Rheumatoid Arthritis: The Treatment Controversy: Proceedings of the meeting held at Stratford-on-Avon 9 and 10 March 1984 PDF
Preview Rheumatoid Arthritis: The Treatment Controversy: Proceedings of the meeting held at Stratford-on-Avon 9 and 10 March 1984
Rheumatoid Arthritis: The Treatment Controversy Rheumatoid Arthritis: The Treatment Controversy Proceedings of the meeting held at Stratjord-on-A von 9 and 10 March 1984 Edited by David Goddard and Robin Butler M MACMILLAN ©D. H. Goddard and R. C. Butler 1984 All rights reserved. No reproduction, copy or transmission of this publication may be made without written permission. No paragraph of this publication may be reproduced, copied or transmitted save with written permission or in accordance with the provisions of the Copyright Act 1956 (as amended). Any person who does any unauthorised act in relation to this publication may be liable to criminal prosecution and civil claims for damages. First published 1984 Reprinted 1986 The symposium 'Rheumatoid arthritis: The treatment controversy' was organised by Medi-Cine Communications International Ltd and supported by a grant from Dista Products Ltd. Published by THE MACMILLAN PRESS LTD HoundmiIIs, Basingstoke, Hampshire RG21 2XS and London Companies and representatives throughout the world This edition is published in the USA and Dependencies by SHERIDAN HOUSE INC. 145 Palisade Street, Dobbs Ferry, New York 10522 British Library Cataloguing in Publication Data Rheumatoid arthritis. I. Rheumatoid arthritis I. Goddard, D. H. II. Butler, R. C. 616.7'22 RC933 ISBN 978-0-333-41920-5 ISBN 978-1-349-08808-9 (eBook) DOI 10.1007/978-1-349-08808-9 Contents Foreword vi List of participants vii Section 1 The need for disease-modifying drugs 3 D. H. Goddard Gold in the treatment of rheumatoid arthritis 8 R. C. Butler Penicillamine 37 D. L. Scott Discussion 56 Section 2 Systemic corticosteroids in the treatment of rheumatoid arthritis 75 M. Byron Discussion 87 Section 3 Immunosuppressive therapy for rheumatoid arthritis 97 C. C. Erhardt Discussion 119 Section 4 Cost versus benefit: a treatment audit 131 T. Price Discussion 150 Section 5 Conclusions 159 H. L. F. Currey Index 163 v Foreword At a combined meeting of the Heberden Society and British Association for Rheumatology and Rehabilitation held in September 1982 in Cambridge, the motion 'Remission-inducing drugs are not worthwhile' was debated. Although the motion was defeated overwhelmingly, a sizeable minority voted in favour and many abstained. Thus, despite the fact that remission-inducing drugs are prescribed by rheumatologists every working day, their use remains highly controversial. How, and indeed if, they should be used, and which studies are needed to answer these questions were the subject of a stimulating meeting held by senior registrars in rheumatology together with a panel of senior members of the specialty on 9 and 10 March 1984 at Stratford-on-Avon. The programme was designed to encourage an exchange of views between participants. Introductory papers reviewed existing background information and these were followed by open discussions. This book contains the proceedings of that meeting. Inevitably many more questions were raised than were answered but definite proposals for future studies were made which, it is hoped, may provide new approaches to the treat ment of rheumatoid arthritis. We would like to thank Dista Products Ltd without whose generous financial support the meeting would not have been possible. Our grateful thanks also go to Medi-Cine Communications International Ltd for their excellent organisation and secretarial help. DHG and RCB London April 1984 vi List of participants CHAIRMEN AND SPEAKERS Dr R. C. Butler, MB, MRCP Department of Rheumatology, Charing Cross Hospital, London Dr M. Byron, MB, MRCP Department of Rheumatology, Nuffield Orthopaedic Centre, Oxford Dr C. C. Erhardt, BSc, MD, MRCP Department of Rheumatology, Charing Cross Hospital, London Dr D. H. Goddard, MD, MRCP Department of Rheumatology, Westminster Hospital, London Dr T. Price, MA, MRCP Department of Rheumatology, Middlesex Hospital, London Dr D. L. Scott, BSc, MD, MB, MRCP Department of Investigative Pathology, University of Birmingham PANEL Prof. P. A. Bacon, MD, FRCP Department of Rheumatology, Rheumatism and Research Wing, The Medical School, University of Birmingham Prof. D. A. Brewerton, BSc, MD, FRCP Department of Rheumatology, Westminster Hospital, London Prof. H. L. F. Currey, M MED, FRCP Bone and Joint Research Unit, The London Hospital Medical College Prof. R. N. Maini, MB, FRCP Department of Rheumatology, Charing Cross Hospital, London Prof. G. Nuki, MD, FRCP Department of Medicine, Rheumatic Diseases Unit, Northern General Hospital, Edinburgh Prof. G. S. Panayi, MD, FRCP Department of Medicine, Guy's Hospital Medical School, London Dr M. L. Snaith, MD, FRCP Department of Rheumatology and Rehabilitation, University College Hospital, London vii viii Rheumatoid arthritis: The treatment controversy OTHER PARTICIPANTS Dr A. N. Bamji, MB, MRCP Department of Rheumatology, Brook General Hospital, London Dr R. M. Bernstein, MA, MB, MRCP Department of Rheumatology, Hammersmith Hospital, London Dr A. J. Crisp, MA, MB, MCRP Department of Rheumatology, Addenbrooke's Hospital, Cambridge Dr W. Dawson, DSc, FPS Dista Products Ltd, Basingstoke Dr P. Emery, MA, MB, MRCP Department of Rheumatology, Guy's Hospital, London Dr A. J. Griffin, MB, MCRP Departmen t of Rheumatology, The Middlesex Hospital, London DrW. H. Lyle, MD Dista Products Ltd, Basingstoke Dr J. S. Reeback, BSc, MB, MRCP Bone and Joint Research Unit, The London Hospital Dr D. M. Reid, MB, MRCP Department of Rheumatology, City Hospital, Aberdeen Dr M. B. Richter, MB, FRACP Department of Rheumatology, Northwick Park Hospital, Harrow Dr D. G. I. Scott, MD, MRCP Department of Rheumatology, Selly Oak Hospital, Birmingham Dr A. J. Silman, MSc, MB, MRCP, MFCM Department of Rheumatology, The London Hospital SECTION 1 The need for disease-modifying drugs D.H. Goddard SUMMARY As yet there is no clearly established way in which the effects of disease-modifying drugs can be evaluated in the treatment of rheumatoid arthritis. This is because there is difficulty in determining which parameters accurately reflect disease activity and disease progression. The Stanford health assessment questionnaire, together with newer radiological techniques, may provide the means by which these assessments can be made. These treatments are potentially toxic. Studies to date have indicated that only a small percentage of patients starting treatment with disease-modifying drugs may derive long-term benefit. A high percentage of patients drop out because of adverse reactions. When analysed in terms of cost versus benefit these treatments may be neither effective nor efficient. INTRODUCTION The need for treatment Patients with rheumatoid arthritis pose a particularly difficult therapeutic challenge. The aetiology of the disease is unknown. It runs a variable course with frequent exacerbations and remissions. Many different systems other than the joints may be affected. The severity of the disease varies from a relatively benign locomotor disorder to a malignant systemic disease with widespread inflamma tory damage. Treatment objectives must therefore take into account variation in the severity of the disease, and its likely outcome. In order to determine which therapy is likely to be most effective, it is necessary to identify features of the disease which will serve as reliable prognostic indicators. The aim of treatment can be defined as a return to complete functional capacity. Any drug which significantly improves functional capacity (or stops its deterioration) can be regarded as being therapeutically useful. 3
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