Blackburn W D
Division of Immunology/Rheumatology, University of Alabama at Birmingham, Alabama 35233, USA.
Am J Med. 1996 Feb 26;100(2A):24S-30S. doi: 10.1016/s0002-9343(97)89543-5.
Conventional drug therapy in rheumatoid arthritis (RA) has failed to control the longterm morbidity and mortality associated with RA. Similarly, drug therapy for osteoarthritis (OA) can relieve symptoms, but it is not clear that it alters progression of disease. Three classes of drugs are widely used for treatment of RA: nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and the slow-acting agents. In most patients, pharmacologic therapy is initiated with NSAIDs. These drugs can relieve symptoms but do not alter the course of the disease. The gastrointestinal and other side effects attributed to these compounds are well known. Similarly, use of corticosteroids can provide rapid pain relief to patients with RA and, if used in low doses, pose limited risk of toxicity. Slow-acting agents, including gold, d-penicillamine, and methotrexate, appear to decrease radiographic progression and improve clinical and biochemical indicators of RA. Therefore, newer treatment philosophies encourage use of slow-acting agents earlier in the course of the disease in order to prevent or diminish bone and joint erosions and destruction and other manifestations of disease progression. Drugs under investigation for the treatment of arthritis appear to exhibit disease-modifying or immunomodulating properties. Tenidap is a novel agent that possesses a dual mechanism of action: cyclooxygenase inhibition and modulation of cytokine activity. In addition, several biologic agents, including antibodies to tumor necrosis factor-alpha (TNF-alpha) and to intercellular adhesion molecule-1, may prove useful. These immunotherapeutic strategies are based on knowledge of the role of cytokines in the inflammatory process in arthritis. Osteoarthritis may be managed using drug and nondrug modalities. Weight loss is especially important when OA is in the weight-bearing joints. Biopsies of synovium from patients with OA show evidence of inflammation, but whether this disease should be treated with analgesics alone or with anti-inflammatory drugs remains controversial. Other treatment modalities, including tissue transplants and cytokine-modulating drugs, are emerging for the potential therapy of OA. Surgery may also be appropriate if drug treatment fails to control symptoms.
类风湿关节炎（RA）的传统药物治疗未能控制与RA相关的长期发病率和死亡率。同样，骨关节炎（OA）的药物治疗可以缓解症状，但尚不清楚其是否能改变疾病的进展。三类药物广泛用于RA的治疗：非甾体抗炎药（NSAIDs）、皮质类固醇和慢作用药物。在大多数患者中，药物治疗从使用NSAIDs开始。这些药物可以缓解症状，但不会改变疾病的进程。这些化合物引起的胃肠道及其他副作用是众所周知的。同样，使用皮质类固醇可以为RA患者迅速缓解疼痛，并且如果小剂量使用，毒性风险有限。慢作用药物，包括金制剂、青霉胺和甲氨蝶呤，似乎可以减少影像学进展，并改善RA的临床和生化指标。因此，新的治疗理念鼓励在疾病过程中更早地使用慢作用药物，以预防或减少骨和关节侵蚀、破坏以及疾病进展的其他表现。正在研究用于治疗关节炎的药物似乎具有改善病情或免疫调节特性。替硝唑是一种具有双重作用机制的新型药物：抑制环氧化酶和调节细胞因子活性。此外，几种生物制剂，包括抗肿瘤坏死因子-α（TNF-α）抗体和抗细胞间黏附分子-1抗体，可能会被证明是有用的。这些免疫治疗策略基于对细胞因子在关节炎炎症过程中作用的认识。OA可以通过药物和非药物方式进行管理。当OA累及负重关节时，减轻体重尤为重要。OA患者滑膜活检显示有炎症迹象，但这种疾病是仅用镇痛药治疗还是用抗炎药治疗仍存在争议。其他治疗方式，包括组织移植和细胞因子调节药物，正在成为OA潜在的治疗方法。如果药物治疗无法控制症状，手术也可能是合适的。
