Putte - Therapy of Systemic Rheumatic Disorders

Cover

Page i

edited by
Leo B. A. van de Putte
University Hospital Nijmegen
Nijmegen, The Netherlands
Daniel E. Furst
Virginia Mason Medical Center
Seattle, Washington
H. James Williams
University of Utah
Salt Lake City, Utah
Piet L. C. M. van Riel
University Hospital Nijmegen
Nijmegen, The Netherlands

Page ii

Library of Congress Cataloging-in-Publication Data

Therapy of systemic rheumatic disorders/edited by Leo B. A. van de Putte... [et al.]
p. cm.
Includes index.
ISBN 0-8247-9516-4 (alk. paper)
1. RheumatismChemotherapy. 2. ArthritisChemotherapy. 3.
Musculoskeletal systemDiseasesChemotherapy. I. Putte, Levinus Boudewijn
Abraham van de.
[DNLM: 1. Arthritis, Rheumatoiddrug therapy. 2. Vasculitisdrug therapy.
3. Arthritisdrug therapy. 4. Antirheumatic Agentstherapeutic use. WE 346
T398 1998]
RC927.T498 1998
616.723061dc21
DNLM/DLC for Library of Congress
97-36795
CIP

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Treatment of rheumatoid arthritis (RA) and other systemic rheumatic disorders remains a fascinating and rapidly changing field, requiring periodic updates as insights into the pathogenesis of these diseases improve and pharmacotherapeutic possibilities expand. Important improvements in disease assessment have had a profound influence on both the monitoring of various diseases and the timing and use of effective antirheumatic agents.

In terms of total burden of disease on society, rheumatoid arthritis remains a major problem. Recent insights into the pathogenesis of rheumatoid arthritis are beginning to identify new targets for therapy and new therapeutic strategies offer hope for better outcomes.

A major step forward has been the realization that early treatment with second-line agents (also called disease-modifying, remission-inducing, or slow-acting anti-rheumatic drugs) is appropriate, especially in RA. In the past, treatment with second-line agents was often delayed, because few drugs were available and serious side effects were feared. Recently, several observations have led to a more aggressive therapeutic approach in which second-line agents are given at the onset of the disease, often in combination. These observations include data indicating that: rheumatoid arthritis is both a chronic and potentially lethal disease, joint damage occurs in the early phases of the disease, and joint damage is irreversible whereas side effects are almost always reversible, if carefully monitored. In addition, early treatment has now been shown to slow joint damage as assessed by radiographs.

An important new development has been improvement in and standardization of methodology of disease assessment, including better disease activity measurements, response criteria and disease outcome measures. This, in turn, has led to improved disease monitoring, a better definition of drug efficacy and toxicity, and a better understanding of how drugs can be used.

This book deals primarily with those treatments that fundamentally influence the immunoinflammatory processes that underlie the systemic rheumatic disorders. It describes the aforementioned principles as they apply to the second-line agents presently available, from standard medications such as corticosteroids and gold to newer therapeutics such as sulfasalazine, methotrexate, or combination therapy. The text then proceeds into less-studied approaches, such as local therapies and biological agents.

Biological agents deserve particular attention. Advanced molecular biological techniques are now available, not only to unravel the disease process but also to construct agents that interfere with relevant pathogenetic processes. The recent successes with monoclonal antibodies against TNF- are just one example of what may await us in the future.

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Although the emphasis has been on treatment of rheumatoid arthritis, definite and welcome improvements have been made in the treatment of other systemic autoimmune rheumatic disorders. For instance, we now have a new taxonomy of vasculitides, and antibodies like ANCA now allow for better disease classification and monitoring. Also, newer syndromes, such as the antiphospholipid syndrome, have been defined. As in rheumatoid arthritis, there is a growing feeling that adequate treatment as early as possible may prevent or postpone irreversible organ damage.

This book provides a state-of-the-art overview of current therapeutic options, possible treatment dilemmas and recommendations, and how to use currently available drugs. It is hoped that this will be useful to all physicians who treat patients with systemic rheumatic disorders. It is also hoped that progress will be so fast that a new edition will be needed within a few years.

Leo B. A. van de Putte
Daniel E. Furst
H. James Williams
Piet L. C. M. van Riel

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