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a substance that exerts some force or effect
a businessman who buys or sells for another in exchange for a commission (同)factor, broker
any agent or representative of a federal agency or bureau (同)federal agent
a representative who acts on behalf of other persons or organizations
an active and efficient cause; capable of producing a certain effect; "their research uncovered new disease agents"
how long something has existed; "it was replaced because of its age"
a time of life (usually defined in years) at which some particular qualification or power arises; "she was now of school age"; "tall for his eld" (同)eld
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『代理人』;周旋人 / 働き(作用)を起こすもの;作用物,薬剤 / (政府機関,特にFBI,CIAなどの)部員,機関員
〈U〉(一般に)『年齢』,寿命;〈C〉(個々の)『年齢』,年 / 〈U〉成年(おとなとしての資格・権利を得る年齢;通例18または21歳) / 〈U〉『老齢』;《集合的に》老人たち / 〈U〉(人生の)『一時期』;〈C〉世代(generation) / 〈U〉〈C〉《しばしばA-》(歴史上の)『時代』 / 〈C〉《話》長い間 / 年をとる,ふける;〈物が〉古くなる / 〈年〉'を'とらせる;〈物〉'を'古びさせる

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出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2015/11/11 22:16:22」(JST)

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Methotrexate

Hydroxychloroquine

Auranofin, a gold salt

Disease-modifying antirheumatic drugs (DMARDs) is a category of otherwise unrelated drugs defined by their use in rheumatoid arthritis to slow down disease progression.^[1]^[2] The term is often used in contrast to non-steroidal anti-inflammatory drug (which refers to agents that treat the inflammation but not the underlying cause) and steroids (which blunt the immune response but are insufficient to slow down the progression of the disease).

The term "antirheumatic" can be used in similar contexts, but without making a claim about an effect on the course.^[3]

Terminology

Although the use of the term DMARD was first propagated in rheumatoid arthritis (hence their name) the term has come to pertain to many other diseases, such as Crohn's disease, lupus erythematosus (SLE), Sjogren's Syndrome, immune thrombocytopenic purpura (ITP), myasthenia gravis, sarcoidosis and various others. Many of these are autoimmune disorders, but others, such as ulcerative colitis, are probably not (there is no consensus on this).

The term was originally introduced to indicate a drug that reduced evidence of processes thought to underlie the disease, such as a raised erythrocyte sedimentation rate, reduced haemoglobin level, raised rheumatoid factor level and more recently, a raised C-reactive protein level.^{[citation needed]} More recently, the term has been used to indicate a drug that reduces the rate of damage to bone and cartilage.^{[citation needed]} DMARDs can be further subdivided into traditional small molecular mass drugs synthesised chemically and newer 'biological' agents produced through genetic engineering.

Some DMARDs (e.g. the Purine synthesis inhibitors) are mild chemotherapeutics but use a side-effect of chemotherapy - immunosuppression - as its main therapeutical benefit.

Other terms that have historically been used to refer to the same group of drugs are "remission-inducing drugs" (RIDs) and "slow-acting anti-rheumatic drugs" (SAARDs).^[4]

Subdivision

DMARDs have been classified as:^[5]

synthetic (sDMARD)

* conventional synthetic and targeted synthetic DMARDs (csDMARDs and tsDMARDs, respectively)

* csDMARDs are the traditional drugs (such as methotrexate, sulfasalazine, leflunomide, hydroxychloroquine, gold salts)

* tsDMARDs are drugs that were developed to target a particular molecular structure

biological: original and biosimilar DMARDs (boDMARDs and bsDMARDs)

* bsDMARDs are those that have the same primary, secondary and tertiary structure as an original (boDMARD) and possess similar efficacy and safety as the original protein

Members

Drug	Mechanism
abatacept	T-cell costimulatory signal inhibitor
adalimumab	TNF inhibitor
azathioprine	Purine synthesis inhibitor
chloroquine and hydroxychloroquine (antimalarials)	Suppression of IL-1 & TNF-alpha, induce apoptosis of inflammatory cells and decrease chemotaxis
ciclosporin (Cyclosporin A)	calcineurin inhibitor
D-penicillamine (seldom used today)	Reducing numbers of T-lymphocytes etc.
etanercept	decoy TNF receptor
golimumab	TNF inhibitor
gold salts (sodium aurothiomalate, auranofin) (seldom used today)	unknown
infliximab	TNF inhibitor
leflunomide	Pyrimidine synthesis inhibitor
methotrexate (MTX)	Purine metabolism inhibitor
minocycline	5-LO inhibitor
rituximab	chimeric monoclonal antibody against CD20 on B-cell surface
sulfasalazine (SSZ)	Suppression of IL-1 & TNF-alpha, induce apoptosis of inflammatory cells and increase chemotactic factors

Although these agents operate by different mechanisms, many of them can have similar impact upon the course of a condition.^[6]

Some of the drugs can be used in combination.^[7] A common triple therapy for rheumatoid arthritis is methotrexate, sulfasalazine, and hydroxychloroquine.

Alternatives

When treatment with DMARDs fails, cyclophosphamide or steroid pulse therapy is often used to stabilise uncontrolled autoimmune disease. Some severe autoimmune diseases are being treated with bone marrow transplants in clinical trials, usually after cyclophosphamide therapy has failed. Furthermore, should DMARDs fail, tocilizumab can be used for tumor necrosis factor (TNF) inhibitor treatments in NICE guidance.^[8]

Combinations of DMARDs are often used together, because each drug in the combination can be used in smaller dosages than if it were given alone, thus reducing the risk of side effects.

Many patients receive an NSAID and at least one DMARD, sometimes with low-dose oral glucocorticoids. If disease remission is observed, regular NSAIDs or glucocorticoid treatment may no longer be needed. DMARDs help control arthritis but do not cure the disease. For that reason, if remission or optimal control is achieved with a DMARD, it is often continued at a maintenance dosage. Discontinuing a DMARD may reactivate disease or cause a “rebound flare”, with no assurance that disease control will be reestablished upon resumption of the medication.

References

^ "disease-modifying antirheumatic drug" at Dorland's Medical Dictionary
^ "Disease modifying antirheumatic drugs (DMARDs)".
^ "antirheumatic" at Dorland's Medical Dictionary
^ Buer, Jonas Kure. 2015. "A history of the term “DMARD”." Inflammopharmacology 23 (4):163-171. doi: 10.1007/s10787-015-0232-5.
^ Smolen JS, van der Heijde D, Machold KP, Aletaha D, Landewé R. Proposal for a new nomenclature of disease-modifying antirheumatic drugs. Ann Rheum Dis. 2014 Jan;73(1):3-5. doi: 10.1136/annrheumdis-2013-204317.
^ Nandi P, Kingsley GH, Scott DL (May 2008). "Disease-modifying antirheumatic drugs other than methotrexate in rheumatoid arthritis and seronegative arthritis". Current Opinion in Rheumatology 20 (3): 251–6. doi:10.1097/BOR.0b013e3282fb7caa. PMID 18388514.
^ Capell HA, Madhok R, Porter DR, et al. (February 2007). "Combination therapy with sulfasalazine and methotrexate is more effective than either drug alone in patients with rheumatoid arthritis with a suboptimal response to sulfasalazine: results from the double‐blind placebo‐controlled MASCOT study". Annals of the rheumatic diseases 66 (2): 235–41. doi:10.1136/ard.2006.057133. PMC 1798490. PMID 16926184.
^ http://www.mims.co.uk/news/1124108/Tocilizumab-Treatment-Rheumatoid-Arthritis-TA247

UpToDate Contents

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1. 末期関節リウマチの評価および内科的マネージメント evaluation and medical management of end stage rheumatoid arthritis
2. 関節リウマチにおける薬剤誘発性肺疾患 drug induced lung disease in rheumatoid arthritis
3. リウマチ性疾患における免疫抑制剤および疾患修飾剤の使用の概要 overview of the use of immunosuppressive and disease modifying drugs in the rheumatic diseases
4. 慢性関節リウマチにおける心不全および左室機能不全 heart failure and left ventricular dysfunction in rheumatoid arthritis
5. 多関節型若年性特発性関節炎：管理 polyarticular juvenile idiopathic arthritis management

English Journal

Evaluating Indeterminate Interferon-γ-Release Assay Results in Patients With Chronic Inflammatory Diseases Receiving Immunosuppressive Therapy.

Calabrese C1, Overman RA2, Dusetzina SB3, Hajj-Ali RA1.
Arthritis care & research.Arthritis Care Res (Hoboken).2015 Aug;67(8):1063-9. doi: 10.1002/acr.22454.
OBJECTIVE: To analyze the rate of indeterminate interferon-γ-release assay (specifically the QuantiFeron-TB Gold In-Tube [QFT-GIT]) testing for Mycobacterium tuberculosis in patients with chronic inflammatory disease (CID) compared with the general hospital population (GH) and a healthy reference g
PMID 25186123

Effectiveness, tolerability, and safety of subcutaneous methotrexate in early rheumatoid arthritis: A retrospective analysis of real-world data from the St. Gallen cohort.

Müller RB1, Kempis Jv2, Haile SR3, Schiff MH4.
Seminars in arthritis and rheumatism.Semin Arthritis Rheum.2015 Aug;45(1):28-34. doi: 10.1016/j.semarthrit.2015.02.009. Epub 2015 Mar 3.
INTRODUCTION: Methotrexate (MTX) is the cornerstone of rheumatoid arthritis (RA) treatment. Recently updated recommendations by the European League Against Rheumatism (EULAR) show MTX as an important part of the first-line strategy in patients with active RA. The study presented here aimed to assess
PMID 25895697

Single-Gene Genotyping and Personalized Preventive Care--Reply.

Wender RC1.
JAMA.JAMA.2015 Jul 21;314(3):298-9. doi: 10.1001/jama.2015.6236.
PMID 26197194

Japanese Journal

関節リウマチ患者における生物学的製剤無効例に対するタクロリムス併用療法と抑うつ状態

三輪裕介,穂坂路男,松島大輔,大塚久美子,佐藤理仁,高橋良,若林邦伸,小田井剛,矢嶋宣幸,笠間毅
心身医学 51(3), 254-259, 2011-03-01
目的:関節リウマチ患者は健常人に比べ抑うつ状態が強い.これまで,生物学的製剤を使用することで,関節リウマチ患者の抑うつ状態が改善することを報告した.生物学的製剤が効果不十分な場合に行うtacrolimus併用療法によって抑うつ状態が改善するかどうか検討した.方法:生物学的製剤を使用した関節リウマチ患者9人,Tacrolimus併用療法開始前,開始14週後,30週後に抑うつ状態の評価としてSelf- …
NAID 110008460549

Chloroquine, an Anti-malarial Agent, Acts as a Novel Regulator of β1-Integrin-Mediated Cell-Cell Adhesion(Molecular and Cell Biology)

CHO Jae Youl
Biological & pharmaceutical bulletin 31(4), 726-730, 2008-04-01
… Chloroquine is one of the disease-modifying antirheumatic drugs (DMARDs) with anti-malarial effect. …
NAID 110006680515