Immunomodulation of rheumatologic disorders with non-biologic disease modifying antirheumtic drugs.

Although biological agents have revolutionized the immunomodulation of many rheumatic disorders, conventional disease modifying antirheumatic drugs (DMARDs) remain important glucocorticosteroid sparing agents and combination partners. In rheumatoid arthritis, low-dose glucocorticosteroids can be regarded as a DMARD due to preventive effects on joint erosions. Therapy with methothrexate and possibly also other DMARDs may alter the natural evolution of rheumatoid arthritis severity over time and therapy should be instituted as early as possible. Leflunomide is an equipotent alternative to methotrexate in rheumatoid arthritis, if methotrexate cannot be tolerated. Hydroxychloroquine inhibits toll-like receptor signaling and exerts antithrombotic and antihyperlipidemic effects, all thought to be beneficial in systemic lupus erythematosus. Hydroxychloroquine improves organ involvement in lupus, prevents lupus flares, and reduces mortality. It should be given to every lupus patient without contraindications.