Once inflammation is controlled, RA patients experience a noticeable difference.
On the quest to find the right treatment for rheumatoid arthritis (RA), there’s no one-size-fits-all solution. There are many different medications that treat RA, but the mainstay of treatment is a class of medications called DMARDs.
DMARD stands for disease-modifying antirheumatic drugs. As the name suggests, DMARDs work to modify the course of the disease and how it progresses. Think of it this way: RA has a plan of how it’s going to affect your body over time, but DMARDs are going to disrupt that plan.
“Unlike nonsteroidal [anti-inflammatory drugs] (NSAIDs) … which just control the pain, what DMARDs do is they control inflammation,” says Saakshi Khattri, MD, a rheumatologist and assistant professor at the Department of Rheumatology, Icahn School of Medicine at Mount Sinai Hospital in New York City. “The idea is, with these medications on board, the disease process is aborted and patients don’t progress.”
What Are Biologics?
Biologics are a type of DMARD that target immune system cells, joint molecules, and substances secreted in the joints that cause inflammation and destroy joints. Different kinds of biologics target specific types of molecules.
“We all know from the pathogenesis of rheumatoid arthritis that there are certain cytokines, which are special proteins that are high in a person’s blood that has rheumatoid arthritis,” says Dr. Khattri. “Biologic DMARDs actually target those molecules.”
Biologics work in different ways, but they all target molecules that are involved in inflammation. The different categories of biologics that treat RA include:
Tumor necrosis factor inhibitors (TNF-inhibitors): These are often the first biologics tried for RA treatment. They work by blocking tumor necrosis factor, a cytokine involved in inflammation.
B-cell inhibitors: These medications decrease the production of B cells, a type of white blood cell that helps fight infections.
Interleukin inhibitors: These work on interleukin-1 (IL-1), interleukin-6 (IL-6) and interleukin-17A (IL-17A), which are cytokines that regulate the immune response.
T-cell costimulation blockers: These prevent the stimulation of T cells, another type of white blood cell.
Biologics are often used in patients who don’t respond to traditional DMARDs and for patients who can’t tolerate DMARDs in doses large enough to be effective. Biologics are administered via an injection or IV.
“When I prescribe a biologic DMARD to my patient, I do tell them that the idea is to be on it for as long as it’s providing relief of your symptoms,” says Dr. Khattri. “It could be months, it could be years—it’s not known.”
Dr. Khattri emphasized that once inflammation is controlled, patients do see a noticeable change. “Joints will move more. They’ll have less pain. They will be able to enjoy their life,” she says.
Saakshi Khattri, MD, is a rheumatologist and assistant professor at the Department of Rheumatology, Icahn School of Medicine at Mount Sinai Hospital in New York City.
00:00:00.867 --> 00:00:03.366
00:00:03.367 --> 00:00:05.932
We all know from the pathogenesis of rheumatoid arthritis
00:00:05.933 --> 00:00:08.699
that there's certain cytokines which are special proteins
00:00:08.700 --> 00:00:12.366
that are high in a person's blood that has rheumatoid arthritis,
00:00:12.367 --> 00:00:17.632
so biologic DMARDs actually target those molecules.
00:00:17.633 --> 00:00:24.732
00:00:24.733 --> 00:00:27.766
Biologic DMARDs are administered differently.
00:00:27.767 --> 00:00:31.166
We can have them self-administered in the form of an injection
00:00:31.167 --> 00:00:32.832
that a patient can give themselves.
00:00:32.833 --> 00:00:36.599
Most of them, they come in a pre-filled syringe or an auto-injector pen.
00:00:36.600 --> 00:00:40.432
Then we have certain biologic DMARDs that are given as an IV infusion.
00:00:40.433 --> 00:00:42.966
Obviously, for those kinds of biologic DMARDs,
00:00:42.967 --> 00:00:45.266
the patient has to come to a healthcare facility.
00:00:45.267 --> 00:00:49.566
So we have a type of biologic DMARD that targets TNF alpha.
00:00:49.567 --> 00:00:54.199
Then there's another type of biologic DMARD that targets the receptor to IL-1,
00:00:54.200 --> 00:00:58.199
Then there's another type of DMARD that targets the receptor to IL-6.
00:00:58.200 --> 00:01:02.232
Then we have biologic DMARDs that decrease B cell production.
00:01:02.233 --> 00:01:05.832
So B cells are also thought to be involved in the pathogenesis
00:01:05.833 --> 00:01:08.432
of rheumatoid arthritis by producing antibodies,
00:01:08.433 --> 00:01:11.599
so we have a biologic DMARD that's given as an infusion,
00:01:11.600 --> 00:01:14.166
which decreases the production of B cells.
00:01:14.167 --> 00:01:18.932
We have another category that prevents the stimulation of T cells.
00:01:18.933 --> 00:01:22.499
And that is known as a T cell costimulator blocker,
00:01:22.500 --> 00:01:26.599
and the thought behind it is that if we don't activate the T cells,
00:01:26.600 --> 00:01:28.732
then we'll have less inflammation.
00:01:28.733 --> 00:01:31.266
So when I prescribe a biologic DMARD to my patient,
00:01:31.267 --> 00:01:35.299
I do tell them that the idea is to be on it
00:01:35.300 --> 00:01:38.099
for as long as it's providing relief of your symptoms,
00:01:38.100 --> 00:01:41.366
which could be months, it could be years.
00:01:41.367 --> 00:01:42.732
It's not known.
00:01:42.733 --> 00:01:46.466
I also tell them that you have rheumatoid arthritis, which is not curable.
00:01:46.467 --> 00:01:51.832
It's treatable, and it's treatable with the idea of preventing destruction of joints.
00:01:51.833 --> 00:01:53.266
So they have to stay on it.
00:01:53.267 --> 00:01:56.466
So I do make it a point to tell my patients that once the inflammation is controlled,
00:01:56.467 --> 00:01:59.099
they will see a noticeable change.
00:01:59.100 --> 00:02:02.432
Their joints will move more, they'll have less pain,
00:02:02.433 --> 00:02:05.899
they'll be able to enjoy their life.
00:02:05.900 --> 00:02:08.733
Rheumatoid Arthritis Treatment (Beyond the Basics). UpToDate. (Accessed on January 21, 2020 at https://www.uptodate.com/contents/rheumatoid-arthritis-treatment-beyond-the-basics)Biologics. Arthritis Foundation. (Accessed on January 21, 2020 at https://www.arthritis.org/living-with-arthritis/treatments/medication/drug-types/biologics/drug-guide-biologics.php)