These meds have changed the whole landscape of rheumatoid arthritis therapy.
If you have rheumatoid arthritis, you know that the disease can significantly affect your daily life. That’s because in RA, the immune system attacks joint tissues, causing chronic inflammation, swelling, and pain in the joints.
When your rheumatoid arthritis is acting up, you do your best to feel better by avoiding RA flare triggers and making RA-friendly lifestyle changes. While self-management and care is important, it’s also important to get your RA treated by a medical professional. The longer RA goes untreated, the more damage occurs to the joints.
Recent treatment options have allowed doctors and patients to control RA better and significantly slow the progression of the disease. “[RA] is a chronic condition, but it can be managed quite well,” says Dr. Blazer. “Most patients can achieve a remission or partial remission.”
Treating Rheumatoid Arthritis with Medication
“The goals of RA treatment are to control inflammation as tightly as possible, while avoiding side effects,” says Dr. Blazer. Here are the medications most often prescribed to treat rheumatoid arthritis.
Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used to help ease arthritis pain and inflammation. They are available over-the-counter and by prescription.
Steroids. “When someone is first diagnosed, or when someone has a very bad rheumatoid arthritis flare and we need to stop it as quickly as possible, we may give a dose of steroids,” says Dr. Blazer. This may include drugs such as prednisone, prednisolone, and methylprednisolone, which are potent and quick-acting anti-inflammatory medications.
While these drugs work well to stop inflammation quickly, they can have side effects over time. “Problems with cardiovascular disease or problems with bone health can worsen with steroids, so we try not to have patients on those drugs for any longer than we have to,” says Dr. Blazer.
Disease-modifying antirheumatic drugs (DMARDs) work to modify the course of the disease and are the mainstay of treatment. “Disease modifying agents take a little longer to affect that patient, so maybe a month or two before we see some impact, but they last longer,” says Dr. Blazer.
Traditional DMARDs include methotrexate, hydroxychloroquine, sulfasalazine, leflunomide, cyclophosphamide, and azathioprine. These “older,” non-biologic drugs affect white blood cells, but not in a tailored way, says Dr. Blazer. Traditional DMARDs are often oral medications.
Biologics are a newer subset of DMARDs that are more targeted. Biologics may work more quickly than traditional DMARDs, and are injected or given by infusion. “[Biologics] affect chemicals that are specific to the immune response and sometimes specific to certain cells in the immune system. So we know that we’re really affecting the immune system and we’re not affecting the rest of the body as much,” says Dr. Blazer.
One of the first line of biologics used are tumor necrosis factor (TNF) inhibitors. “That’s because [TNF inhibitors] have been around the longest and many patients respond to that. If a patient is not responding over time, we might switch to a different drug,” says Dr. Blazer.
The side effects of biologic and non-biologic DMARDs vary depending on the drug, but in general, patients may get moderate symptoms, like nausea, diarrhea, and upset stomach, or more severe symptoms, like hair loss, liver damage, or increased risk of infection.
To determine which medication to treat RA is right for you depends on many factors. These may include:
- Level of disease activity (mild vs. moderate to severe)
- Presence of co-existing conditions
- The patient’s preference (convenience vs. price. vs. side effects)
“Biologics have changed the whole landscape of rheumatoid arthritis therapy,” says Dr. Blazer. “Before we had anything to modify the disease progression, the patients would end up having permanent deformities and end up needing surgery at very high rates, but now that we can prevent that damage in the first place, patients are not needing to go to those extremes.”
Dr. Blazer is a rheumatologist and instructor in the department of medicine at NYU Langone Health.
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The goals of RA treatment, are to control
inflammation as tightly as possible,
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while avoiding side effects.
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When someone is first diagnosed or
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if someone has a very bad
rheumatoid arthritis flare and
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we need to stop it as quickly as possible,
we may give a dose of steroids.
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We may also give non-steroidal
anti-inflammatories or incense,
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things that you might be able
to buy over the counter.
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Steroids are great at stopping
inflammation quickly, but
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they have many side effects over time.
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Problems with cardiovascular disease, or
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the problems with bone health,
can worsen with steroids.
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And we try not to have
the patients on those drugs.
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For any longer than we have to, and
then the mainstay of treatment over
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time are disease modifying
anti-arthritic drugs or DMARD's.
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Disease modifying agents take a little
while longer to affect the patient.
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So maybe a month or
two before we see some impact, but
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they last longer and
they again change the course of disease.
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There are a number of
different kinds of DMARDs.
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There are the older ones that are the
non-biologics, which essentially mean that
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they affect the white blood cells,
but in no tailored way specifically.
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The non-biologic DMARDs
are usually oral medications.
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The most common one that
we use is methotrexate, and
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methotrexate can be taken once a week.
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Now the newer drugs
are the biologic drugs.
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Biologics are different than other forms
of DMARDs, because they are very targeted.
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They affect chemicals that are specific
to the immune response, and
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sometimes even specific to certain
cells in the immune system.
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So, we know that we're really
affecting the immune system and
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we're not affecting the rest
of the body as much.
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One of the first-line biologics that we
use are tumor necrosis factor inhibitors,
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or TNF inhibitors.
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And that’s because they’ve
been around the longest.
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And many patients will respond to them.
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If the patient is not
responding over time,
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we might switch to
a different one of our drugs.
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There are a number of different biologics
and how we determine what biologic is
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right for which patient,
has to do with several factors.
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The first is patient preference and
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We also take into consideration
the other disease
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processes that the patient might have.
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And then we try to tailor it to
the response of the patient.
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Biologics have changed the whole landscape
of rheumatoid arthritis therapy.
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Before we had anything to
modify the disease progression.
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Patients would end up having
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end up needing surgery at very high rates.
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But now that we can prevent
that damage in the first place,
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patients are not needing
to go to those extremes.
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General principles of management of rheumatoid arthritis in adults. UpToDate. (Accessed on June 21, 2018 at https://www.uptodate.com/contents/general-principles-of-management-of-rheumatoid-arthritis-in-adults)
Rheumatoid Arthritis Treatment. Arthritis Foundation. (Accessed on June 21, 2018 at https://www.arthritis.org/about-arthritis/types/rheumatoid-arthritis/treatment.php)
DMARDs: Side Effects and Solutions. (Accessed on June 21, 2018 at https://www.arthritis.org/living-with-arthritis/treatments/medication/drug-types/disease-modifying-drugs/dmards-side-effects.php)