Editorial Foreword

Therapeutics and Clinical Risk Management 2007:3(5) 705–706 © 2007 Dove Medical Press Limited. All rights reserved This issue of Therapeutics and Clinical Risk Management contains interesting reviews on rheumatoid arthritis (RA), ulcerative colitis (UC) and steroid-resistant asthma all of which are distressing chronic infl ammatory conditions of unclear etiology. Rheumatoid arthritis (RA) is a prevalent condition whose clinical sequelae can result in signifi cant reductions in functional capacity and quality of life with considerable attendant debilitating impact upon psychological health. Despite recent therapeutic advances, a number of challenges remain: only a percentage of patients will respond to the disease-modifying antirheumatic drugs (DMARDs); toxicity and/or resistance dictate that another sub-group requires combinations of DMARDs and the antitumor necrosis factor-α (TNF-α) agents. Poor disease control in RA leads to joint pain and deformity with consequent functional impairment and loss of independence, patients may also experience signifi cant systemic illness including nodules, vasculitis, pulmonary fi brosis and nerve entrapment. Among the new and more powerful DMARDs that have recently become available infl iximab (IFX), a chimeric TNF-α monoclonal antibody (mAb), has shown great promise. Levels of TNF-α, a potent pro-infl ammatory cytokine, are elevated in the sites of infl ammation associated with RA, for example in the synovial fl uid and sera of patients with active disease. TNF-α acts as a potent osteogenic cytokine and is thought to be the central mediator of joint destruction in rheumatoid arthritis. However, as Sophie Martin Du Pan and colleagues (2007) point out in the current issue of TCRM, the use of the more expensive biologic agents such as IFX tend to be limited to patients who have failed one or more traditional approaches to treatment on cost grounds. As this effectively eliminates these agents from the management of early RA, these authors have examined the evidence in support of the use of IFX in early RA as this approach may be more effective than treatment later in the course of the disease. They therefore conducted a systematic review of the literature and performed a meta-analysis of the RA bone erosion score (vdH Sharp Score) and RA functional disability score in randomized clinical trials that compared treatment with methotrexate-IFX (MTX-IFX) with methotrexate-placebo (MTX-placebo). The authors report that there is no evidence to support the superiority of MTX-IFX over MTX in combination with traditional disease-modifying antirheumatic drugs but they recommend that IFX should be used in those early RA patients demonstrating signs of aggressive disease, such as a limited response to MTX alone or the presence of rapidly progressing erosions. Ulcerative colitis is a chronic infl ammatory condition of the large bowel leading to abdominal pain, diarrhea and in some cases other systemic features such as fever and weight loss. The underlying cause of UC remains elusive although current thinking favours defects in the mucosal immune system and/or epithelial integrity resulting in an abnormal infl ammatory response to normal intestinal microfl ora. Raffi Karagozian and Robert Burakoff (2007) have provided an excellent review on the eitiology, pathogenesis and clinical course of UC. They detail current treatment modalities for UC with an emphasis on mesalamine a 5-aminosalicylate; these are newer formulations of salicylates-based drugs with fewer side-effects. The authors rate mesalamine as an excellent fi rst-line therapy for treatment of mild to moderate UC and also for the maintenance of remission. They further emphasise the importance of maximization of local mucosal concentration of mesalamine by utilizing the most appropriate delivery Garry M Walsh