1. Disease Modifying Anti-Rheumatic Drugs (DMARDs) Immunomodulatory and immunosuppresive Xenobiotic – Gold salts – Azathioprine – Methotrexate Biological – Adalimumab – Infliximab

2. Indications – active synovitis not responsive to NSAIDs – rapidly progressive, erosive arthritis – dependence on steroids to control synovitis

3. MTX is one of the most active compounds in terms of frequency of remissions and time to onset of action and provide the best risk-benefit ratios. MTX alone or in combination with other agents has become the standard of care for moderate-to-severe RA. An initial MTX dose of 15 mg/week orally with escalation of 5 mg/month to achieve target doses of 25-30 mg/week or maximum tolerable doses was the optimal, evidence-based dosing strategy.

4. The most important and most common adverse events relate to liver and bone marrow toxicity (MTX, azathioprine, gold compounds), renal toxicity (parenteral gold salts), pneumonitis (MTX), allergic skin reactions (gold compounds), and infections (azathioprine).

5. Infliximab, a chimeric monoclonal antibody against TNF-alpha, is administered at doses of 3 mg/kg IV at weeks 0, 2, and 6 and then every 4-8 weeks, usually with MTX. Adalimumab, a recombinant human IgG1 monoclonal antibody specific for human TNF monoclonal antibody, is administered 40 mg SC every 2 weeks. These agents bind TNF and thus prevent its interaction with its receptors

6. Adverse effects associated with the biological agents include the generation of antibodies against these compounds, emergence of antinuclear antibodies, occasional drug-induced lupuslike syndromes, and infections

7. Glucocorticoids Indications – bridging time until DMARDs take effect – persistent synovitis despite NSAIDs and DMARDs – severe constitutional symptoms or extra-articular disease Oral administration of 5-20mg qd is sufficient for synovitis, 1mg/kg qd for severe cases Timely dose reductions and cessation are important because of the adverse effects associated with long- term steroid use.