Drug treatments for Rheumatoid Arthritis
Drugs are used to control the inflammation in the joints caused by rheumatoid arthritis (disease modifying drugs). Drugs are also used to control the pain of rheumatoid arthritis (Link to pain relief).
The inflammation is what damages the joints in the long term as well as causing pain and stiffness in the short term. Supressing the inflammation will therefore result in less pain, stiffness and fatigue now but will also result in less damage to the joints and less disability in the long term.
There have been great advances in the drugs which can suppress rheumatoid arthritis and as a result there is far less chance of being severely disabled from this disease.
The aim is to supress the disease as much as possible and as early after it onset as possible. When rheumatoid arthritis is well controlled there will be much less pain and also less limitation of what you can do. There will be less painful and swollen joints and the markers of inflammation in the blood (ESR and CRP) will be less.
These drugs may be used on their own or you may be taking a combination of several of them.
Taking medication in RA can be therefore be complex, it could mean a person needing to take several different medications at different times of the day, in differing combinations, with and without food, and/or avoiding other medicines. Alcohol can interfere with how the body handles arthritis medication and can allow it to cause side effects more readily. This is why doctors advise people on many of the disease modifying drugs to avoid alcohol (For more information on drinking and alcohol see: http://www.nhs.uk/livewell/alcohol/Pages/Alcoholhome.aspx).
For some people managing their medication can be simple, for others such a strict regimen can be difficult to juggle within everyday life.You should discuss this with your doctor, the practice nurse or the pharmacist to ensure you understand what your different drugs are for and how to take them.
Disease Modifying Drugs
Disease-modifying anti-rheumatic drugs (DMARDs) are used mainly to treat inflammatory arthritis but also some other rheumatic diseases including lupus and other diseases in which there is inflammation of the blood vessels (vasculitis).
DMARDs work by reducing the activity of the arthritis, thus improving the symptoms of pain, swelling and stiffness. They may take several weeks to be effective and you should continue with all other prescribed medication until advised otherwise. Most people have no problems with them, but side effects do sometimes occur, particularly in the first few weeks of treatment.
Most people have no or few problems with these drugs but the most common side effects include diarrhoea, nausea, rashes, headaches, dizziness, bruising and mouth ulcers. You will be fully counselled regarding possible side effects prior to starting any new medication and given written information to support this. Often side effects are mild and resolve spontaneously. However, occasionally side effects may be serious and it is important to seek advice from the rheumatology team or from your own doctor (GP) if you experience any side effects, whether listed or not.
DMARDs can affect the blood and the liver or kidneys and regular blood tests and/or urine tests may be necessary (see below). Results of all blood tests are reviewed by your GP. If problems occur you may be advised to stop the drug responsible, or to reduce the dose.
Many arthritic conditions are controlled by drugs which suppress the overactivity of the body’s immune system that is causing rheumatoid arthritis, thereby reducing the degree of inflammation and slowing down progression of the disease. These drugs are slow-acting and can take several weeks to work, so it’s important to keep taking them even if they don’t seem to have any effect at first. If you don’t respond well to one of these drugs, or if you develop any side-effects, then your doctor may try one of the others. Click on the drug name to read more about the following conventional DMARDs:
- gold injections
Side effects sometimes occur, particularly in the first few weeks of treatment. The most common include nausea, diarrhoea, mouth ulcers, bruising and occasionally skin rashes. You will be fully counselled regarding possible side effects prior to starting any new medication and given written information to support this.
Often side effects are mild and resolve spontaneously, however, occasionally side effects may be serious and it is important to seek advice from the rheumatology team or from your own doctor (GP) if you experience any side effects, whether listed or not.
If you are prescribed methotrexate and/or leflunomide you should, ideally, avoid alcohol, or at least keep this to a minimum, as this increases the likelihood of liver damage whilst on these treatments.
Some DMARDs can affect the blood and the liver or kidneys and regular blood tests and/or urine tests will be necessary whilst on treatment. Results of all blood tests are reviewed by your GP. If problems occur you may be advised to stop the drug responsible, or to reduce the dose to prevent more serious side effects occurring.
Some drugs have other potential side effects, for example leflunomide may cause a rise in blood pressure and this should be monitored regularly whilst on treatment.
Rarely, methotrexate causes respiratory problems such as a dry cough and/or shortness of breath so a chest x-ray is usually performed before starting treatment with this drug. If such side effects occur, this may be repeated and lung function tests and/or a CT scan may also be requested.
Hydroxychloroquine occasionally causes visual disturbances so an eye check is usually carried out when you first start treatment and repeated periodically whilst you remain on this drug.
Although patients often worry about potential side effects of treatment, it is important to realise that if left untreated, your rheumatoid arthritis may cause you greater harm than the drugs prescribed to control it. Most patients do derive considerable benefit from treatment, withnone or minimal side effects.
Biological therapies (also known as biologics) are newer drugs that have been developed in recent years to target messenger proteins that research has identified as being important parts of the disease process. They tend to work more quickly than conventional DMARDs.
Biological therapies are only given to people who haven’t responded to conventional DMARDs or who’ve had side-effects from them. Biological therapies are often given in combination with a conventional DMARD such as methotrexate.
Biologics are not suitable for women who are pregnant or breastfeeding or people with chronic or acute infection.
Baseline blood tests and a chest x-ray will be required before starting biologic therapy, and further blood tests monitored regularly whilst you remain on the treatment to check for side effects and ensure the treatment is working. You will also be reviewed by one of the rheumatology team approximately every 3 months in order to formally assess your disease activity. At each appointment your joints will be examined for pain and swelling and your blood tests reviewed.
Click on the name of the drug to find more about the following biological therapies:
The National Rheumatoid Arthritis Society has produced a very useful patient guide to biological therapies for the Treatment of Rheumatoid Arthritis:
Some biological therapies are called anti-TNF drugs. They target a protein called tumour necrosis factor, which increases inflammation when excess amounts are present in the blood or joints. Other biological therapies target different proteins. Anti-TNF drugs are costly. These drugs can only be prescribed by a consultant rheumatologist and strict criteria must be fulfilled in order to qualify for treatment.
Anti-TNF treatment is not usually appropriate if you have multiple sclerosis (MS) or have previously had tuberculosis (TB), cancer (with the exception of some skin cancers), blood disorders or other recurrent infections.
Click on the name of the drug to find more about the following Anti-TNF drugs:
Blood tests for monitoring your RA
Blood tests are used to monitor if your RA is adequately treated and also to ensure you are having no side-effects from your disease-modifying anti-rheumatic drugs (DMARDs) as they all have the potential to cause adverse effects. Regular monitoring is to ensures your safety. DMARDs are excreted mainly via the liver and kidneys and may occasionally affect either organ adversely. They can also rarely have adverse effects on the blood.
Regular blood tests are important both to check for adverse effects and to monitor how active your disease is and how well you are responding to treatment. Samples are usually taken from a vein in your arm or the back of your hand. This can be done at the hospital pathology department by a phlebotomist but many GP practices also provide a phlebotomy service – if this would be more convenient for you please check that your surgery offers this service.
For patients on DMARDs regular blood tests usually include the following: full blood count (FBC), erythrocyte sedimentation rate (ESR) and biochemical profile (liver function tests (LFTs), C-reactive protein (CRP) and sometimes renal (kidney) function tests (urea, electrolytes and creatinine)).
A full blood count includes the haemoglobin, white cell count and platelet (thrombocyte) count. These are briefly explained below.
If you become anaemic your haemoglobin level will decrease. Anaemia is common in many forms of arthritis and may be due to a number of reasons. Iron deficiency is a common cause and iron or dietary supplements may be necessary. Non-steroidal anti-inflammatory drugs (NSAIDs) are known to cause stomach irritation (gastritis) and ulceration in some people. This may lead to bleeding from the stomach or bowel resulting in anaemia.
Other causes of anaemia include malabsorption (where certain nutrients are poorly absorbed via the bowel) – this may occur if you have other conditions such as Crohn’s disease or coeliac disease. Some people have a form of anaemia called pernicious anaemia, which requires regular injections of Vitamin B12. Anaemia commonly occurs as a symptom of chronic inflammation, however, and is not always helped by iron supplements. However, as your arthritis comes under better control the haemoglobin often improves and the anaemia resolves. Very occasionally severe anaemia requires a blood transfusion.
White cell count
The white blood cells may be affected by both your disease and its treatment. The number often increases when infection is present, or with long-term use of corticosteroids. However drugs which suppress the immune system may reduce the number of white cells. The number of white cells is checked to ensure that you retain sufficient to fight infection. There are different types of white cells; the most important being neutrophils. If the level of neutrophils falls too low you may need to temporarily stop treatment, or change to an alternative.
The number of platelets in the blood is also monitored. These are cells involved in blood clotting and may increase in number when there is active inflammation. Some drug treatments may cause a reduction in platelets which could increase the risk of bleeding, making it necessary to stop treatment.
Erythrocyte sedimentation rate (ESR)
The ESR is a simple test which indicates the level of inflammation in the blood and may increase when your arthritis is more active, but this is not always the case: in some conditions the ESR remains normal despite on-going inflammation. The ESR may also be affected by any other illness or infection. The ‘normal’ ESR varies: it is often higher in women and increases with age.
Some hospitals use a different test, the plasma viscosity, which also measures the level of inflammation in the body.
Biochemistry Tests (LFTs, U&Es, Creatinine) check how well your liver and kidneys are working. These can be affected by many conditions and by drug treatments.
C-reactive protein (CRP) is a protein produced by the liver which increases in response to inflammation, whatever the cause. It provides a means of assessing the extent of your disease activity. It will however be increased by any other illness where there is inflammation such as an infection.
Further information about these and other blood tests used in rheumatology is available from your rheumatology consultant, specailist nurse or rheumatology pharmacist.