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Rheumatoid arthritis (RA) is a chronic, disabling autoimmune disease characterized by progressive joint destruction and functional decline, together with a significant increase in morbidity and mortality. Along with an improved understanding of the disease and advances in technology, the treatment of RA has evolved from a pyramid-based approach to the early and aggressive use of conventional disease-modifying antirheumatic drugs (DMARDs) such as methotrexate (MTX), gold, hydroxychloroquine, d-penicillamine and sulfasalazine as the cornerstone of therapy.
Although the new and expensive biologic DMARDs that have more specificity to cytokines have shown promise in the treatment of RA at present, further evidence is needed to demonstrate their superiority over conventional DMARDs as initial therapy. Thus, conventional DMARDs still remain the first choice for monotherapy or combination treatment in patients with RA.
Several clinical trials demonstrated the effectiveness of combination among conventional DMARDs in patients with RA and supported their use. The findings summarized that the combination with MTX as triple therapy (e.g. MTX, hydroxychloroquine and sulfasalazine) or double therapy (e.g. MTX plus either hydroxychloroquine or sulfasalazine) demonstrated superiority over monotherapy. While combination with sulfasalazine (a derivative of less absorbable sulfonamides) has shown fewer adverse events and provide better tolerability in long-term use. The action of sulfasalazine on RA depends mainly on one of its metabolites.
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