Lack of research into long-term effects means the patient has to play a game of Russian roulette to discover whether he will develop symptoms worse than his condition. Fortunately, with gold treatment at least, an intolerance can usually be quickly spotted when the patient develops mouth sores or rashes.
Specialists do not understand how SAARDs work if and when they do but accept they can be highly toxic and even life-threatening (Drug and Therapeutics Bulletin, 1993; 31:18).
The overall impression is a stumble in the dark. As two American rheumatologists Joseph Cash and John Klippel concluded in their recent paper: ". . . substantial advances in the drug treatment of rheumatoid arthritis will require a much better understanding of the processes that propagate the disease and, ultimately, the identification of the factors that cause it." (New Eng Jrnl of Med, 12 May 1994).
Besides NSAIDS, here are the main orthodox treatments:
The traditional, and favoured, SAARD, even described by some rheumatologists as "the gold standard". A surprising title for a highly toxic treatment that can lead to fatal bone-marrow suppression (Drugs and Therapeutics Bulletin, 1993; 31: 18).
As it has been administered since the 1920s, it is staggering that there has never been a long-term trial to test for reactions.
It became the treatment of choice only because researchers misunderstood the causes of arthritis. German bacteriologist Robert Koch had shown that gold and other heavy metals could fight tuberculosis and other infectious diseases. As it was believed arthritis was an infection, the theory was that gold could treat it as well.
It can be administered either as an injection, the most common course, or in tablet form, introduced about seven years ago. The usual dose by injection is 50mg a week for 18 months, although the doctor should be monitoring carefully for early side effects such as skin rashes and mouth sores. More serious side effects include kidney problems and bone marrow suppression. Because of these concerns, gold tablets were developed. Early studies show they cause fewer side effects than injections (Arthritis Rheum 1990; 33: 1449-61), but conversely are also less efficacious (Ann Rheum Dis 1986; 45: 705-11).
Methotrexate is fast becoming the most popular second-line therapy in the US as it is supposedly less toxic than gold (J Cash and J Klippel, cited above). This is an astounding statement to make about a powerful drug developed to treat cancer and, if true, can apply only at very low dosages.
The usual dosage is between five and 15mg a week, and improvements have been noted in between 30 and 70 per cent of patients (Eur J Rheumatol Inflamm 1991; 11: 148-61).
However, the typical side effects of stomach complaints, nausea and anorexia can worsen dramatically if the dose is increased or the drug mixed with another. Damage to the liver and lungs has been reported (Ann Rheum Dis 1990; 49: 25-7). Death can occur with high doses, especially if the patient takes the dose daily instead of weekly (Drugs and Therapeutics Bulletin, 1993; 31: 18).
As the name sugggests, penicillamine is a component of penicillin and was originally developed to treat Wilson's disease (copper accumulation in the liver). For arthritis the daily maintenance dose can be as high as 750mg, although the patient is usually started with between 125 and 250mg to test for adverse reactions.