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1. Early treatment with a DMARD may alter the course of the disease - initiate within 3 mths of symptoms, add additional DMARDs or biologic agents as required.

2. NSAIDs decrease inflammation and joint swelling but do not alter the course of the disease.

3. The anti-inflammatory effects of COX-2 inhibitors are comparable to NSAIDs, with reduced GI effects, less risk of bleeding & no effect on platelets, but increase risk of adverse cardiac events.

4. DMARDS (methotrexate, leflunomide, hydroxychloroquine). They have a slow onset of action (several months), so concurrent NSAIDs or low-dose glucocorticoids are required initially.

5. MTX is an anti-folate agent with anti-inflammatory properties - initial DMARD for moderate-to-severe RA and the main DMARD when combination therapy is used in those with poor prognostic features.

6. Pre-existing liver disease (HBV, HCV, heavy alcohol use), severe renal disease, pregnancy are contraindications to MTX.

7. SE of MTX - alopecia, GI upset, bone marrow suppression, hepatotoxicity, pneumonitis, nephrotoxicity.


1. Wilkinson, I. (2017). Oxford handbook of clinical medicine. Oxford: Oxford University Press.
2. Hannaman, R. A., Bullock, L., Hatchell, C. A., & Yoffe, M. (2016). Internal medicine review core curriculum, 2017-2018. CO Springs, CO: MedStudy.
3. Image: no reference available.

Ⓒ A. Manickam 2018

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