Medicines to Treat Rheumatoid Arthritis

Remission, or the absence of signs and symptoms of significant inflammatory disease activity, is the doctor's primary goal of treatment for your rheumatoid arthritis (RA). If remission is not possible, then reaching and maintaining low disease activity is the goal.1 The good news is that many different treatment options exist for treating your RA.

Your doctor may need to try several different drugs or a combination of drugs until finding what works best for you. Expect to see your doctor often while looking for the right balance of benefits and side effects. Ask your doctor how a medicine may improve your RA and your life. Ask how long you should wait before seeing a result. Tell your doctor what matters to you. If you don't think your medicine is working — speak up!

Most doctors treat RA with powerful medicines early on. This may prevent later joint damage. There are several categories of drugs that may be used for treating your RA — DMARDs, corticosteroids, analgesics, and NSAIDs.

DMARDs

DMARDs (dee-mards) refer to a number of medications that actually change the course of your rheumatoid arthritis. The letters D-M-A-R-D stand for disease modifying antirheumatic drug. DMARDs may reduce or prevent joint damage, preserve function, and maintain your quality of life. All people with RA should ask their doctor about DMARD therapy.2

DMARDs are most effective when you begin using them early in your treatment. But they are slow acting. Your doctor may prescribe an additional drug — such as a corticosteroid or an NSAID (see below) — to help control your pain and inflammation for a short period of time while the DMARD starts to work.

All DMARDs can cause stomach side effects. Because DMARDs dampen your immune system, you should always watch for signs of infection (chills, fever, sore throat, cough, etc).3 Report any signs of infection to your doctor as soon as possible. And, for the same reason, always talk with your doctor before getting any vaccinations while you are taking these drugs.

DMARDs can be separated into two major types — non-biologic and biologic. Non-biologic DMARDs have been used to treat RA for a long time. There are many different kinds and they work in non-specific ways to quiet the immune system.

Biologic DMARDs, on the other hand, target specific parts of the immune response that leads to inflammation. Biologic DMARDs are a newer class of drugs compared to non-biologic DMARDs. There are several drug choices in each category described below.

Non-Biologic DMARDs

Methotrexate (Rheumatrex®)2 is one of the most effective and commonly used DMARDs. It may be taken by mouth or by injection. Many people take methotrexate with one or more other DMARDs.4 If you take methotrexate, you should talk to your doctor about the vitamin supplement folate.5,6 There may be serious side effects like diarrhea, reddening of your skin, or sores in your mouth.5

Hydroxychloroquine (Plaquenil®)7 is taken by mouth. It usually has few side effects. You should have an eye exam within a year of starting therapy and report any change in vision to your doctor.4 It may take up to six months to feel the full effects.7

Azathioprine (Imuran®)8 is taken by mouth. Azathioprine can temporarily lower the number of white blood cells in your blood. This increases your chance of getting an infection. Check with your doctor as soon as possible if you think you are getting an infection or if you notice any unusual bleeding or bruising, fever, or rash.

Leflunomide (Arava®) is taken by mouth. The most common side effect is diarrhea, which occurs in approximately 2 out of 10 patients.9 If you are female, you absolutely must avoid pregnancy during treatment.

Sulfasalazine (Azulfidine®)10 contains the main ingredient in aspirin (salicylate) plus a sulfa antibiotic. It is often given for mild symptoms or used in combination with other drugs. You take it by mouth, and it is usually well tolerated.

Cyclosporine (Sandimmune®, Neoral®)11 is sometimes used to treat people who have severe, active RA that has not responded well to methotrexate.12

Cyclophosphamide (Cytoxan®)13 is used to treat rheumatoid arthritis only in very unusual circumstances, such as if you have blood vessel inflammation in addition to your arthritis.

D-penicillamine (Cuprimine®, Depen®)2 is effective but unpopular because scheduling doses is hard. Rare but potentially serious side effects include autoimmune disease (eg, Goodpasture's syndrome and myasthenia gravis).

Tetracycline, or minocycline (Minocin®)14 is sometimes prescribed if you have mild rheumatoid arthritis.4 Taken by mouth, it usually causes only moderate side effects like gastrointestinal symptoms, dizziness, and skin rash.

Biologic DMARDs

Biologic DMARDs get their name because they are copies of proteins that occur naturally in the human immune system. These drugs often work when other therapies have failed. In many cases they slow the progress of joint damage.

Although biologics work in different ways, they all block the action of certain proteins that contribute to the inflammation of your joints and tissues. The downside of these drugs is that they are expensive. Biologics are infused through a vein or injected, and they can have serious side effects.15

TNF Inhibitors16

TNF inhibitors are antibodies that block one kind of protein called TNF-alpha. They are used to treat active disease when other DMARDs have failed. TNF inhibitors may be used in combination with other DMARDs. For example, the TNF inhibitor infliximab (Remicade®) is often used in combination with methotrexate therapy.1 A tight control of disease activity using methotrexate and a TNF inhibitor allows more patients to achieve remission.17 Improvement with TNF inhibitors is usually seen within 12 weeks.

TNF inhibitors weaken the immune system. For this reason, they make people more likely to get a serious infection, including tuberculosis. It is very important to watch for symptoms of infection and report them to a doctor. In addition, all TNF inhibitors can have significant side effects. Talk to your doctor about the possible side effects of any medicines you take.

There are a few precautions you can take while being treated with TNF inhibitors18:

Infliximab (Remicade®)19 is delivered through a vein. Rapid improvement may be seen as early as the first two weeks of therapy.

Adalimumab (Humira®)20 is injected under the skin every other week. Patients or caregivers must be able to demonstrate to their healthcare provider that they're able to correctly inject this medicine. The Humira® Pen is a tool that makes injection easier and ensures correct dosing.

Etanercept (Enbrel®)21 is injected under the skin one to two times each week. Etanercept comes in a prefilled auto injector for ease-of-use and proper dosing.

Certolizumab pegol (Cimzia®) is used to treat moderately to severely active RA. It is injected under the skin every two to four weeks.

Golimumab (Simponi®) is a TNF inhibitor used with methotrexate in adults with moderately to severely active RA. It is administered monthly by subcutaneous injection.

Your doctor might prescribe one of the other biologics listed below if22-24:

Like TNF inhibitors, these drugs make you more prone to infection.

Rituximab (Rituxan®)24 is a cancer drug. It blocks inflammation by targeting your body's B cells.15 Rituximab may provide relief from symptoms for up to six months. People on rituximab therapy usually take methotrexate, too.16

Abatacept (Orencia®) is a medicine that targets your body's T cells.15 Abatacept is administered through a vein or injected under the skin.25 Meaningful improvement takes about 16 weeks.16

Tocilizumab (Actemra®)26 targets a specific protein called IL-6. It is used to treat adults with moderately to severely active RA. It is also used in children over two years of age who have an active, severe type of arthritis called systemic juvenile idiopathic arthritis (SJIA).

Anakinra (Kineret®)23 targets a specific protein called IL-1, which contributes to inflammation.15 Anakinra is taken daily by injection under the skin. An auto-injector system is available to help make this easier.16

Combination therapy

Sometimes drugs are more effective when they can work together. For example, some people with RA respond to combination therapy using one of the newer biologics and a standard DMARD, such as methotrexate.15

Corticosteroids3

Corticosteroids (kor-ti-ko-stir-oid) include some of the most effective and fastest-working drugs for treating your RA. But they also can do great harm by causing brittle bones, cataracts, and elevated blood sugar, to name a few. To minimize your side effects, your doctor may prescribe low-dose steroids for as short a period of time as possible. Usually doctors recommend combining steroids with DMARDs — or replacing the steroids altogether.

Pain Relievers3

Analgesics (a-nl-je-ziks), like acetaminophen (Tylenol®) and codeine, are used just for pain relief. They do not treat or improve your RA. Although acetaminophen is relatively safe and inexpensive, high doses can be toxic. Avoid taking over-the-counter (OTC) acetaminophen when your doctor has prescribed drugs that combine acetaminophen and opioids like Percocet® and Darvocet®.

NSAIDs

NSAIDs (en-seds) are the most commonly used drugs for treating RA.3 The letters N-S-A-I-D stand for "nonsteroidal anti-inflammatory drug." Examples include aspirin, ibuprofen, and naproxen sodium. NSAIDs relieve pain and help reduce your joint inflammation. But they can cause serious side effects, like heart and blood vessel disease, stomach upset, and gastrointestinal bleeding.3

People who take NSAIDs on a regular basis may develop stomach ulcers. About 2% of regular NSAID users experience bleeding, tearing or blockage of the intestines. NSAIDs also increase the chances of having a heart attack or stroke. If you already have heart disease, you're at higher risk.

Risk Factors for Complications

Some people are at higher risk of NSAID-related problems such as heart attack, stroke, ulcers or bleeding. Factors that you should consider include:

Preventing Complications

There are several ways to reduce the risk for NSAID-related problems. Your doctor and Accordant nurse can help you find a strategy that is best for you. Possible options include:

Above all, if your medications are not working, remain positive and talk to your doctor. Explain what works and what doesn't. Your doctor may prescribe several different drugs before finding the best treatment course for you. The sooner you and your doctor find the right drug combination, the better.

How Are My RA Medicines Working?

Your medicine should help you meet the demands of how you live every day. It's important that your doctor knows if there are things you need to do but can't because of RA.

Answer these questions to see how you are doing on a normal day. Then take this worksheet to your doctor. Your answers will help you and your doctor develop a medicine plan that works best for you.

 
 

Please check () the one best answer for your abilities over the past week.

 
 

Without

ANY

Difficulty

With

SOME

Difficulty

With

MUCH

Difficulty

UNABLE

To Do

On a typical day how well can you:

Dress yourself, including tying shoelaces and doing buttons

❑

❑

❑

❑

Get in and out of bed by yourself

❑

❑

❑

❑

Lift a full cup or glass to your mouth

❑

❑

❑

❑

Walk outdoors on flat ground

❑

❑

❑

❑

Wash and dry your entire body

❑

❑

❑

❑

Bend down to pick up something from the floor

❑

❑

❑

❑

Turn faucets on and off

❑

❑

❑

❑

Get in and out of a car by yourself

❑

❑

❑

❑
 

Are there things you'd like to do but can't because of RA?
 
 
 
 
 
 
 

If you are having trouble with things you need to do during the day, let your doctor know. It may be time to change medicines or adjust your dose. Fill out the chart on the next page to show your doctor every medicine or supplement you're taking and how much of it you use.

Medicine Chart

Name:_________________________________ Date:__________________

Medicine/Supplement

Why I Take It

Dose

Times Per Day
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       

Last Modified Date: October 31, 2012 © Accordant Health Services, a CVS/Caremark company.   All rights reserved. This article has been reviewed for accuracy by a member of the Accordant Health Services Medical Advisory Team. This information is not intended to be a substitute for professional medical advice. You should not use this information to diagnose or treat a health problem or disease without consulting with a qualified healthcare provider. Please consult your healthcare provider with any questions or concerns you may have regarding your condition. Use of this online service is subject to the disclaimer and the terms and conditions.

References

  1. Singh JA, Furst DE, Bharat A, et al. 2012 update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken ). 2012;64(5):625-639.
  2. Guidelines for the management of rheumatoid arthritis: 2002 Update. Arthritis Rheum. 2002;46(2):328-346.
  3. Arthritis Foundation Web site. http://ww2.arthritis.org/conditions/DrugGuide/types.asp. Accessed September 12, 2007.
  4. Saag KG, Teng GG, Patkar NM, et al. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis Rheum. 2008;59(6):762-784.
  5. American College of Rheumatology. http://www.rheumatology.org/practice/clinical/patients/medications/methotrexate.asp. Accessed November 4, 2011.
  6. Whittle SL, Hughes RA. Folate supplementation and methotrexate treatment in rheumatoid arthritis: a review. Rheumatology (Oxford). 2004;43(3):267-271.
  7. American College of Rheumatology. http://www.rheumatology.org/practice/clinical/patients/medications/hydroxychloroquine.asp. Accessed November 4, 2011.
  8. Azathioprine. American College of Rheumatology. http://www.rheumatology.org/practice/clinical/patients/medications/azathioprine.asp. Accessed November 4, 2011.
  9. American College of Rheumatology. http://www.rheumatology.org/practice/clinical/patients/medications/leflunomide.asp. Accessed November 4, 2011.
  10. American College of Rheumatology. http://www.rheumatology.org/practice/clinical/patients/medications/sulfasalazine.asp. Accessed November 4, 2011.
  11. American College of Rheumatology. http://www.rheumatology.org/practice/clinical/patients/medications/cyclosporine.asp. Accessed November 4, 2011.
  12. Wells G, Haguenauer D, Shea B, Suarez-Almazor ME, Welch VA, Tugwell P. Cyclosporine for rheumatoid arthritis. Cochrane Database Syst Rev. 2000;(2):CD001083.
  13. American College of Rheumatology. http://www.rheumatology.org/practice/clinical/patients/medications/cyclophosphamide.asp. Accessed November 4, 2011.
  14. American College of Rhematology. http://www.rheumatology.org/practice/clinical/patients/medications/minocycline.asp. Accessed November 4, 2011.
  15. Handout on Health: Rheumatoid Arthritis. National Institute of Arthritis and Musculoskelatal and Skin Diseases. http://www.niams.nih.gov/Health_Info/Rheumatic_Disease/default.asp. Accessed July 20, 2011.
  16. Furst DE, Breedveld FC, Kalden JR, et al. Updated consensus statement on biological agents for the treatment of rheumatic diseases, 2006. Ann Rheum Dis. 2006;65 Suppl 3:iii2-15.
  17. Soubrier M, Lukas C, Sibilia J, et al. Disease activity score-driven therapy versus routine care in patients with recent-onset active rheumatoid arthritis: data from the GUEPARD trial and ESPOIR cohort. Ann Rheum Dis. 2011;70(4)(PMC3048626):611-615.
  18. Arthritis Foundation. http://ww2.arthritis.org/resources/news/TNF_infection_malignancy.asp. Accessed April 2, 2008.
  19. Remicade [package insert]. Malvern, PA: Centocor, Inc.; February 2011.
  20. Humira [package insert]. North Chicago, IL: Abbott Laboratories; March 2011.
  21. Enbrel [package insert]. Thousand Oaks, CA: Amgen and Wyeth Pharmaceuticals; March 2011.
  22. Kineret [package insert]. Thousand Oaks, CA: Amgen Inc; May 2010.
  23. Orenica [package insert]. Princeton, NJ: Bristol-Myers Squibb Company; August 2009.
  24. Rituxan [package insert]. South San Francisco, CA: Biogen Idec Inc. and Genentech, Inc.; January 2011.
  25. Orencia [package insert]. Princeton, NJ: Bristol-Myers Squibb Company; July 2011.
  26. Actemra (tocilizumab) [package insert]. South San Francisco, CA: Genentech, Inc; April 2011.
  27. Strasser B, Leeb G, Strehblow C, Schobersberger W, Haber P, Cauza E. The effects of strength and endurance training in patients with rheumatoid arthritis. Clin Rheumatol. 2011;30(5):623-632.
  28. Duexis [package insert]. Northbrook, IL: Horizon Pharma USA; April 2011.