WHEN I was about five I noticed that Grandfather Royden always wore immaculately polished shoes. My curiosity overcame my awe and I asked him why he always had new shoes, and why they were always so clean. Not content with telling me that personal comments were unacceptable, he went on to say that he thought the question reflected badly on my intellect as the answer was obvious: his shoes were never worn out because his crippling rheumatoid arthritis meant that he was chairbound. Since he had to rule his kingdom from his chair beside the fire, his shoes — polished each morning — were never dirtied. He added that he hoped my powers of observation and deduction would grow.

Most people are helped by the standard treatment for rheumatoid arthritis — NSAIDs (anti-inflammatory drugs), or the older disease-modifying anti-rheumatic drugs — so that relatively few are left totally crippled, as were my grandfather and mother.

But although it may be only a small proportion of patients who fail to respond, when there are 420,000 with the condition (three times as many women as men), that still represents a great number of patients whose lives have been devastated by the disease. Life expectancy, too, is shortened — by approximately four years in men and ten years in women. This reduction of life expectancy surprisingly gives rheumatoid arthritis as bad a prognosis as Hodgkin’s lymphoma or coronary arterial disease. In both these conditions medicine has improved dramatically in the past 20 years, and now so has the outlook in about 50 per cent of cases of crippling rheumatoid arthritis.

My grandfather was born too early to benefit from NSAIDs, the symptomatic relief that can be provided by steroids, or the real advantages of the disease-modifying anti-rheumatic drugs. Had he been born 100 years later, he would probably have had dirty, worn shoes for the last 30 years of his life.

Even more dramatically, there is now a weapon to fight rheumatoid arthritis that, compared with current treatment, is like the hydrogen bomb instead of the wartime 1,000lb high-explosive bomb.

These new drugs are the TNF-alpha inhibitors, the anti-TNF drugs. They undermine the inflammatory reaction that causes the erosion in the joints. Tumour necrosis factor (TNF alpha) is a master pro-inflammatory cytokine that is involved in many inflammatory responses in the body including those triggered by autoimmune diseases, of which rheumatoid arthritis is one.

There is a whole group of these new drugs. I have seen more patients treated by Remicade (infliximab) than the others and in these patients the results have been astounding, their lives transformed. As well as Remicade, the other TNF inhibitors are Humira (adalimumab) and Enbrel (etanercept). Some are usually used with methotrexate, a disease-modifying anti-rheumatic drug, others without methotrexate if there is a contraindication. There are minor differences in their side-effect profiles.

Treating symptoms, rather than causes, of diseases can be risky, but symptomatic treatment is more likely to represent a medical sin of omission rather than commission. Too often a patient given only symptomatic treatment is deprived of medication that could have influenced a disease. Only 50 per cent of people in whom rheumatoid arthritis has been disagnosed have been given a disease-modifying anti-rheumatic drug.

After discovering the success in treating rheumatoid arthritis with TNF alpha-inhibiting drugs, doctors realised that they might also be useful in other inflammatory conditions. These patients had widely dissimilar symptoms, but all the conditions had arisen from the same problem — an inflammatory response to an autoimmune disease.

The TNF-alpha inhibitors have now been used with revolutionary success in treating many cases of Crohn’s disease, uveitis of the eyes, ankylosing spondylitis, psoriasis and psoriatic arthritis.

As an example of their effect, patients whose Crohn’s disease was so severe that even when they were not languishing in hospital their lives were so restricted by their symptoms that they could never be far from a lavatory, have been restored to a normal social and professional existence after treatment with an anti-TNF alpha.

E-mail Dr Thomas Stuttaford your questions on treatment for arthritis and allied complaints