Internal Medicine

0521779407-18 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 8:1

1302 Rheumatoid Arthritis

➣Bad prognosis: methotrexate (MTX)

Best combination of efficacy, safety & cost: 70% of pts continue

it for 5 years or more

If response inadequate, add SSZ, HCQ, leflunomide (2/3 of

MTX responders require this “step up”)

MTX+SSZ+HCQ substantially better than MTX or MTX+

HCQ in randomized trial

If response still inadequate, add or switch to anti-TNF agent,

including etanercept, infliximab, adalimumab (>70% response

rate, serious infections as complications) or anti IL-1 agent,

anakinra (30% response rate).

■Azathioprine, gold salts, cylcosporine are also options

Side Effects & Complications

■NSAIDs: decreased renal function, GI toxicity (selective COX-2

inhibitors [celecoxib] avoid GI but not renal problems)

■HCQ: retinal damage

■SSZ: leukopenia, rash

■MTX: cirrhosis, pneumonitis

■Minocycline: skin pigmentation

■Leflunomide: diarrhea & liver disease

■Anti-TNF or anti-IL-1 biologics: infections up to 5 per 100 pnt-years

■Azathioprine: liver disease, leukopenia

■Gold salts: rash, membranous glomerulopathy, cytopenia

■Cylcosporine: increased creatinine

Contraindications

■NSAIDS: renal failure, peptic ulcer disease

■All DMARDs: potential for pregnancy (prednisone safest)

■MTX: alcohol intake, liver disease, lung disease

■HCQ: retinal disease

■SSZ: allergy to sulfa drugs

■Leflunomide: liver disease

■Biologics: underlying infection, cost (>$10,000/yr)

follow-up

■Initial treatment: 4–6 weeks while adjusting doses & choice of drugs

■Routine: 3-month intervals at a minimum while stable

■Monitor toxicities (eg, liver function on MTX) every 6–8 weeks

complications & prognosis

■Extra-articular involvement