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4.3.4 Sustained DMARD therapy While early initiation of therapy is of importance, a sustained input is vital if disease suppression is to be maintained. Remission is the goal but is seldom achieved. Equally 'cure' is not attained, thus withdrawal of treatment is seldom appropriate. Two randomised placebo controlled studies have demonstrated relapse on withdrawal of disease modifying agents.1, 2 In both these studies, disease modifying effect was unequivocal. These results confirm the efficacy of DMARDs in comparison with placebo, and demonstrate that sustained prescription of DMARDs is necessary to suppress disease activity. Serial use of DMARDs has been shown to be safe after 10-15 years.3 Evidence level 1 + DMARD therapy should be sustained in inflammatory disease in order to maintain disease suppression. Grade B recommendation ; 1. ten Wolde S, Breedveld FC, Hermans J, Vandenbroucke JP, van de Laar MA, Markusse HM et al. Randomised placebo-controlled study of stopping second-line drugs in rheumatoid arthritis. Lancet 1996; 347: 347-52. Gotzsche PC, Hansen M, Stoltenberg M, Svendsen A, Beier J, Faarvang KL et al. Randomised, placebo controlled trial of withdrawal of slow-acting antirheumatic drugs and of observer bias in rheumatoid arthritis. Scan J Rheumatol 1996; 25: 194-9. Sokka T, Hannonen P. Utility of disease modifying antirheumatic drugs in "sawtooth" strategy. A prospective study of early rheumatoid arthritis patients up to 15 years. Ann Rheum Dis 1999; 58: 618-22, for example, smpc.
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Treatment of narcolepsy Current treatment of narcolepsy is symptomatic and includes non-pharmacological and pharmacological strategies see table 3 ; . Patients should be informed about the chronic course of the disease and the value of counselling to address issues such as sleep hygiene, driving licence, professional choices, pregnancy. The most important nonpharmacological treatment are scheduled daytime naps even in late stages of disease. In milder forms short daytime nappings of 1060 min may control excessive daytime sleepiness sufficiently but even in severely affected patients this strategy helps to reduce the dosage of stimulants. Most narcoleptic patients need pharmacological medication, which is effective in two thirds with tolerable side effects. Excessive daytime sleepiness and and lysergic and lescol, because pulmonary arterial hypertension.
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Table 11. Summary of the comparative evidence on CCBs and the overall strength of the evidence by key question.

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