- Indian Rheumatology association
D-Penicillamine was mostly used in the treatment of systemic sclerosis. I have not used it in the treatment of rheumatoid arthritis (RA) because of its side effects and limited availability. It was abandoned in view of the better and more easily available drugs. I do not think it is required anymore.
Azathioprine is still a very useful drug in lupus and RA related Interstitial lung disease (ILD). I use it in combination with hydroxychloroquine and methotrexate, especially when they are not giving adequate relief in maximum doses. I have used azathioprine as an add on therapy in what is called aggressive RA or progressive RA. I have never given it in doses above 100 mg, when using it along with hydroxychloroquine and methotrexate. It works better in lupus lung and other connective tissue disease (CTD) associated lung diseases. In such patients, I have used it in doses of up to 200 mg for short periods. Before considering biologics or JAK inhibitors, one should seriously consider using azathioprine in RA. In terms of cost, availability and safety profile, it is a very good add on drug.
Cyclosporine was extensively used in the 1990s and early 2000, but the cost and fear of nephrotoxicity (Patients – relatives, Google advice) restricted its use in RA. I still use it rarely in refractory cases if patients cannot afford biologics or when JAK inhibitors are contraindicated.
Methotrexate (MTX), Hydroxychloroquine (HCQ), Sulfasalazine (SSZ), Leflunomide (LEF) and others are extensively used in the treatment of all types of arthritis, either as monotherapy or in combination.
In the last 45 years, no drug, including biologics and JAK inhibitors has matched MTX in terms of cost, effectiveness, availability and side-effect profile. MTX is also indicated for use along with biologicals and JAK inhibitors, improving their efficacy and reducing their antigenicity. If used in adequate doses, MTX still remains an anchor drug.
Personally, I still use glucocorticoids as a bridging therapy. Side-effects are mainly due to the rampant abuse by non-rheumatologists, alternate system practitioners and patients themselves. There were some studies from Canada where 2.5 mg to 5 mg of Prednisolone was used up to 7 years without any major problems. I personally use it in refractory RA patients for a long time or those who cannot afford biologicals. More collaborative cohort studies are needed in our country regarding its use in longer duration.
We have brilliant, hardworking and lateral thinking young rheumatologists, but the tendency to jump to using either a biological or JAK inhibitor without giving a fair trial of csDMARDs, i.e. in adequate and optimal doses for sufficient time (3 to 6 months), is increasing. CsDMARDs have served well for the last 50 years and they will continue to do so. Rampant use of JAK inhibitors must be stopped.
I started my rheumatology training and practice in 1978 in the United Kingdom. I came back to India in 1983 to start rheumatology services, when lab facilities and medicines were not easily available. I seem to have done fairly well, particularly in RA, utilising just conventional synthetic DMARDs along with judicious use of steroids.
If you look at my patient base of 3,60,000 plus, only 5% of them are on biologicals and roughly 10% of them are on JAK inhibitors. I cannot cite any particular reference because all these life lessons have been accumulated by me in the guidance of some of the greatest masters of rheumatology and by my own trial and error experience taking into account patient safety, affordability and improvement in patient’s quality of life.
