Common side effects include a skin rash, mouth ulcers and a loss of taste; a more serious reaction is skin eruptions when the treatment should be stopped immediately. The blood disorder thrombocytopenia is common and can be severe (Drugs and Therapeutics Bulletin, 1993; 31:18).

Sulfasalazine

Sulfasalazine is from the family of cytotoxic drugs which block the growth of cells. Serious side effects including bone-marrow suppression, increased risk of infection, infertility, cancer, and defects in the embryo (G W Cannon and J R Ward, Arthritis and Allied Conditions, Lea & Febiger, Philadelphia 1989).

The drug was originally developed to treat ulcerative colitis and Crohn's disease (ABPI Data Sheet Compendium 1993-4).

Its beneficial effects can be swift, usually within two to three months and, in one study, a daily 2g dose achieved partial or complete remission in 30 of 59 patients (Ann Rhem Dis 1985; 44: 194-8). Nonetheless, it is less effective than gold, although the side effects seem less severe (Lancet 1989; i: 1036-8).

Chloroquine/hydroxychloroquine

These are anti-malaria drugs that, through trial and error, have been found to have some beneficial effects on rheumatoid arthritis. They were used to treat a number of conditions after the Second World War.

A common side effect can be visual impairment, even leading to blindness; the drugs may cause lesions on the eye in doses above six mg a day (Arthritis Rheum. 1979; 22:832). Other effects include tinnitus, insomnia, hyperactivity and anemia.

Cyclosporin

This immunosuppressant, originally developed to stop the body from rejecting transplant organs, is the current flavour of the month in medicine, used to treat every disease doctors otherwise don't know how to handle. It acts by lowering the immune system T-cells and should be used in treating rheumatoid arthritis only when the condition is life-threatening. Other immunosuppressants that may be recommended include azathioprine and cyclophosphamide, although they come with the same high risks. None are licensed in the UK for treatment of arthritis, although they are being investigated.

A common side effect can be kidney dysfunction, high blood pressure and stomach problems.

Steroids

After the immunosuppressants, steroids are the most controversial and possibly damaging treatments available for arthritis.

Steroid overuse in the 1950s to treat arthritis and the horrors that came from that has put paid to this treatment among those with long enough memories. The Medical Research Council trial in 1960 concluded that the risks outweighed any benefits.

The side effects of the glucocorticoids which include cortisol, cortisone, prednisone and dexamethasone are many and various, and include the suppression of the immune system, osteoporosis, muscular dystrophy, peptic ulcer, psychiatric disorders, infections and eye problems (T W Behrens and J S Goodwin, Arthritis and Allied Conditions, Lea & Febiger, Philadelphia 1989).

!ABryan Hubbard