Drug Treatments for Rheumatoid Arthritis: What Are Your Options?
What is Rheumatoid Arthritis (RA)?
Rheumatoid arthritis (RA) is an inflammatory disease of the joints in areas like the hands, feet or wrist. The joints become painful, stiff, and tender and may feel warm or look red.
Normally, inflammation is a beneficial process used for repair of injury or illness. However, in an autoimmune disease like RA, healthy tissues are attacked. RA cannot be cured but there are treatments that help control the pain, inflammation and joint destruction.
RA differs from osteoarthritis, which is due to the wear-and tear on the joints and cartilage over time.
What is the Goal of RA Treatment?
Minimizing pain, inflammation and joint damage are the top goals of rheumatoid arthritis (RA) treatment. Drug treatment that can slow down or even stop joint destruction are recommended for most patients.
Treatment should allow you to keep up with your normal daily activities and maintain a good quality of life with the fewest possible drug side effects.
You and your doctor will develop a long-term plan for your RA therapy. Becoming involved in your therapy is important for its success.
What Non-Drug Measures Are Used to Control RA?
Non-drug treatments are also a cornerstone of rheumatoid arthritis (RA) treatment. Joint rest and exercise, physical and occupational therapy, nutritional education and diet counseling are all important components of successful RA treatment.
You can learn to better control your RA symptoms and maximize your ability to stay active with work, physical fitness and social activities by combining non-drug therapies with your medicines. In severe cases, joint replacement surgery may be elected to treat RA.
What is the First Line of Drug Treatment for RA?
Your rheumatoid arthritis (RA) drug treatment will be uniquely tailored to your needs. Your doctor will discuss the risks and benefits of drug treatment with you. Treatment will depend upon the severity and length of time you have had RA.
Your doctor may start treatment by prescribing one or more disease-modifying anti-rheumatic drugs (DMARDs). A drug from the nonsteroidal or glucocorticoid anti-inflammatory drug class might be used initially or for more severe RA symptoms to control your acute pain and inflammation.
What are DMARDs?
Non-biologic disease-modifying anti-rheumatic drugs (DMARDs) are the anchor drugs used for treatment of rheumatoid arthritis (RA), but their full effect may take one to three months. DMARDs decrease inflammation, lessen joint damage, and help to maintain joint function.
Methotrexate (MTX) is a first-line DMARD that is often used in conjunction with an anti-inflammatory drug, such as ibuprofen (Motrin, Advil) or naproxen (Aleve). Methotrexate is usually taken once per week as a pill or as an injection.
What Are Common Side Effects with Methotrexate?
Methotrexate (MTX) side effects may include stomach upset, blurred vision, headache, mouth or lip sores, feeling tired, diarrhea and abnormal liver tests. MTX can reduce the production of certain blood cells and this may increase the risk for bleeding or bruising. There may be a greater risk for fevers and infections, too.
MTX and leflunomide should not be used in pregnancy or breastfeeding. Any woman with rheumatoid arthritis planning a pregnancy should consult with her doctor first.
What If a DMARD Does Not Control the Symptoms of RA?
Other treatments are available that can be added to non-biologic DMARD therapy for patients who do not respond or who have severe rheumatoid arthritis (RA) disease at diagnosis. Another DMARD might be added to treatment, or a biologic DMARD can be tried alone.
Biologic DMARD examples include adalimumab (Humira), etanercept (Enbrel), infliximab (Remicade), abatacept (Orencia), certolizumab (Cimzia), golimumab (Simponi), rituximab (Rituxan), and tocilizumab (Actemra).
Several biosimilars are now available for RA, as well, including Cyltezo (adalimumab-adbm), Inflectra (infliximab-dyyb), Erelzi (etanercept-szzs), and Amjevita (adalimumab-atto), which may be more affordable, but must be specifically prescribed by your doctor.
Most biologics are given by injection and can be added to non-biologic DMARDs, NSAIDs or corticosteriods.
How Do Biologics Work in RA?
Biologics target proteins and other molecules in the immune system that cause inflammation, pain and destruction.
Enbrel, Remicade, Humira, Simponi, and Cimzia are tumor necrosis factor (TNF) blockers. The use of TNF blockers, with or without methotrexate, is recommended for patients with early rheumatoid arthritis who have more severe disease or who fail non-biologic DMARDs.
What Special Precautions are Needed for TNF Blockers?
TNF blockers suppress the immune system and may increase the risk of getting an infection; report any signs, such as a fever, to your doctor immediately. Also report any night sweats or weight loss that occurs during treatment.
You may need vaccinations prior to or during treatment with biologics. Tell your doctor if you have a history of congestive heart failure (CHF), cancer or hepatitis.
You will also be tested for tuberculosis (TB) before starting a biologic agent.
What Other Drugs Are Used in Combination with DMARDs and/or Biologics?
DMARDs, including the biologics are the backbone of rheumatoid arthritis (RA) treatment and help prevent pain and joint destruction.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are also used to alleviate pain and decrease inflammation but do not reduce joint damage. Common NSAID examples include ibuprofen (Advil, Motrin), naproxen (Aleve), diclofenac, and celecoxib (Celebrex).
Glucocorticoids (steroids) such as prednisone, prednisolone or triamcinolone can provide rapid relief and are given in pill form or by injection. However, these are usually given early in therapy to lower inflammation and pain while slower acting drugs take effect. Glucocorticoids are also reserved for more severe RA or flare-ups due to toxicity with long-term use.
Xeljanz: An Oral Biologic RA Treatment
Xeljanz (tofacitinib) was approved in November of 2012 for treatment of patients with moderate-to-severe RA who have had an inadequate response to methotrexate. The extended release Xeljanz XR was approved in February 2016.
Xeljanz is the first oral biologic in a new class of drugs called Janus Kinase (JAK) inhibitors. Xeljanz is given twice daily in pill form if you have had an inadequate response to methotrexate; the XR form is given once daily. It can be used alone or with nonbiologic DMARDs such as methotrexate.
Like other biologics, Xeljanz may be associated with serious side effects such as infections, cancer, and stomach or intestinal tears. Discuss the benefits and risks of this therapy with your doctor.
Kevzara Approved: May 2017
In May, 2017 the FDA approved a new IL-6 antagonist to treat rheumatoid arthritis -- Kevzara (sarilumab) -- from Regeneron and Sanofi. By blocking IL-6, an inflammatory cytokine, the swelling and pain linked to rheumatoid arthritis can be improved. Kevzara (sarilumab) is specifically used for the treatment of patients with moderate-to-severe rheumatoid arthritis who have had an inadequate response or cannot tolerate one or more disease-modifying antirheumatic drugs (DMARDs). It can be used alone or in combination with methotrexate (MTX) or other conventional DMARDs.
In studies, the most common side effects linked with Kevzara included:
- increased liver enzymes
- injection site redness
- upper respiratory infections
- urinary tract infections.
In the MOBILITY study, treatment with Kevzara plus MTX reduced signs and symptoms, improved physical function, and demonstrated significantly less radiographic progression of structural damage, compared to placebo plus MTX.
Finished: Drug Treatments for Rheumatoid Arthritis - What Are Your Options?
- Singh JA, et al. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care & Research 2016;68:1-25. Accessed 06/27/2016. http://www.rheumatology.org/Portals/0/Files/ACR%202015%20RA%20Guideline.pdf
- Drugs.com Rheumatoid Arthritis. Accessed 06/27/2017. https://www.drugs.com/rheumatoid-arthritis.html
- Up To Date. Patient Information: Rheumatoid Arthritis symptoms and diagnosis (Beyond the Basics). Accessed 06/27/2017. http://www.uptodate.com/contents/rheumatoid-arthritis-treatment-beyond-the-basics
- Pfizer. Xeljanz XR Prescribing Information. Revised Feb 2016. Accessed 06/26/2017 at http://labeling.pfizer.com/ShowLabeling.aspx?id=959
- Kevzara. Product Label. Regeneron. Accessed 6/27/2017 at https://www.regeneron.com/kevzara-injection