Treatment Strategy and Principles
Therapy for rheumatoid arthritis and other autoimmune pathologies requires a systematic and balanced approach. The primary goal of the clinician is to achieve sustained remission and protect the patient's joints from irreversible destruction.
A key rule in rheumatology is that treatment with disease-modifying antirheumatic drugs starts immediately once a definitive diagnosis is established.
To achieve maximum efficacy, a combination regimen is applied:
- DMARD (serves as the cornerstone of treatment, affecting pathogenesis).
- Nonsteroidal anti-inflammatory drugs (NSAIDs) for controlling current inflammation and pain.
- Glucocorticoids (GCs) in low doses.
The minimum continuous course of DMARD therapy is 3 months. This is because they are slow-acting agents; their therapeutic effect develops gradually.
Classification of DMARDs
DMARDs are divided into several classes based on their chemical structure and targets within the immune system:
- Gold compounds: classical representative is auranofin.
- 4-aminoquinoline derivatives: originally developed as synthetic antimalarial agents (chloroquine, hydroxychloroquine).
- Targeted therapy (proinflammatory cytokine inhibitors): specifically block inflammatory mediators. These include:
- Interleukin-1 (IL-1) receptor antagonists: anakinra.
- Tumor necrosis factor (TNF-alpha) inhibitors: etanercept, infliximab.
- Cytostatics and immunosuppressants: a broad group including methotrexate, leflunomide, azathioprine, sulfasalazine, and penicillamine.
Characteristics of Key Immunosuppressants
Let us examine several important drugs from the synthetic DMARD group, their mechanisms, and clinical features in more detail.
Azathioprine Pharmacologically, this is a prodrug. Upon entering the body, it is metabolized in the liver into active 6-mercaptopurine. This substance inhibits nucleic acid synthesis, thereby suppressing the proliferation of immune cells. It is used in rheumatoid arthritis (in combination with NSAIDs and low-dose GCs) and systemic lupus erythematosus. It is strictly contraindicated during pregnancy and lactation.
Penicillamine It is a structural analog of the amino acid cysteine. The drug effectively slows down bone tissue destruction in rheumatoid arthritis. Interestingly, in addition to rheumatology, it works as a potent antidote for heavy metal poisoning and is also prescribed for cystinuria.
Sulfasalazine Often used in mild forms of rheumatoid arthritis. In complex cases, a combination therapy regimen is used: sulfasalazine is prescribed together with chloroquine and methotrexate.
Toxicity and Side Effects
Interference with the immune system and the cell cycle inevitably carries serious risks that require constant monitoring.
| Drug / Group | Specific Risks and Side Effects |
|---|---|
| 4-aminoquinoline derivatives (chloroquine) | Ocular toxicity. Accumulate in eye tissues, causing retinopathy, corneal opacity, and decreased visual acuity. |
| Penicillamine | With prolonged use, causes nephrotoxicity (nephritis) and hematotoxicity (aplastic anemia). |
| Sulfasalazine | Potential development of leukopenia. |
Important Clinical Tactic: Regular ophthalmological monitoring is mandatory during treatment with chloroquine or hydroxychloroquine. At the very first visual complaints, the drug must be discontinued immediately.