1. Slow Acting Anti-inflammatory Drugs

2. DEFINITION Drugs used to relief pain & inflammation

3. General Features Low doses commonly are used early in the course of the disease. Used when the disease is progressing & causing deformities. Can not repair existing damage, but prevent further progressing, injury or deformity Have no analgesic effects Their effects need from 6 weeks to 6 months to be evident

4. Clinical Uses Treatment of different types of arthritis as rheumatoid arthritis rheumatic arthritis Musculoskeletal pain Ankylosing spondylitis.

5. Hydroxychloroquine Mechanism of action : Inhibition of lysosomal enzyme activity Trapping of free radicals ( H 2 O 2 ) Suppression of T lymphocytes Suppression of leukocytes actions Large doses for a long duration are used for treatment of arthritis

6. Adverse Effects Nausea & vomiting Irrreversible retinal damage Corneal deposits Allergic skin reactions Cinchonism ( tinnitus & vertigo)

7. Methotrexate Mechanism of Action Inhibition of polymorphonuclear chemotaxis Dihydrofolate reductase inhibitor

8. Adverse Effects Nausea Mucosal ulcers Bone marrow depression Hepatotoxicity is dose related

9. Tumor necrosis factor-α(TNF-α) blocking agents Infliximab Mechanism of action is a chimeric ( 25% mouse, 75% human) antibody. Binds with high affinity to human TNF-α resulting in inhibition of macrophage & T cell function.

10. Infliximab Given as IV infusion Half-Life 8-12 days Given every 8 weeks regimen. Infliximab elicits up to 62% incidence of human antichimeric antibodies. Concurrent therapy with methotrexate decreases the prevalence of human antichimeric antibodies

11. Adverse Effects Upper respiratory tract infections Headache Cough Activation of latent tuberculosis Infusion site reaction

12. Comparison DMARDs NSAIDs Slow onset of action 6 weeks-6 months Arrest the progression of the disease. Prevent formation of new deformity. Used in chronic cases when deformity is exciting Rapid onset of action Few minutes –few hours No effect on the progression of the disease Can not stop the formation of new deformity. Used in acute cases to relief inflammation & pain