DMARDs for Treating Rheumatoid Arthritis

Disease-modifying antirheumatic drugs, a class of medicines commonly used to treat types of inflammatory arthritis such as rheumatoid arthritis (RA), ankylosing spondylitis, psoriatic arthritis, and systematic lupus erythematosus. DMARDs are not used to treat osteoarthritis. Unlike nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil) and corticosteroids such as prednisone, DMARDs affect the disease process of the arthritis itself, not only its symptoms. That is, DMARDs can slow or even stop the joint damage arthritis causes, whereas NSAIDs and corticosteroids only treat the symptoms of pain and inflammation. This article explores how DMARDs for rheumatoid arthritis work, common DMARD brand names, and what to know before you start taking biologic drugs.

How do DMARDs work?

The inflammatory types of arthritis mentioned above are autoimmune conditions, in which the body’s immune system mistakenly attacks the body’s own tissues. In RA, for example, the disordered immune response is mostly directed toward the lining of the joints. DMARDs work by interfering with aspects of this immune process in ways that are, in many cases, not yet entirely understood.

Common DMARDs

Common DMARDs include methotrexate (Rheumatrex, Trexall), hydroxychloroquine (Plaquenil), leflunomide (Arava), and sulfasalazine (Azulfidine). Less common, but still sometimes used, are DMARDs such as azathioprine (Imuran) and cyclosporine (Neoral). In the late 1990’s, a new class of DMARDs, called biologic response modifiers, or biologics, began to appear. These include adalimumab (Humira), etanercept (Enbrel), and infliximab (Remicade). In contrast to the older DMARDs, biologics are made using live organisms, and they target specific immune-system substances known to be involved the autoimmune processes of inflammatory arthritis. Since the advent of the biologics, the older DMARDs have been commonly referred to as “traditional” or “nonbiologic” DMARDs. People with RA often take a biologic and a traditional DMARD together. The biologics are much more expensive than the traditional DMARDs and are not available in generic formulations. They are also given as injections or intravenous infusions, whereas traditional DMARDs are usually taken as pills.

Many of the traditional DMARDs were first used for conditions other than arthritis. Methotrexate was — and still is — used to treat cancer, though in much higher doses than when used to treat arthritis. Hydroxychloroquine is known as an antimalarial drug and was originally used to treat malaria. Cyclosporine and azathioprine are both used during organ transplantation to prevent the body from rejecting the new organ.

How soon can you start taking DMARDs and what are the side effects?

In people with RA, DMARDs used to be reserved for severe cases. Now, because joint damage is known to occur early in the course of RA, it is recommended that a DMARD be given as soon as possible. The American College of Rheumatology’s latest guidelines recommend that in people with high RA disease activity, methotrexate and a biologic be given within three months of RA diagnosis.

All DMARDs have potential side effects. Many of the traditional DMARDs, including methotrexate, increase the risk of liver damage, and people taking them need to have periodic blood tests to monitor liver function. Hydroxychloroquine increases the risk of eye problems, and people taking it must have periodic eye examinations. The biologics, because they powerfully suppress the immune system, increase the risk of infections. Before taking biologics, people should be tested for tuberculosis. People taking biologics should be aware of the signs of infection and avoid live vaccines.

Learn more about taking the proper safety precautions when starting new medication here.

Robert S. Dinsmoor is a medical writer and editor based in Massachusetts.

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