Sulphasalazine in rheumatoid arthritis: combination therapy with D-penicillamine or sodium aurothiomalate

Pharmacotherapeutic combination strategies with disease-modifying antirheumatic drugs in established rheumatoid arthritis

Pharmacotherapy is still the cornerstone in the management of rheumatoid arthritis (RA). Due to several reasons the pharmacotherapeutic strategy has changed dramatically in the past decades. It has become clear that in most cases single treatment with disease modifying antirheumatic drugs (DMARDs) is insufficient to control the disease on the long term. This is the main reason why combinations of second-line agents are increasingly being used in the treatment of established RA. Many different ways of prescribing combination treatment and a large number of different combinations have been published. However definite conclusions which drugs to combine or what strategy to apply are difficult to make as solid studies which enable these conclusions are sparse. Several studies have shown that the best opportunity to achieve a good response is to use a set-up approach, in addition different studies have shown that corticosteroids do have a profound effect on disease activity variables.

Combination of second-line antirheumatic drugs

Single drug therapy is often not satisfactory in the treatment of chronic arthritis. The combination of second-line antirheumatic drugs is therefore increasingly employed. Various strategies of combining drugs can be used, starting with combinations or adding agents in case of insufficient effect of single therapy. Effective combinations have to be found empirically because lack of knowledge about pharmacodynamics and pharmacokinetics often hinders rational choices. Few controlled studies on combinations of second-line antirheumatic drugs exist, results suggesting very moderately increased efficacy and increased toxicity. Recently, results of combinations, mainly with methotrexate, have become available. Combining this agent with azathioprine did not offer advantages. Cyclosporin added to insufficiently effective methotrexate possibly has some value and antimalarials combined with methotrexate may be beneficial regarding effectivity and/or toxicity. Methotrexate added to insufficiently effective sulphasalazine seems to be better than methotrexate alone, although this combination when used from the start of the therapy was disappointing. Triple therapy of the latter combination together with hydroxychloroquine turned out to be superior to single methotrexate and to the combination of sulphasalazine and hydroxychloroquine. Surprisingly, the toxicity of these combinations was mainly comparable to single therapy. In conclusion, combinations of second-line antirheumatic drugs have a role, although not yet clearly defined, in the therapy of chronic arthritis.

Treatment of rheumatoid arthritis

The management of rheumatoid arthritis (RA) remains a challenging objective. Recent trends have led to the earlier and more "aggressive" treatment of patients with active disease. This change in outlook is largely the result of the recognition that significant damage can occur fairly soon after the onset of disease. This article reviews the currently available therapies, including a discussion of the benefits and side effects associated with individual agents. In addition, possible approaches to the treatment of RA will be reviewed.

Innovative treatment approaches for rheumatoid arthritis. Combination therapy

It is accepted that combination DMARD therapy is a useful tool in current rheumatological practice. However, well-designed, large, long-term, controlled clinical trials are needed to determine which combinations, dosage schedules, and sequences of administration are most beneficial and least toxic. Until we develop treatment regimens that reliably induce and sustain acceptable control of disease manifestations in all patients for the rest of their natural lifespan, daily oral prednisone will continue to be a troublesome component of 'bridge' therapy, as it becomes the sole surviving constant in complex regimens whose other components are eventually discontinued because of toxicity, lack of efficacy, or non-compliance. We have often seen patients in whom the replacement of a well-tolerated but presumable ineffective DMARD with another DMARD has led to worsening of disease, when the modest benefits of the discontinued DMARD were lost before the hoped for onset of benefit from its replacement became evident. Since the toxicity of combinations of DMARDs has not appeared to be excessive, one can reasonably add the second DMARD to the first, while carefully monitoring for adverse effects and planning ton continue the combination until increased benefit occurs. Subsequently, if the second DMARD is not tolerated, the partial benefit from the first has not been given up, and a longer duration of treatment with the initial DMARD is sometimes associated with satisfactory improvement. If better control of rheumatoid arthritis is evident after 3-6 months of treatment with the combination of DMARDs, one must still decide whether to stop the first DMARD, stop the second, or continue with the combination. In the absence of major toxicity, we are most likely to choose to continue the combination if the patient has had a good response, thus inadvertently embarking on prolonged combined DMARD therapy (Paulus, 1990). Of course, other drugs besides those discussed above are available to control different aspects of joint damage; they should be considered in any combination therapy. Drugs which potentially protect cartilage from damage, such as orgotein, glycosaminoglycan polysulphate (Arteparon), and Rumalon, may prove useful in rheumatoid arthritis; they have been studied in osteoarthritis, but there is evidence that they protect cartilage from breakdown by inflammation in some animal models. As one of the many goals of treatment in rheumatoid arthritis is to protect cartilage, these chondroprotective agents might also be considered as part of the combinations to be studied. The combination of modest clinical efficacy with minimal toxicity reported with minocycline treatment of rheumatoid arthritis make this another potentially interesting addition to combination therapy regimens (Tilley et al, 1995). It is also important to continue the development of so-called 'biological agents', such as interleukin-2 receptor antibodies, anti-CD4 antibodies, anti-TNF-alpha agents and anti-thymocyte globulin. Combinations which include such agents have not yet been evaluated, although is seems logical considering that these agents offer the possibility of precise intervention directed at specific steps of the immuno-inflammatory process; their combination may thus be more effective than the use of single agents alone. While we await results of well-designed studies of these newer agents in RA therapy, we should continue to consider creative ways of using drugs that are already available.

Additive two DMARD therapy of the patients with rheumatoid arthritis

From the beginning of 1987 to the end of 1989, 72 rheumatoid arthritis patients (RA) whose disease could not be controlled by a single disease modifying antirheumatic drug (DMARD) were selected for the trial treatment. They continued the DMARD treatment used initially at its regular dose, and then started another DMARD regimen at 1/3 to 1/2 of the regular dose as an additive DMARD treatment, which we have designated as Additive Two DMARD Therapy (ATDT). The patients were followed until the end of 1992. In the 3 months of ATDT, the effectiveness of ATDT was obtained in 42 (58.3%) patients who showed more than a 30% decrease in the initial Lansbury's activity index (AI). The rate of side effects at 3 months were 5.6%. Tiopronin, bucillamine or salazopirine added to gold sodium thiomalate or tiopronin were suggested as the recommended DMARD combinations for ATDT. The suppressive effects on AI, ESR, CRP and rheumatoid factor continued for as long as 18 to 24 months. The mean period of ATDT was 21.7 months and that at which ATDT proved useful was 31.9 months. A discontinuation of the first DMARD treatment without any following disease aggravation was obtained in 10 of 15 patients whose disease activity had been sufficiently suppressed for longer than a year. In conclusion, ATDT was suggested to be a useful way of treating RA patients whose disease activity could not be controlled by a single DMARD treatment, as well as a way of evaluating the next DMARD while the ongoing DMARD was observed to gradually lose its initial drug effect.

A disease activity index: its use in clinical trials and disease assessment in patients with rheumatoid arthritis

Measuring disease activity is important in the assessment of patients with rheumatoid arthritis (RA). The value of composite indices in determining activity is discussed. A validated index, the Stoke index, has been used in clinical trials of combination therapy in patients with RA, both to evaluate efficacy and to stratify response to single-agent therapy before randomization to combination treatment. Disease activity determines the use of disease-modifying antirheumatic drugs. Should these drugs be used in mild RA when disease activity is low? Results of a study comparing hydroxychloroquine with placebo in this situation suggest that they should. Finally, the outcome of suppressing disease activity over a 5- to 10-year period is unknown. Measured either radiologically or functionally, preliminary data suggest that the lower the mean disease activity over time, the more favorable the outcome.

Early, aggressive therapy for rheumatoid arthritis: concerns, descriptions, and estimate of outcome

The past few years have witnessed changing perceptions about rheumatoid arthritis (RA); it is now considered a serious systemic disease that confers not only physical and social morbidity but also earlier mortality. The long-term outcome of sequential monotherapy based on the therapeutic pyramid has been disappointing. A review of prognostic factors, acute disease activity measures, functional measures, and the results of preliminary trials with combination therapy suggests that specific goals of treatment can be established and that logical, aggressive treatment in early disease can be accomplished. These goals should include prompt control and continuous reduction of the active joint count to < or = 4 and normalization of acute-phase reactants. The "graduated-step paradigm" of treatment designed with these goals in mind is described, and a retrospective series that gives an estimate of outcome with its use is reported.

Comparison of auranofin, methotrexate, and the combination of both in the treatment of rheumatoid arthritis. A controlled clinical trial

OBJECTIVE

To compare the relative safety and efficacy of auranofin (AUR), methotrexate (MTX), and the combination of both in the treatment of active rheumatoid arthritis (RA).

METHODS

Three hundred thirty-five patients with active RA were entered into a 48-week, prospective, controlled, double-blind, multicenter trial and were randomly assigned to 1 of 3 treatment groups.

RESULTS

Two hundred eleven patients completed the trial. No remissions were seen, and there were no statistically significant differences among the treatment groups in the clinical or laboratory variables measured. Patients taking AUR alone had a slower onset of response than did patients taking MTX alone or in combination. Withdrawals because of adverse drug reactions were slightly more common for those taking combination therapy, but the differences were not statistically significant. Withdrawals because of lack of response were more common for single-drug therapy, with the difference between AUR and the combination reaching statistical significance. No unexpected adverse drug effects were identified, and all reactions resolved without sequelae.

CONCLUSION

Except for fewer withdrawals because of lack of response, combination therapy did not demonstrate any advantage in efficacy over single-drug treatment within the time frame of the study.

Therapy for rheumatoid arthritis: combinations of disease-modifying drugs and new paradigms of treatment

The last 10 years have witnessed a change in the way rheumatologists view rheumatoid arthritis (RA). It is no longer considered a slowly progressive disease limited to the joints, but rather an aggressive systemic disease that results in clinically significant morbidity early in its course and can contribute to excess mortality. Heightened awareness of the health impact of RA has spurred a search for effective therapy to be applied early in the course of disease for patients with moderate to severe RA. Combinations of disease-modifying antirheumatic drugs (DMARD) have become an increasingly popular alternative to sequential monotherapy. In this report, we review published series of patients with RA who have been treated with combinations of DMARDs, sometimes including chemotherapeutic agents, with some critical comment. Published paradigms of treatment are also reviewed and a new strategy is presented. The "step-down bridge" strategy allows early treatment with at least four DMARDs, but may place some patients with mild disease at an inappropriately high risk of adverse effects. The "sawtooth" strategy gives little guidance as to which DMARD(s) should be chosen for initial treatment. We describe a "graduated-step" strategy that provides numerical grading to match disease severity and disease activity with appropriate initial therapy and that facilitates therapeutic decisions throughout the course of treatment.

Intra-articular steroids: confounder of clinical trials

The effect of intra-articular (i-a) steroid injection on ESR and C-reactive protein (CRP) in rheumatoid arthritis (RA) was investigated. One week following injection of 1 or 2 knees there was a significant fall in ESR (p less than 0.0001) and CRP (p less than 0.01) in a cohort of 20 RA patients. The mean drop for both ESR and CRP was 46%. This effect lasted over a variable period up to 6 months. A survey of 50 published drug efficacy studies in RA revealed that, while 44 used ESR and 20 CRP as efficacy measures, 37 neither excluded nor recorded i-a steroid injections during the study. Steroid injections were excluded in 8 studies and recorded in 5, being used as an outcome measure in 2 of these. It is recommended that the frequency with which i-a injections are used in drug efficacy studies is reported and that they are avoided in the 3 months preceding an outcome measurement if ESR or CRP are being used as outcome measures.

D-penicillamine

D-Pen represents an effective treatment for a proportion of patients with RA and PSS. Its status in the treatment of juvenile RA is uncertain. The best results will be obtained by a skillful, careful physician maintaining careful surveillance for toxicity. Neither the mode of action nor the mechanisms of toxicity are well understood in RA. Consequently, safer and more effective analogues of D-pen have not been produced.