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SP0109 How useful are conventional dmards and when should biologics, in particular tnf blocking agents, be used?
  1. L Van de Putte
  1. Rheumatology, University Medical Centre Nijmegen, Nijmegen, The Netherlands


Rheumatoid arthritis is a chronic, systemic, inflammatory disease with polyarthritis as the most dominant clinical sign. Pharmacotherapy is, increasingly, the corner stone of treatment. Conventional drug treatment consists of NSAIDs, (combinations of) DMARDs and corticosteroids.

In recent years dramatic changes have occurred in the treatment of the disease. These can be categorised as follows:

  • Early treatment: it has become clear that (irreversible) joint damage occurs relatively early in the disease course. In addition recent studies have indicated that more advanced stages of the disease are more difficult to treat.

  • More and more effective DMARDs. Some of these DMARDs have a relatively fast mode of action, allowing for more adequate drug titration towards efficacy. Another interesting development is the attempt towards side effect reduction. Successful examples are comedication with folic acid during methotrexate treatment and of biphosphonate during corticosteroid treatment.

  • Target oriented therapies: whereas anti-T cell therapies so far have not been consistently successful, TNF blocking agents have revolutionised treatment of rheumatoid arthritis. These agents work fast and give a good response in over half of the patients. In addition it has been shown that these therapies have the potential of stopping (radiographic) joint damage. From a practical point of view there are at least a few problems: these therapies are rather expensive and long term follow-up data are not yet available. Especially the latter is important, since TNF plays an important role in inflammation and immunity and thefore chronic suppression may also have negative consequences. Furthermore, it is advised that during TNF blocking therapies, doctor and patiënt should be alert on the presence or development of infectious diseases.

In view of the above considerations, current use of TNF blocking therapies should be restricted to patiënts with active disease, despite adequate DMARD therapy, including methotrexate. Possible future strategies will be discussed.

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