Methotrexate given in weekly oral-pulse regimens is rapidly becoming the most popular of the antirheumatic drugs. It seems to act relatively quickly (within 6 to 8 weeks) and patients continue to take it for a longer period of time than other antirheumatic drugs. This issue of long-term hepatotoxicity still has not been clarified, and concerns are now being raised regarding increased infection rates and whether methotrexate should be stopped before joint replacement surgery. Methotrexate, however, remains a very easy drug to use, although in the future it will probably be used as part of combination therapy. Although several clinical trials have demonstrated efficacy for cyclosporine in active rheumatoid arthritis, problems with renal toxicity are still significant. The majority of patients exhibit a rise in the serum creatinine level, although this returns to a normal level when cyclosporine is ceased. In view of this, cyclosporine is likely to remain a drug used in selected, severe cases not responding to other agents.
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