permanent sequelae. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the mainstay of initial treatment for inflammation. In addition, the slow-acting antirheumatic drugs (SAARDs) and disease-modifying antirheumatic drugs (DMARDs) have efficacy of anti-inflammatory action in children with chronic arthritis. New therapeutic modalities for inflammation, such as etanercept and infliximab, promise even further improvements in the risk/benefit ratio of treatment. It is not typically possible at the onset of the disease to predict which children will recover and which will go on to have unremitting disease with lingering disability or enter adulthood with serious functional impairment. Therefore, the initial therapeutic approach must be vigorous in all children.
Anti-Inflammatory Agents, Non-Steroidal ; Antibodies, Monoclonal ; Antirheumatic Agents ; Arthritis ; Arthritis, Juvenile Rheumatoid ; Child ; Humans ; Immunoglobulin G ; Inflammation ; Receptors, Tumor Necrosis Factor ; Infliximab ; Etanercept

OBJECTIVES: The study aims to describe the disease characteristics of Filipino patients diagnosed with ankylosing spondylitis (AS) in different rheumatology clinics in Metro Manila, Philippines.

METHODS: The study retrospectively reviewed the records of all Filipino AS patients aged 18 years old and above,diagnosed by the Rome Criteria and seen from January 2000 to May 2012 at the rheumatology outpatient clinic of the Philippine General Hospital and in different rheumatology clinics in Metro Manila. Demographics, joint manifestations, radiographic findings, and medications were described and tabulated. Descriptive statistics included mean and standard deviation for quantitative variables and frequency and percentage for qualitative variables. .

RESULTS: Forty-seven Filipino AS patients were included in the study. The male to female ratio was 46:1. The mean age at diagnosis was 33.2 +/- 10.93 years while the mean disease duration was 7.04 +/- 4.28 years. Seven (14.8%) patients had a family history of AS while twelve (70.6%) tested positive for HLA-B27. The lumbar spine was the most commonly affected site in the majority (80.9%) of subjects. A significant number of participants (70.2%) also had peripheral joint involvement,with the knee being the most common peripheral joint involved (72.7%). In terms of imaging, sacroiliitis was found in the majority (87.5%) of patients. All patients received standard rehabilitation exercises and almost all (97.9%) were on NSAIDs. Nine (19.1%) patients each received opioids and DMARD therapy, while eight (17%) received anti-TNF therapy.

CONCLUSION: Filipino patients with AS are mostly young males presenting with chronic lumbar pain and HLA-B27 positivity.The data gathered in this study may help local physicians identify AS early in affected patients, giving them access to early intervention and thereby preventing progressive structural and functional deterioration.

Human ; Male ; Female ; Aged ; Middle Aged ; Adult ; Young Adult ; Spondylitis, Ankylosing ; Sacroiliitis ; Analgesics, Opioid ; Tumor Necrosis Factor-alpha ; Antirheumatic Agents ; Anti-inflammatory Agents, Non-steroidal ; Rheumatology ; Philippines

Rheumatoid arthritis(RA) is an autoimmune disease that seriously affects the physical and mental health of patients, but its pathogenesis is still unclear. At present, clinical treatment drugs include conventional synthetic disease modifing anti-rheumatic drugs(csDMARDs), nonsteroid anti-inflammtory drugs(NSAIDs), hormones, small molecule targeted drugs, biological agents, etc. These drugs can relieve the clinical symptoms of most patients with RA to a certain extent, but there are still many limitations, such as drug adverse reactions and individual differences in drug efficacy. Therefore, the research on drug treatment targets and the development of low-toxicity drugs helps further improve the precise prevention, diagnosis, and treatment of RA. There is an urgent need for efficient and low-toxic treatments to delay the clinical progress of RA. As a treasure of Chinese culture, traditional Chinese medicine(TCM) is widely used as an alternative therapy in the treatment of various diseases, and has a significant clinical efficacy. TCM therapy(including monomer traditional Chinese medicine, classical compounds, and non-drug therapies) has a significant curative effect on RA. Based on the literature research in recent years, this paper reviewed the clinical and mechanism research of TCM therapy in the treatment of RA, and provided more in-depth thinking for the wide application of TCM therapy in clinical practice.
Humans ; Medicine, Chinese Traditional ; Drugs, Chinese Herbal/therapeutic use* ; Arthritis, Rheumatoid/drug therapy* ; Antirheumatic Agents/therapeutic use* ; Anti-Inflammatory Agents, Non-Steroidal/therapeutic use*

BACKGROUND: Leflunomide, a novel immunoregulatory drug, has been shown to be effective in rheumatoid arthritis (RA) as monotherapy and as combination therapy with methotrexate (MTX). The aims of this study were to investigate the efficacy and safety of combination therapy with leflunomide and MTX in active RA patients and to identify the patients with a better response to this combination. METHODS: The patients received a maintenance dose of 20 mg of leflunomide with or without a loading dose. Parameters for disease activity in RA were measured at baseline and at 12 and 24 weeks after initiation of leflunomide. At 24 weeks, the baseline data from the patients classified as leflunomide responders were compared with data from nonresponders and analyzed to determine the potential predisposing factors for treatment response. RESULTS: A total of 103 patients with RA were included and 93 (90.3%) patients received leflunomide for 24 weeks. At 24 weeks, 67 (65.1%) patients were DAS28 responders; 14 (13.6%) were good responders and 53 (51.5%) moderate responders. At 12 weeks, significant improvements were noticeable in the individual efficacy measures of diseases activity. There were also significant improvements between 12 and 24 weeks in swollen joint count, tender joint count, HAQ disability index, and patients' and physicians' global assessments of diseases activity; but no further improvements in ESR or CRP could be seen after the first 12 weeks. When comparing the baseline data from responders with the nonresponders, patients on a higher MTX dose and patients with a higher disease activity at baseline responded better to leflunomide. However, age, sex, disease duration of RA, functional status, loading dosage of leflunomide, and previous number of DMARDs used did not affect the patients' response to leflunomide. CONCLUSION: Combination therapy with leflunomide and MTX is effective and safe across a wide range of patients, especially those with a high disease activity in spite of treatment with other traditional DMARDs.
Antirheumatic Agents ; Arthritis, Rheumatoid* ; Causality* ; Humans ; Joints ; Methotrexate*

The paradigm for the management of rheumatoid arthritis (RA) has shifted in the past two decades. The appreciation of increased mortality in patients with RA and the poor outcomes with conventional therapy led to the concept of the early aggressive treatment to suppress ongoing inflammation and prevent joint injury. RA results from acute and chronic inflammation in the synovium associated with proliferative and destructive processes in the joint. Affected areas may either heal without structural defects, or be irreversibly damaged if inflammation is severe and does not remit. Therefore, measures aimed at identifying early active disease and ameliorating inflammation are essential and may be highly effective in modifying disease outcome. The goal of treatment is to achieve and maintain a state of remission or, at the least, a state of low disease activity, in order to prevent joint damage and disability. This requires the initiation of treatment early in the disease process, as well as vigilant monitoring throughout the course of disease, with prompt readjustment of therapy, for flares of activity and for medication toxicity. This aggressive approach has been made possible by the increasing number of effective non-biologic and biologic disease-modifying anti-rheumatic drugs (DMARDs). Recent trends and guidelines for the management of RA are presented here.
Antirheumatic Agents ; Arthritis, Rheumatoid ; Humans ; Inflammation ; Joints ; Synovial Membrane