Signs of RA have been found in the skeletal remains of Stone Age humans, and descriptions of RA have been found in the writings of doctors and healers for thousands of years. The ancient physicians understood that the disease began with pain and stiffness and progressed to increasing joint swelling, joint deformity, limitation of motion, and disability. When physicians first began to treat RA effectively, they used drugs such as salicylic acid (aspirin) and ibuprofen (Motrin.) Doctors call these drugs nonsteroidal anti-inflammatory drugs (NSAIDs). While these drugs reduced the pain, stiffness, and swelling of inflamed joints, they did little to alter the course of the disease. For many people with RA, their disease continues to progress toward disability despite the use of NSAIDs. In an effort to improve on this therapy, medical researchers looked for medications that would both treat the symptoms of RA and prevent disease progression.
Extensive clinical research led to the introduction of a group of medications that were thought to alter the course of RA—the so-called disease-modifying antirheumatic drugs (DMARDs). DMARDs improve the signs and symptoms of RA and were thought to slow the progression of joint degeneration in some patients. Their onset of action is slower than that of NSAIDs or corticosteroids; they improve symptoms of RA only after several weeks to months in some cases. In addition, DMARDs are associated with more adverse side effects than the NSAIDs.
To decide whether use of a DMARD is necessary, a physician may evaluate the condition of the patient's joints by taking x-rays of those joints that are swollen and tender. If the x-rays reveal the development of erosions or joint space narrowing, it is a clear indication for DMARD therapy. Physicians should not wait for these changes to occur before treating patients, however. Once a patient experiences persistent disease activity, his or her doctor should consider prescribing one of the DMARD agents.
Once a patient experiences persistent disease activity, his or her doctor should consider prescribing a diseasemodifying antirheumatic drug.
Many factors influence which particular DMARD a physician will choose for a patient. The doctor must consider the following questions:
- How effective is this medication compared to the other DMARDs?
- Will administering a particular drug be more or less convenient for the patient?
- What are the requirements of the monitoring program for this drug?
- How expensive is this drug, and what are the costs of tests to monitor the patient? Can the patient afford to pay for the DMARD?
- What is the likelihood of the patient being able to comply with this drug regimen?
- Does the patient have other medical conditions that might interfere with the effectiveness of this medication?
- Are the risks associated with the DMARD appropriate given the severity of the patient's disease?
- What is the physician's level of familiarity with this medication? Is he or she confident enough to administer it, deal with any side effects, and monitor the patient while he or she is on this drug?
You should discuss with your doctor the benefits and risks of every medication you take.