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Immunosuppressive therapy for rheumatoid arthritis

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Rheumatoid Arthritis: The Treatment Controversy

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Abstract

Immunosuppressive drugs have been used to treat patients with severe rheuma­toid arthritis for the last thirty years. The drugs commonly used are cyclophos­phamide and chlorambucil (alkylating agents), azathioprine (purine analogue) and methotrexate (folic acid analogue). A Medline search and review articles were used to identify clinical trials of these drugs in patients with rheumatoid arthritis. A scoring system was used to assess the design and execution of these trials.

There is evidence that all four immunosuppressive drugs studied can reduce synovitis assessed by a range of clinical measurements. The occurrence of spontaneous remissions in rheumatoid arthritis, and the known response to bed rest and anti-inflammatory drugs, render the results obtained from controlled trials of cyclophosphamide and azathioprine more convincing. Reports on the use of immunosuppressive drugs for severe vasculitic manifestions of rheumatoid arthritis are largely confined to case reports. These suggest that cylcophosphamide and chlorambucil are effective in these patients, but azathioprine was found to be ineffective in one trial. Cyclophosphamide, but not other drugs, has been shown to retard radiographic progression of joint destruction.

Adverse effects occurring with all four drugs include bone marrow depression, gastro-intestinal symptoms, rashes and increased susceptibility to infections. Data on the possible increased risk of malignancy in patients treated with immunosuppressive drugs for non-malignant conditions are still being collected; cautious interpretation is required because of the excess frequency of lymphoproliferative malignancy in patients with rheumatoid arthritis.

Until further information is available, use of immunosuppressive drugs, particularly alkylating agents, in rheumatoid arthritis should be confined to patients with life-threatening complications such as severe vasculitis and patients with severe progressive joint disease.

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Authors
  1. C. C. Erhardt
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Editors and Affiliations

  1. Department of Rheumatology, Westminster Hospital, London, UK

    David H. Goddard MD, MRCP

  2. Department of Rheumatology, Charing Cross Hospital, London, UK

    Robin C. Butler MB, MRCP

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© 1984 D. H. Goddard and R. C. Butler

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Erhardt, C.C. (1984). Immunosuppressive therapy for rheumatoid arthritis. In: Goddard, D.H., Butler, R.C. (eds) Rheumatoid Arthritis: The Treatment Controversy. Palgrave, London. https://doi.org/10.1007/978-1-349-08808-9_5

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