For patients with rheumatoid arthritis, disease-modifying therapy is initially based on the so-called conventional immuno-suppressants: methotrexate as the first choice, alone or in combination with another immunosuppressant such as sulfa-salazine. In cases where efficacy is considered inadequate, or when adverse effects are too troublesome, TNF-alpha inhibitors such as adalimumab, which are protein-based "biologic" immuno-suppressants given by injection, are the medicines of choice due to their favourable harm-benefit balance in this situation and their long history of use. Since the late 2010s, Janus kinase inhibitors such as tofacitinib, which are orally administered immunosuppressants, have been authorised forthe treatment of rheumatoid arthritis. They have not, however, been shown to be more effective than other disease-modifying drugs, and their adverse effect profile is at least as burdensome (1-3).
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