Medication Options for Rheumatoid Arthritis
If you’ve recently been diagnosed with rheumatoid arthritis (RA) or are struggling with your treatment plan, the medication options can be confusing. There are various drug classes and they work in different ways to treat your RA symptoms or slow the progression.
There are five drug classes that are typically used to treat RA. Although they can each be used separately, they are often most helpful when used in conjunction with another.
Disease-Modifying Anti-Rheumatic Drugs (DMARDs)
A drug from the DMARD category is often selected shortly after diagnosis. DMARDs are known to slow or even halt the progression of RA.
DMARDs work by stopping the immune response that causes inflammation. However, they can take several months to be effective.
DMARDs are often effective on their own, at least initially. Sometimes they are used in correlation with a glucocorticoid, or an NSAID to control pain.
Like all medications, DMARDs are not without their side effects. Because their action is to block immune response, they may actually reduce immunity, which can lead to increased risk of infections and subsequent illnesses.
For some people, DMARDs may also be hurtful to organs such as the kidneys and liver, so routine blood testing may be recommended.
Conventional DMARDs include methotrexate, hydroxychloroquine, sulfasalazine and leflunomide.
There are various side effects that may be associated with these drugs, including stomach upset, sore mouth, increased risk of infections, liver damage and bleeding (methotrexate), damage to the retina of the eye (hydroxichloroquine), rash, hair loss, liver damage, weight loss, diarrhea (leflunomide), orange tinge of the urine, tears and sweat, and sensitivity to light and headaches (sulfasalazine).
Rheumatoid arthritis and hair loss (along with several other of the symptoms) is common, so it can be difficult to distinguish whether it is caused by RA or by the medication.
Biologic Response Modifiers
Biologic response modifiers, or “biologics,” are a sub-category of DMARDs. They are intravenous medications that are given as an infusion.
An advantage to biologics is that, unlike DMARDs, which can decrease immune function, biologics work by targeting a specific immune response. This means that the risk of lowered immunity and subsequent illness is much lower.
Examples include adalimumab (Humira), etanercept (Enbrel), infliximab (Remicade) and rituximab (Rituxan).
The potential side effects can be serious and include infections with bacteria and fungi, nerve disorders (including multiple sclerosis) and heart failure. In addition, there is an increased risk of allergic reactions, including the most severe form – anaphylaxis, when taking infliximab.
JAK Inhibitors (or Targeted Synthetic DMARD)
JAK inhibitors are a new sub-category of DMARDs. This new medication specifically blocks the Janus kinas (JAK) pathway, which is involved in immunity.
An example of a JAK inhibitor is tofacitinib, which has an advantage over biologics, as it can be taken orally.
Side effects that have been associated with it include various bacterial infections, anemia, headaches, high blood pressure, liver damage (including fatty liver) and in rare cases cancer.
Glucocorticoids, also known as corticosteroids, can be used for RA treatment but are often used on a short-term basis, when symptoms flare up or when initiating treatments that may take several months to take effect.
Steroids are potent anti-inflammatory drugs that are available in pill or injection form. They also help decrease joint pain and stiffness and are recommended to treat flare-ups. They have many possible side effects, including RA weight gain, aggravation of diabetes, cataracts, osteoporosis and increased risk of infections.
Glucocorticoids are quick acting and are effective in reducing inflammation. They reduce inflammation by decreasing activity of the immune system. They also reduce the production of chemicals that cause inflammation, which lowers overall tissue damage.
If possible, glucocorticoids should be used on a short-term basis. Along with undesirable side effects, such as increased appetite with subsequent weight gain, difficulty sleeping, acne and anxiety, they can have much more serious side effects, such as elevated blood sugar levels, high blood pressure, glaucoma and increased risk for infection.
Examples of glucocorticoids include prednisone, prednisolone, and methylprednisolone.
Nonsteroidal anti-inflammatory medications (NSAIDs) and Analgesics
Unlike the previously listed drug classes, NSAIDs will not treat RA specifically but will treat the symptoms associated with RA. This class of drugs include about 20 drugs – from the over the counter ibuprofen and naproxen, to the prescription drug Celecoxib.
NSAIDs are used to treat pain associated with RA; in fact, they block an enzyme that increases inflammation so they actually cause a reduction in inflammation — hence the name. Although they reduce pain and inflammation, they cannot reduce damage already done to the joints.
NSAIDs are taken in conjunction with other medications that are used to specifically treat RA. They also may need to be limited in certain patient populations, such as those with kidney or liver disease, so discussing with your physician prior to taking an NSAID is recommended.
These drugs can affect the cardiovascular system (causing high blood pressure and heart diseases), the digestive system (stomach upset/irritation, peptic ulcers, bleeding), cause liver and kidney damage and ringing in the ears.
Two drugs from this group (Rofecoxib and Valdecoxib) had been removed from the market after being linked with increased risk of heart attacks and strokes. NSAIDs interact with many drugs including blood thinners and some anti-seizure drugs.
Examples include Celebrex, ibuprofen and diclofenac.
As with NSAIDs, analgesics treat pain associated with RA. However, they do not treat inflammation so they will not reduce swelling of the joints. As with NSAIDs, they should not be used alone and should be used in conjunction with other RA treatments.
NSAIDs may be purchased over-the-counter or also may be given as a prescription, depending on the severity of the pain.
Examples of analgesics include acetaminophen, tramadol, oxycodone and hydrocodone.
Remember that everyone who has RA has their own treatment plan that is individualized by their physician. Your treatment plan will likely look different than someone else’s.
Also keep in mind that if one medication does not work for you, there are a multitude of other options available — and there is further research being done every day to better the lives of RA sufferers.