Abstract
Autoimmune joint diseases occur due to uncontrolled abnormal immune responses (autoimmunity). The commonest autoimmune diseases seen in clinical practice are rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis and un-differentiated arthritis. These are a source of significant morbidity and some mortality within the population. Non-biologic disease modifying anti-rheumatic drugs (Nonbiologic DMARD’s) commonly used in the treatment of these disorders include: methotrexate, sulpha-salazine, leflunomide, hydroxychloroquine and gold. However, a significant proportion of patients do not show adequate responses to these agents. The last few years has seen the introduction of a class of drugs directed at specific patho-physiological abnormalities identified in these diseases. These drugs have not only brought the promise of better response rates but also the possibility of a cure for some patients. These agents are called biologic disease modifying anti-rheumatic drugs (biologic-DMARDS). Biologic-DMARDS show better response rates and appear to be well tolerated by patients. Currently, the biologic- DMARDS are mainly used in rheumatoid arthritis, ankylosing spondylitis and psoriatic arthropathy. The currently approved biologics for autoimmune diseases are: TNF alpha antagonists (Infliximab, Etanercept, Adalimumab, and Golimumab), IL-1 antagonists (Anakinra), anti CD-20 antibodies (Rituximab), IL-6 antagonists (Tocilizumab) and the T-cell inhibitor (Abatacept). Recently, increased rates of infection have been reported and the long-term safety profiles of the biologic-DMARDS are still unknown. Due to these problems coupled with the prohibitive costs, the exact place of these agents within treatment algorithms is still been defined. In many developed countries these agents are now included in the management with provision of specific guidance on when and how to use them. Our review outlines important pharmacological and clinical aspects of these agents in the treatment of autoimmune joint diseases. DOI: http://dx.doi.org/10.4038/jccp.v41i2.3770 Journal of the Ceylon College of Physicians , 2010, 41, 76-82
Highlights
Autoimmune joint diseases with the exception of rheumatoid arthritis (RA) are rare but collectively affect around 5% of the population in western countries[1]
In ankylosing spondylitis (AS) they are recommended as second line therapy after NSAIDs24
Abatacept is recommended in patients with moderate to severe RA having inadequate responses to one or more DMARD’s or to anti-TNF therapies[10]
Summary
Autoimmune joint diseases with the exception of rheumatoid arthritis (RA) are rare but collectively affect around 5% of the population in western countries[1] These diseases are conventionally managed using nonbiologic disease modifying anti-rheumatic drugs (nonbiologic DMARDS), which include methotrexate, sulphasalazine, hydroxychloroquine and leflunomide in conjunction with corticosteroids and NSAID’s. Other immunosuppressants such as azathioprine, cyclophosphamide, cyclosporine and mycophenolate mofetil are used occasionally. Compared to traditional drugs these drugs are created by biological processes such as recombinant DNA technologies They generally exhibit high molecular complexity and are usually monoclonal antibodies or fusion proteins (receptors bound to immunoglobulins). Biologic-DMARD’s target selected harmful cells and molecules in the cascade of events involved in autoimmunity
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