Treatment of the Patient With Rheumatoid Arthritis Refractory to Standard Therapy

SELECTED CASE AT THE age of 23 years, following a pregnancy, a woman developed severe fatigue, morning stiffness, and marked swelling and tenderness of multiple peripheral joints. On presentation to her physician, she was found to have serum rheumatoid factor in a high titer, an elevated erythrocyte sedimentation rate, and an elevated level of C-reactive protein. Roentgenographic studies revealed diffuse periarticular demineralization without bony erosions. A diagnosis of rheumatoid arthritis was made. During the next three years, the woman, in addition to undergoing physical therapy, was treated without significant or sustained improvement with several nonsteroidal anti-inflammatory drugs, hydroxychloroquine sulfate, gold salts, and penicillamine. In addition, treatment with low-dose prednisone was begun at a dosage of 5 to 10 mg orally per day. Moreover, she received many intra-articular injections of corticosteroids in many of her most troublesome joints to provide transient disease suppression in those joints. Progressive disease and disability were