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.
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We all know from the pathogenesis of rheumatoid arthritis
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that there's certain cytokines which are special proteins
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that are high in a person's blood that has rheumatoid arthritis,
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so biologic DMARDs actually target those molecules.
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Biologic DMARDs are administered differently.
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We can have them self-administered in the form of an injection
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that a patient can give themselves.
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Most of them, they come in a pre-filled syringe or an auto-injector pen.
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Then we have certain biologic DMARDs that are given as an IV infusion.
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Obviously, for those kinds of biologic DMARDs,
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the patient has to come to a healthcare facility.
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So we have a type of biologic DMARD that targets TNF alpha.
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Then there's another type of biologic DMARD that targets the receptor to IL-1,
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Then there's another type of DMARD that targets the receptor to IL-6.
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Then we have biologic DMARDs that decrease B cell production.
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So B cells are also thought to be involved in the pathogenesis
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of rheumatoid arthritis by producing antibodies,
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so we have a biologic DMARD that's given as an infusion,
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which decreases the production of B cells.
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We have another category that prevents the stimulation of T cells.
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And that is known as a T cell costimulator blocker,
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and the thought behind it is that if we don't activate the T cells,
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then we'll have less inflammation.
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So when I prescribe a biologic DMARD to my patient,
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I do tell them that the idea is to be on it
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for as long as it's providing relief of your symptoms,
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which could be months, it could be years.
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It's not known.
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I also tell them that you have rheumatoid arthritis, which is not curable.
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It's treatable, and it's treatable with the idea of preventing destruction of joints.
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So they have to stay on it.
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So I do make it a point to tell my patients that once the inflammation is controlled,
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they will see a noticeable change.
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Their joints will move more, they'll have less pain,
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they'll be able to enjoy their life.
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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)