Treating rheumatoid arthritis was a thankless task until modern drugs. The age-old panacea of salicylate preparations seemed helpful but didn’t alter the course of the disease by one jot. Aspirin, introduced about 100 years ago, was better and even before the Second World War there was talk of gold salts.

Until the 1950s doctors confronted by a case of rheumatoid arthritis recommended bed rest, an easier lifestyle, and a nutritious diet with an emphasis on fish oils. The medical contribution to a patient’s treatment was confined to useful joint splinting, especially at nights, discussion on the best kinds of shoe and the type of exercise that would help rather than increase joint contractures.

The advent of steroids and the non-steroidal anti-inflammatory drugs in the 1950s revolutionised treatment but unfortunately the side-effects of heavy, continuous steroid use soon limited their prescription.

Many patients who had seemingly recovered miraculously with steroids developed appalling complications, some of which were fatal, while others produced severe psychiatric symptoms, and nearly all had long-lasting side-effects.

The ever useful but gut-rotting NSAIDs anti-inflammatory COX-1 drugs controlled inflammation and the pain from it as never before. When combined with a sleeping pill, at least some patients had a reasonable night’s sleep.

Later the COX-2s, some of which are now under a cloud because of the risk of cardiac disease, were as good, if not better, at controlling inflam- mation than the COX-1s. The anti-inflammatory agents of both were a great improvement in controlling symptoms, but the progress of the disease was uninterrupted.

The rheumatoid disease-modifying drugs introduced in recent years have altered the long-term outlook. These include modern immuno-suppressants as well as by now well-established gold salts, folic acid antagonists such as methotrexate which acts as an immuno-suppressant as well as an anti-inflammatory agent. Likewise penicillamine and sulfazalazine are useful, well tried remedies but could hardly be described as dramatically effective.

A few years ago the TNF (tumour necrosis factor) alpha antagonists were introduced. Patients who for years had had rheumatoid arthritis and many other inflammatory diseases suddenly found that at last they were relieved of many of the worst symptoms. Life again seemed to be worth living.

Patients weren’t cured but one or other of the anti-TNF therapies gave them a glimpse of their former days.

Hardly had the enthusiasm for the anti-TNF drugs become established than it was found that Mabthera (rituximab), a drug used to treat beta cell lymphoma, a form of non-Hodgkin’s lymphoma, was also effective against rheumatoid arthritis. It will probably be useful in the treatment of some other inflammatory conditions.

Mabthera (rituximab) had already revolutionised the treatment in many cases of beta cell lymphoma and is now repeating its dramatic effect on some people with rheumatoid arthritis.

In some cases Mabthera, when used early in the patient’s disease, seems to bring about such a complete remission of symptoms that even the possibility of a cure has been talked about in whispers. It will be many years before anyone would be in a position to commit themselves publicly to such a claim.

Research is needed to discover whether Mabthera, possibly combined with such drugs as methotrexate, used as a first-line treatment, may prevent the progress of early rheumatoid arthritis to a point at which lasting damage is done to a joint.