Rheumatoid Arthritis (RA): Management problems - Intractable disease.

Abstract: It is difficult to define what exactly is intractable RA. Intractable RA may be defined as a patient. resistant to standard treatment. The difficult point is how to define the standard treatment. Shall we say intractable disease to a patient resistant to single DMARD and an NSAID? Or shall we say intractabIe disease to a patient resistant to a combination of DMARD with low dose steroid and associated NSAID who had undergone necessary chemical or surgical synovectomy? If the second definition is adopted there is not much left to do. Fortunately this is not a very common condition. There is no consensus on what to do far these patients and the proposed methods are more empirical or experimental than scientifically proven methods: PULSE METHYL PREDNISOLONE: One gram methyl prednisolone is diluted in 200 milliliters of normal glucose and instillate in half an hour. The treatment is repeated 3 consecutive days. The result is usually miraculous, unfortunately not for long time. After 2 to 4 weeks symptoms reoccur, however this will give enough time to change the treatment protocol if possible. PULSE CYCLOPHOSPHAMIDE (PCP) : The infusion of 500 mg to 1 g cyclophosphamide per square meter of body surface may help to improve or overcome a resistant inflammatory state. If the patient is improved PCP may be repeated. The interval between each pulse is from 1 to 3 months. PLASMAPHERESIS: By washing out the circulating immune complexes may help to control the disease. However there is always a stimulation of the immune reaction as a feed back to the removal of immune complexes. Concomitant pulse cyclophosphamide may be of help by controlling the immune reaction. TOTAL LYMPHOID IRRADIATION: By suppressing and destroying the t cells may down regulate the immune system. Result of trials were conflicting and symptoms recur almost in every cases. Before deciding for one of these methods it is better to hospitalize the patient. Some patients will improve dramatically without any change of their treatment strategy. The imposed bed rest, the change of the daily environment, and the patient's belief that she or he will get better may be an explanation. A review of the drug history of the patient may be helpful in some cases. A drug classified as no more efficient may regain its efficiency few years after its withdrawal. This is the basis of the saw tooth strategy proposed by Fries. A drug discontinued for its side effect, may in some condition be used again under close supervision. Psychological evaluation of the patient may in some cases direct to a psychiatric treatment and improve his physical condition, perhaps by down regulating the immune system via the neuro-endocrine axis. Pulse methyl prednisolone is a good supplement therapy at this stage. Other treatments mentioned above are to be decided with caution and if no other alternative is left.