Rheumatoid Arthritis
Medication for Rheumatoid Arthritis
Courtesy: Arthritis Today
Medications are the cornerstone of treatment for active rheumatoid arthritis. The goals of treatment with rheumatoid arthritis medications are to achieve remission and prevent further damage of the joints and loss of function, without causing permanent or unacceptable side effects.
The type and intensity of rheumatoid arthritis treatment with medication depends upon individual factors and potential drug side effects. In most cases, the dose of a medication is increased until inflammation is suppressed or drug side effects become unacceptable.
The challenge of using medications is to balance the side effects against the need to control inflammation. All patients with rheumatoid arthritis who use medications need regular medical care and blood tests to monitor for complications. If side effects occur, they can often be minimized or eliminated by reducing the dose or switching to a different drug.
Several classes of drugs are used to treat rheumatoid arthritis: Non-steroidal antiinflammatory drugs (NSAIDs), disease modifying antirheumatic drugs (DMARDs), biologic response modifiers, glucocorticoids, and if needed, analgesics.
The type and intensity of rheumatoid arthritis treatment with medication depends upon individual factors and potential drug side effects. In most cases, the dose of a medication is increased until inflammation is suppressed or drug side effects become unacceptable.
The challenge of using medications is to balance the side effects against the need to control inflammation. All patients with rheumatoid arthritis who use medications need regular medical care and blood tests to monitor for complications. If side effects occur, they can often be minimized or eliminated by reducing the dose or switching to a different drug.
Several classes of drugs are used to treat rheumatoid arthritis: Non-steroidal antiinflammatory drugs (NSAIDs), disease modifying antirheumatic drugs (DMARDs), biologic response modifiers, glucocorticoids, and if needed, analgesics.
Nonsteroidal anti-inflammatory drugs — Nonsteroidal anti-inflammatory drugs (NSAIDs) may be recommended to relieve pain and reduce minor inflammation. However, NSAIDs do not reduce the long term damaging effects of rheumatoid arthritis on the joints.
NSAIDs must be taken continuously and at a specific dose to have an anti-inflammatory effect. Even at the correct doses, NSAIDs must usually be taken for two to four weeks before their effectiveness is known. If the initial dose of NSAIDs does not improve symptoms, a clinician may recommend increasing the dose gradually or switching to another NSAID. You should not take two NSAIDs at the same time.
Many NSAIDS have significant side effects, including gastrointestinal bleeding, fluid retention, and an increased risk of heart disease. The risks need to weighed carefully against the benefit when taking these drugs.
Disease-modifying antirheumatic drugs — Disease-modifying antirheumatic drugs (DMARDs) can substantially reduce the inflammation of rheumatoid arthritis, reduce or prevent joint damage, preserve joint structure and function, and enable a person to continue his or her daily activities. Although DMARDs act slowly, they may allow you to take a lower dose of glucocorticoids to control pain and inflammation.
Drugs in this class include hydroxychloroquine (Plaquenil®), methotrexate (Rheumatrex®), gold salts (Ridaura®, Solganal®), D-penicillamine (Depen®, Cuprimine®), sulfasalazine (Azulfidine®), azathioprine (Imuran®), leflunomide (Arava®), and cyclosporine (Sandimmune®, Neoral®).
An improvement in symptoms may require four to six weeks of treatment with methotrexate, one to two months of treatment with sulfasalazine, and two to three months of treatment with hydroxychloroquine. Even longer durations of treatment may be needed to derive the full benefits of these drugs.
Minocycline — In some people with early rheumatoid arthritis, taking an antibiotic (minocycline) may have some benefit. This treatment may be a reasonable alternative to hydroxychloroquine and sulfasalazine.
Biologic response modifiers — Biologic response modifiers, also known as biologics, are medications that were designed to prevent or reduce the inflammation that damages joints. Biologics target molecules on cells of the immune system, joint, and the products that are secreted in the joint, all of which can cause inflammation and joint destruction. There are several types of biologics, each of which targets a specific type of molecule involved in this process (tumor necrosis factor, interleukin-1, and cell surface molecules on T and B lymphocytes).
· Biologics that bind tumor necrosis factor (TNF), called anti-TNF treatments, include Etanercept (Enbrel®), adalimumab (Humira®), and infliximab (Remicade®). These are called anti-TNF agents.
· Anakinra (Kineret®) inhibits interleukin-1. Anakinra is significantly less potent than TNF inhibitors in most people with rheumatoid arthritis. It is occasionally recommended for selected individuals who do not respond to anti-TNF agents. Anakinra cannot be used at the same time as anti-TNF agents due to the risk of infection.
· Abatacept (Orencia®) interferes with the activation of T cells. Abatacept is usually recommended only for people with moderate or severe rheumatoid arthritis that is not controlled with methotrexate and an anti-TNF agent.
· Rituximab (Rituxan®) depletes B cells. Rituximab is usually recommended only for people with moderate or severe rheumatoid arthritis that is not controlled with methotrexate and an anti-TNF agent.
Unlike DMARDs, which can take a month or more to begin working, biologics work rapidly, within two weeks for some medications (Enbrel®, Humira®, Remicade®) and within four to six weeks for others (Rituxan®, Orencia®). Biologics may be used alone or in combination with other DMARDs (eg, methotrexate), NSAIDs, and/or steroids.
Because of their cost (generally more than $15,000 per year in the United States), biologics are often reserved for people who have not completely responded to DMARDs and for those who cannot tolerate DMARDs in doses large enough to control inflammation.
All biologic response modifiers must be injected. Humira®, Enbrel®, and Kineret® are injected under the skin by the patient, a family member, or nurse. Remicade®, Orencia® and Rituxan® must be injected into a vein, which is typically done in a doctor's office or clinic; this takes between one and three hours to complete.
NSAIDs must be taken continuously and at a specific dose to have an anti-inflammatory effect. Even at the correct doses, NSAIDs must usually be taken for two to four weeks before their effectiveness is known. If the initial dose of NSAIDs does not improve symptoms, a clinician may recommend increasing the dose gradually or switching to another NSAID. You should not take two NSAIDs at the same time.
Many NSAIDS have significant side effects, including gastrointestinal bleeding, fluid retention, and an increased risk of heart disease. The risks need to weighed carefully against the benefit when taking these drugs.
Disease-modifying antirheumatic drugs — Disease-modifying antirheumatic drugs (DMARDs) can substantially reduce the inflammation of rheumatoid arthritis, reduce or prevent joint damage, preserve joint structure and function, and enable a person to continue his or her daily activities. Although DMARDs act slowly, they may allow you to take a lower dose of glucocorticoids to control pain and inflammation.
Drugs in this class include hydroxychloroquine (Plaquenil®), methotrexate (Rheumatrex®), gold salts (Ridaura®, Solganal®), D-penicillamine (Depen®, Cuprimine®), sulfasalazine (Azulfidine®), azathioprine (Imuran®), leflunomide (Arava®), and cyclosporine (Sandimmune®, Neoral®).
An improvement in symptoms may require four to six weeks of treatment with methotrexate, one to two months of treatment with sulfasalazine, and two to three months of treatment with hydroxychloroquine. Even longer durations of treatment may be needed to derive the full benefits of these drugs.
Minocycline — In some people with early rheumatoid arthritis, taking an antibiotic (minocycline) may have some benefit. This treatment may be a reasonable alternative to hydroxychloroquine and sulfasalazine.
Biologic response modifiers — Biologic response modifiers, also known as biologics, are medications that were designed to prevent or reduce the inflammation that damages joints. Biologics target molecules on cells of the immune system, joint, and the products that are secreted in the joint, all of which can cause inflammation and joint destruction. There are several types of biologics, each of which targets a specific type of molecule involved in this process (tumor necrosis factor, interleukin-1, and cell surface molecules on T and B lymphocytes).
· Biologics that bind tumor necrosis factor (TNF), called anti-TNF treatments, include Etanercept (Enbrel®), adalimumab (Humira®), and infliximab (Remicade®). These are called anti-TNF agents.
· Anakinra (Kineret®) inhibits interleukin-1. Anakinra is significantly less potent than TNF inhibitors in most people with rheumatoid arthritis. It is occasionally recommended for selected individuals who do not respond to anti-TNF agents. Anakinra cannot be used at the same time as anti-TNF agents due to the risk of infection.
· Abatacept (Orencia®) interferes with the activation of T cells. Abatacept is usually recommended only for people with moderate or severe rheumatoid arthritis that is not controlled with methotrexate and an anti-TNF agent.
· Rituximab (Rituxan®) depletes B cells. Rituximab is usually recommended only for people with moderate or severe rheumatoid arthritis that is not controlled with methotrexate and an anti-TNF agent.
Unlike DMARDs, which can take a month or more to begin working, biologics work rapidly, within two weeks for some medications (Enbrel®, Humira®, Remicade®) and within four to six weeks for others (Rituxan®, Orencia®). Biologics may be used alone or in combination with other DMARDs (eg, methotrexate), NSAIDs, and/or steroids.
Because of their cost (generally more than $15,000 per year in the United States), biologics are often reserved for people who have not completely responded to DMARDs and for those who cannot tolerate DMARDs in doses large enough to control inflammation.
All biologic response modifiers must be injected. Humira®, Enbrel®, and Kineret® are injected under the skin by the patient, a family member, or nurse. Remicade®, Orencia® and Rituxan® must be injected into a vein, which is typically done in a doctor's office or clinic; this takes between one and three hours to complete.
Side effects — Biologic response modifiers interfere with the immune system's ability to fight infection and should not be used in people with serious infections.
Testing for tuberculosis is necessary before starting anti-TNF therapy. People who have evidence of prior TB infection should be treated because there is an increased risk of developing active TB while receiving anti-TNF therapy.
TNF-inhibitors are not recommended for people who have lymphoma or have been treated for lymphoma in the past; people with rheumatoid arthritis, especially those with severe disease, have an increased risk of lymphoma regardless of what treatment is used. TNF-inhibitors have been associated with a further increase in the risk of lymphoma in some studies; more research is needed to define this risk.
Steroids (glucocorticoids) — Glucocorticoids, also called steroids have strong anti-inflammatory effects. Drugs in this class include prednisone and prednisolone. Glucocorticoids may be taken by mouth, injected into a vein, or injected directly into a joint. Glucocorticoids quickly improve symptoms of rheumatoid arthritis such as pain and stiffness, and also decrease joint swelling and tenderness.
However, when used alone, glucocorticoids only modestly reduce damage to cartilage and bone caused by rheumatoid arthritis. Glucoacorticoids are generally used to treat rheumatoid arthritis that severely limits a person's ability to function normally. For such people, glucocorticoid treatment may help control symptoms and preserve function until other, slower acting drugs begin to work.
Side effects — Steroids have many side effects, including weight gain, worsening diabetes, promotion of cataracts in the eyes, thinning of bones (osteopenia and osteoporosis), and an increased risk of infection. Thus, when steroids are used, the goal is to use the lowest possible dose for the shortest period of time.
Simple analgesics — Simple analgesics relieve pain, but they have no effect on inflammation. Drugs in this class include acetaminophen (Tylenol®), tramadol (Ultram®), and capsaicin cream or ointment (Zostrix®). Use of narcotic analgesics such as such as codeine, oxycodone, and hydrocodone is generally discouraged because of the long term nature of rheumatoid arthritis and the risk of dependence and addiction.
However, people with a badly damaged joint who cannot undergo joint replacement surgery may benefit from use of a long acting narcotic under the supervision of a rheumatologist or pain specialist.
Treatment of flares — Flares are temporary exacerbations of rheumatoid arthritis that can occur in addition to the ongoing inflammation. In people who are already taking methotrexate or oral steroids, flares can often be controlled by increasing the doses of these drugs. Alternately, flares can be controlled by steroids that are given by injection. Rest is often helpful during flares; hospitalization is rarely necessary.
Testing for tuberculosis is necessary before starting anti-TNF therapy. People who have evidence of prior TB infection should be treated because there is an increased risk of developing active TB while receiving anti-TNF therapy.
TNF-inhibitors are not recommended for people who have lymphoma or have been treated for lymphoma in the past; people with rheumatoid arthritis, especially those with severe disease, have an increased risk of lymphoma regardless of what treatment is used. TNF-inhibitors have been associated with a further increase in the risk of lymphoma in some studies; more research is needed to define this risk.
Steroids (glucocorticoids) — Glucocorticoids, also called steroids have strong anti-inflammatory effects. Drugs in this class include prednisone and prednisolone. Glucocorticoids may be taken by mouth, injected into a vein, or injected directly into a joint. Glucocorticoids quickly improve symptoms of rheumatoid arthritis such as pain and stiffness, and also decrease joint swelling and tenderness.
However, when used alone, glucocorticoids only modestly reduce damage to cartilage and bone caused by rheumatoid arthritis. Glucoacorticoids are generally used to treat rheumatoid arthritis that severely limits a person's ability to function normally. For such people, glucocorticoid treatment may help control symptoms and preserve function until other, slower acting drugs begin to work.
Side effects — Steroids have many side effects, including weight gain, worsening diabetes, promotion of cataracts in the eyes, thinning of bones (osteopenia and osteoporosis), and an increased risk of infection. Thus, when steroids are used, the goal is to use the lowest possible dose for the shortest period of time.
Simple analgesics — Simple analgesics relieve pain, but they have no effect on inflammation. Drugs in this class include acetaminophen (Tylenol®), tramadol (Ultram®), and capsaicin cream or ointment (Zostrix®). Use of narcotic analgesics such as such as codeine, oxycodone, and hydrocodone is generally discouraged because of the long term nature of rheumatoid arthritis and the risk of dependence and addiction.
However, people with a badly damaged joint who cannot undergo joint replacement surgery may benefit from use of a long acting narcotic under the supervision of a rheumatologist or pain specialist.
Treatment of flares — Flares are temporary exacerbations of rheumatoid arthritis that can occur in addition to the ongoing inflammation. In people who are already taking methotrexate or oral steroids, flares can often be controlled by increasing the doses of these drugs. Alternately, flares can be controlled by steroids that are given by injection. Rest is often helpful during flares; hospitalization is rarely necessary.
