25 Years in Arthritis: New Treatments, New Hope

When MedPage Today contacted Dr. Joan Von Feldt to talk about the changes she'd witnessed in rheumatoid arthritis (RA) care in the past 25 years, she offered one piece of advice:

"I hope, in your article, you reflect the excitement that rheumatologists have in managing this disease, because it's so much more satisfying," said Von Feldt, a rheumatologist at the University of Pennsylvania.

In 1984, the outlook for newly diagnosed RA patients was grim: a regimen of often toxic drugs that might slow the onset of crippling pain, but not for very long. Younger women were advised to forget about having children because they probably would be too disabled for the rigors of motherhood. The best outcome for many patients was joint fusion or replacement surgery.

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"Our orthopedic surgeon came around to our offices two or three times a week to just kind of check in," Von Feldt recalled.

Today, although disease flares and progression can't be prevented entirely, doctors can now tell patients to expect long periods of remission and the availability of many effective, nonsurgical treatment options when their current regimens begin to fail.

Dr. Dennis Boulware, a rheumatologist at the University of Alabama at Birmingham, said he tells new patients that they can live normal lives.

"I would also mention one of my former patients with significant rheumatoid arthritis who ran and completed a marathon after we got her condition under control."

Out With the Gold

For RA patients in the mid-1980s, the gold standard for treatment was, in fact, gold.

"Parenteral gold salts ... are the preferred choice for first-line remission inducing drug therapy," according to a 1985 review article on RA management in the American Journal of Medicine.

Most patients would first receive either steroids or nonsteroidal anti-inflammatory drugs (NSAIDs), but since these do not slow destruction of the joints, physicians would eventually prescribe gold or other agents believed to modify the disease process.

At that time, recalled Dr. Nortin Hadler of the University of North Carolina at Chapel Hill, "gold salts were in favor ... drugs like sulfasalazine and methotrexate [were] just gaining ground."

Another option was the malaria drug hydroxychloroquine, also believed to inhibit the autoimmune process that drove the joint degradation.

Antimalarials were considered "effete," Hadler told MedPage Today in an e-mail, although hydroxychloroquine remains in common use for patients with mild and stable symptoms.

It wasn't long after that review was published that methotrexate replaced gold as the go-to drug for inducing symptom remission. It received FDA approval in 1988.

Boulware said he was already recommending it to patients in 1984. "I was fortunate to have completed a fellowship at the University of Washington in 1983 where methotrexate was used early as a remission-inducing agent (the term used at the time)," he said in an e-mail.

Gold was not a pleasant drug to take. Injectable versions induced mouth sores, skin rashes, and itching, while diarrhea was common with oral formulations.

It remains available but is seldom prescribed. "Gold is best used by a jeweler or a banker," said Dr. Eric Matteson of the Mayo Clinic, when asked if he ever considers it.

He called it "a poison," and added that the same could be said of penicillamine, another drug that was in vogue in the 1970s and early 1980s.

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