Rheumatoid arthritis can’t be cured, but symptoms can be managed. Some drugs fight inflammation and ease pain, while others help slow the disease. All have benefits and risks.
Early aggressive treatment is the best way to prevent irreversible joint damage and maintain quality of life for people with arthritis.
First-line treatments include DMARDs and fast-acting anti-inflammatories.
Monitoring by your doctor is key to ensure that treatment is working, and that side effects aren't developing.
If there's any comfort in having rheumatoid arthritis these days, it’s that there's a growing number of drugs available to deal with its symptoms.
Not only can some medications help manage the inflammation, pain, and symptoms of rheumatoid arthritis, but they can stop or slow the progression of the disease, too.
Traditionally, rheumatoid arthritis treatments have included a combination of DMARDs, or disease modifying anti-rheumatic drugs that now include different forms of biologics and two other classes of medications: non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids.
Treatment guidelines from the American College of Rheumatology (ACR) state that early aggressive treatment is the best way to prevent irreversible joint damage and to maintain quality of life for people with rheumatoid arthritis.
Doctors who treat rheumatoid arthritis now have more drugs to use, and they are using them earlier.
This class of drugs includes over-the-counter medications such as aspirin, Advil (ibuprofen), and Aleve (naproxen), as well as prescription-strength drugs (Naprelan).
Pros: NSAIDs reduce joint inflammation, pain, and fever.
Cons: They have no effect on the eventual progression of the disease, can irritate the lining of the stomach, and can damage the kidneys when used at high doses for extended periods of time. Additionally, in July 2015, the Food and Drug Administration (FDA) strengthened the warning that NSAID use can increase your chance of having a heart attack or stroke. Risk occurs as early as the first few weeks after initiating therapy and rises with higher doses of NSAIDs. While anyone can be at risk, the threat is higher for people with underlying cardiac disease.
“For patients with pre-existing cardiac disease and patients who smoke, risk/benefit discussions need to reflect this heightened awareness of the cardiovascular risk of NSAIDs," says Susan Goodman, MD, an associate professor of medicine at Weill Cornell Medical College and a rheumatologist at the Hospital for Special Surgery in New York City.
Treatment guidelines from the ACR state that everyone with RA should be started on at least one DMARD at the beginning of treatment, and that people with more disease activity and features of poor prognosis should be started on — or considered for — two or more DMARDs. The guidelines also say that if you're started on one DMARD and aren't doing well after three months, then another DMARD should be added. Commonly used DMARDs include Rheumatrex and Trexall (methotrexate), Plaquenil (hydroxychloroquine sulfate), leflunomide, and sulfasalazine.
Pros: DMARDs not only help control symptoms, but they can also minimize joint damage and stave off future complications. “The advantage of DMARDs is that they've been in use for years, so rheumatologists are very well-versed in the best ways to assess a patient’s response and benefit, and are very experienced in monitoring side effects,” Dr. Goodman says.
Cons: Doctors must monitor your blood work and symptoms closely while you're taking DMARDs. Benefits of DMARDs may take weeks or months to take effect. Side effects of methotrexate include liver damage, lung damage, and a decreased ability to fight off infections. Eye damage can be a side effect of hydroxychloroquine. Sulfasalazine may cause allergic reaction if you are sensitive to sulfa drugs, and leflunomide has been associated with birth defects when taken during pregnancy.
Because of an increased risk for infection while taking a DMARD, the ACR guidelines suggest getting vaccinated for pneumocccus, influenza, hepatitis B, human papillomavirus (HPV), and herpes zoster (shingles) before starting treatment. If you're already on a DMARD, talk to your doctor about what vaccines you may need.
These drugs are targeted DMARDs that turn down your body's immune response. They can reduce joint pain and swelling, as well as reduce long-term damage. The two basic types are anti-tumor necrosis factor inhibitor (anti-TNF) drugs and non-TNF drugs.
Anti-TNF medications work by blocking the effects of TNF — a protein that encourages inflammation and revs up the immune system — thereby decreasing the joint inflammation that is a hallmark of rheumatoid arthritis.
The ACR guidelines recommend starting an anti-TNF drug with or without methotrexate if you have high disease activity and poor prognostic features in early rheumatoid arthritis. If you've been started on DMARD therapy and have moderate to high disease activity after three months, your doctor may add or switch to an anti-TNF.
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If you're taking an anti-TNF already and you are not doing well after three months, your doctor may switch to another anti-TNF or to a non-TNF biologic. Anti-TNF drugs include Enbrel (etanercept), Remicade (infliximab), and Humira (adalimumab). Non-TNF biologics include abatacept, rituximab, and tocilizumab.
Pros: Biologic medications are effective in controlling symptoms and preventing complications of rheumatoid arthritis. “The major advantages of the biologics are the fast onset of action and high rate of response,” Goodman says.
Cons: They can cause several potentially life-threatening side effects. Because these drugs interfere with the immune system, they increase your risk for infection, including tuberculosis, so the ACR guidelines recommend screening for tuberculosis if you’re taking biologics. Additionally, some of these medications have been linked to the development of lymphoma, a cancer of the white blood cells. Biologics are given by injection, and one of the most common side effects is burning, itching, and swelling at the site of the injection. You should not take a biologic if you have untreated chronic hepatitis B, have had a cancer tumor in the past five years, or have severe heart failure. Vaccination recommendations for biologics are similar to those for DMARDs, so you should talk to your doctor about them.
JAK inhibitors are the latest RA medications, Goodman says. This new class of biologic DMARDs specifically targets JAK enzymes involved in inflammation. Because they're given in pill form, they're sometimes called oral biologics. Tofacitinib was the first of these drugs to get FDA approval for adults with moderate to severe RA.
Pros: This medication is effective for people who haven’t seen results with methotrexate or can't take that drug.
Cons: As with other biologics, tofacitinib affects the immune system and can leave you vulnerable to serious infections, such as tuberculosis, as well as certain cancers. Increases in cholesterol and liver enzymes are also risks.
Corticosteroid drugs help fight inflammation and depress your immune response. Steroid drugs include prednisone and Solu-Medrol (methylprednisolone). Steroids are used to control rheumatoid arthritis symptoms, but they do not alter the course of the disease in the same way that DMARDs do.
Pros: They can be given by mouth, intravenously, or be injected directly into a joint. Because steroids act quickly, they can be used while waiting for other drugs like DMARDs to take effect. They are useful for a sudden flare of symptoms.
Cons: Steroid use is limited because they can lead to a host of side effects, including weight gain, high blood pressure, elevated blood sugar, osteoporosis, and mood disturbances.
RA treatment isn't one-size-fits-all. Work closely with your doctor to find the best treatment or treatment combination for you. The benefits of treatment typically outweigh the side effects, but it's good to know what to look for.
Additional reporting by Mikel Theobald.
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