ReviewRheumatoid arthritis
Section snippets
Clinical features
The range of presentations of rheumatoid arthritis is broad, but disease onset is insidious in most cases, and several months can elapse before a firm diagnosis can be ascertained. The predominant symptoms are pain, stiffness, and swelling of peripheral joints (Panel 1). The clinical course of the disorder is extremely variable, ranging from mild, self-limiting arthritis to rapidly progressive multisystem inflammation with profound morbidity and mortality (Panel 2). Analyses of the clinical
Genetic data
The results of several studies have shown a higher disease concordance among monozygotic twins (12–15%) than dizygotic twins (4%), implying the influence of genetic factors.6, 7 Heritability analysis of these studies suggests that about 60% of a population's predisposition to rheumatoid arthritis can be accounted for by genetic factors,8 although on analysis of twin pairs concordant for rheumatoid arthritis, striking diversity in disease severity was noted.8, 9
Analysis of genetic markers has
Paradigm shift
The past decade has seen a major transformation in the treatment of rheumatoid arthritis in terms of approach and choice of drugs. The previous therapeutic approach, termed the therapeutic pyramid, generally involved initial conservative management with non-steroidal anti- inflammatory drugs (NSAIDs) for several years; disease- modifying antirheumatic drugs (DMARDs) were withheld until clear evidence of erosions was seen. DMARDs were then added individually in slow succession as the disease
Conclusions
The ability of the new anti-TNF-α biological response modifiers to intervene in the disease process has generated enthusiasm for therapeutic interventions and for the possibility of future drugs that target individual inflammatory pathways. However, this excitement is tempered by the potential for long-term side-effects and toxicity. Rare events that have now been seen with anti- TNF therapy include infections (Mycobacterium tuberculosis, fungal and bacterial sepsis), a lupus-like syndrome, and
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Sulfated hyaluronic acid gel for the treatment of rheumatoid arthritis in rats
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