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This is because it is now known that joint damage occurs within the first onset of symptoms. In use DMARDs reduce the symptoms and signs of inflammatory joint disease and also improve systemic effects such as vasculitis. In addition, serum markers of disease progression are reduced. For many of these drugs the mode of action is not fully understood, but they all interfere with the activity of cells of the immune system in one way or another.

To minimize side effects the maintenance dose of prednisolone should be kept as low as possible. In moderate to severe rheumatoid arthritis of less than two years duration, low dose prednisolone may reduce the rate of joint destruction. Nevertheless, it is recommended that maintenance therapy should be for two to four years only and then gradually reduced to avoid possible long-term adverse effects. In some cases where there is involvement of only a few joints, corticosteroids (usually triamcinolone or hydrocortisone) can be administered locally by intra-articular injection to relieve pain, increase mobility and reduce deformity.

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Calcium salt supplements can be added to calcitonin therapy if the diet is low in calcium or if the patient is very old. There have been some relatively new developments in the treatment of osteoporosis. Selective oestrogen receptor modulators, for example raloxifene mimic the inhibitory effects of oestrogen on osteoclasts. Teriparatide, which is a recombinant fragment of parathyroid hormone paradoxically stimulates the activity of osteoblasts.

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