1. Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Chapter 73 Drug Therapy of Rheumatoid Arthritis

2. Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc.2 Drugs for Rheumatoid Arthritis  Rheumatoid arthritis (RA)  Autoimmune inflammatory disorder  Treatment  Relieve symptoms  Maintain joint function  Minimize systemic involvement  Delay progression of disease

3. Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc.3 Classes of Antiarthritic Drugs  NSAIDs  Nonsteroidal anti-inflammatory drugs  DMARDs  Disease-modifying antirheumatic drugs  Glucocorticoids  Adrenal corticosteroids

4. Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc.4 Drug Selection for Rheumatoid Arthritis  Protocol  Start with NSAIDs  If symptoms persist, add DMARDs  Glucocorticoids may be added until DMARDs take effect

5. Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc.5 DMARDs I: Major Nonbiologic DMARDs  Methotrexate  Sulfasalazine

6. Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc.6 Methotrexate  Most rapid-acting DMARD  Therapeutic effect: 3 to 6 weeks  Adverse effects  Hepatic fibrosis  Bone marrow suppression  GI ulceration  Pneumonitis

7. Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc.7 Sulfasalazine  Used to treat inflammatory bowel disease (IBD); now used for RA as well  Anti-inflammatory and immunomodulatory actions  Can slow progression of joint deterioration  GI side effects may be intolerable

8. Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc.8 Other DMARDs I: Major Nonbiologic DMARDs  Leflunomid (Arava)  Hydroxychloroquine (Plaquenil)

9. Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc.9 DMARDs II: Major Biologic DMARDs  Tumor necrosis factor inhibitors  Suppress immune function  Pose risk of serious infection  Work by neutralizing tumor necrosis factor (TNF) Etanercept (Enbrel) Etanercept (Enbrel) Infliximab (Remicade) Infliximab (Remicade) Adalimumab (Humira) Adalimumab (Humira)

10. Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc.10 Etanercept  New DMARD  Inactivates TNF  Use  Moderate to severe RA  Adverse effects  Infection (may be serious)  Injection-site reactions  Tuberculosis  Heart failure  Cancer  Other adverse effects