In previous decades, a pyramid model dominated the treatment of rheumatoid arthritis. Early in the course of the disease, salicylates were used to control pain and stiffness. If salicylates were poorly tolerated or began to lose efficacy, they were discontinued and a different NSAID was used. As the efficacy of NSAID therapy waned and joint deterioration progressed, treatment with a DMARD was added. DMARDs were employed singly and sequentially for periods of up to 6 months before clinicians could determine their efficacy and switch to a new drug if necessary.
The most recent treatment paradigm calls for earlier, more aggressive treatment of rheumatoid arthritis. DMARDs are frequently employed along with NSAIDs in the initial treatment of the disease. The COX-2 inhibitors are often used because they are less likely to cause serious GI toxicity than are the nonspecific COX inhibitors. The usual DMARD of choice for patients with mild rheumatoid arthritis is hydroxychloroquine or sulfasalazine; methotrexate is used for those with moderate to serious disease. Other DMARDs are used if these agents are poorly tolerated or do not produce sufficient response. Combination therapy of methotrexate and another agent is also used to treat disease that is not responsive to individual DMARDs.
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