CATEGORY-III SYMPTOM-MODIFYING ANTIRHEUMATIC DRUGS - A COMPARATIVE REVIEW

The antirheumatic drugs used in the treatment of rheumatoid arthritis have recently been reclassified, There are 2 main groups: (a) symptom-modifying antirheumatic drugs, including nonsteroidal anti-inflammatory drugs (category I), corticosteroids (category II) and slower-acting drugs such as gold, methotrexate, sulfasalazine and cytotoxic agents (category III); and (b) disease-controlling antirheumatic therapy. The category III symptom-modifying drugs are compared, in particular methotrexate with sulfasalazine; gold with penicillamine; cyclophosphamide with azathioprine; cyclosporin; and hydroxychloroquine with chloroquine. Comparative studies of these drugs include a meta-analysis of short term trials (<1 year), with the end-points being drug efficacy and toxicity. The drugs with the best efficacy : toxicity ratio were hydroxychloroquine and methotrexate. From these studies, methotrexate is the drug of first choice for mild to severe rheumatoid arthritis. Hydroxychloroquine with its low toxicity is the drug of choice for mild rheumatoid arthritis. These data are also supported by survival analysis of drug therapy. If duration of therapy is assumed to be a measure of efficacy in the long term, then methotrexate is the most effective drug and hydroxychloroquine the least toxic.