Second-line treatments to treat rheumatoid arthritis are being pushed to the front at greater risk to the patient.
Medicine's response to arthritis and rheumatoid arthritis in particular has been to throw ever more powerful drugs at a condition they don't understand.
Rheumatologists are beginning to routinely subject sufferers to an alarming range of drugs whose side effects range from death, blindness, cancer and mental disorders.
Many of these drugs are powerful immunosuppressants and cell-blockers, developed to treat more serious and life threatening conditions. Methotrexate, which is fast becoming the treatment of choice in the US for rheumatoid arthritis, was developed as a cancer drug. Penicillamine, a component of penicillin, and several anti-malaria drugs are also being added to the options open to the rheumatologist.
In the wrong hands, methotrexate is a potential killer, causing liver and kidney damage, lung disease and bone marrow suppression. (Physicians' Desk Reference 1992). Not surprisingly, the PDR, the US's drugs reference bible, reports deaths among arthritis patients on the drug. It stresses that the drug should be given only by "physicians whose knowledge and experience includes the use of anti-metabolite [substances which fundamentally changes the body's metabolism] therapy".
This already powerful drug can form a lethal cocktail when taken with other drugs. Some rheumatologists are combining drugs, such as methotrexate with non-steroidal anti-inflammatory drugs (NSAIDs), which, on their own, account for 4,000 deaths in Britain every year.
Methotrexate is one in a family of drugs called slow-acting antirheumatic drugs (SAARDs) which have been considered as second-line therapies. Traditionally, they have been prescribed to patients with advanced rheumatoid arthritis to slow its progress.
Front-line treatments have included high-dose aspirin, to reduce inflammation in the joints, but continual use has caused stomach bleeding. The newer, front-line treatment are NSAIDs, a group of pain killers which have brought their own host of side-effects such as ulcers and life-threatening gastrointestinal problems (see WDDTY vol 2, no 12).
But because front-line treatment can only ease the pain, many specialists are pushing the SAARDs to the front to slow the progress of rheumatoid arthritis and to help prevent damage to the joints. They are working on the theory that arthritis is a malfunction of the immune system; as such, they are using powerful immunosuppressants, cell-blockers and steroids to arrest the condition.
Favourite among the SAARDs has always been gold, given either as an injection or in tablet form. But it is so toxic that about 35 per cent of patients have suffered side effects bad enough to stop the treatment (Arthritis Rheum 1990: 33; 1449-61).
In fact, gold is considered so toxic that many specialists are turning to methotrexate as a safer option! (New Eng Jrnl of Med, 12 May 1994.)
Common among the side-effects of most of the SAARDs are nausea, vomiting, abdominal pain and diarrhea. Even after suffering these reactions, the patient may be no better off. Benefits have been either observational or studied only over a short period. One of the few double-blind studies which tested the second-line treatments against a placebo among 3,439 arthritis patients concluded that the benefits of the drugs were uncertain. (J Clin Epidemiol 1993; 46(3): 315-21).