Revised RA med

Medication RA

 

 

 

 

For information on pain relief medication go to: Pain Relief

There are two main aims in treating people with RA; firstly, to relieve their pain and inflammation, and secondly to prevent damage to joints that will lead to increasing disability.

Taking medication in RA can be complex; a person might need to take several different medications at different times of the day, in differing combinations, with and without food, and/or avoiding other medicines. For some people managing their medication can be simple, but many people can find it difficult to fit this into their day-to-day life. There are many people that can help you to manage your medicines better, including your local pharmacist, Rheumatology Specialist Nurses, practice nurses at your GP surgery, and many others. If they’re not able to help you they will be able to find someone that can.

What are Disease Modifying Drugs?

Disease-modifying anti-rheumatic drugs (DMARDs for short) are used to treat inflammatory arthritis and some other rheumatic diseases including lupus and vasculitis (inflammation of the blood vessels). They are also used by other medical specialists such as dermatology and gastroenterology.
Different DMARDs work in different ways to reduce the activity of the arthritis and so improve the symptoms of pain, swelling and stiffness. They do this by suppressing your immune system – in inflammatory arthritis your body’s immune system becomes overactive and starts to attack your joints.
DMARDs may take several weeks to start working and you should continue with all other prescribed medication until advised otherwise.

Are there side-effects?

Side effects sometimes occur, particularly in the first few weeks of treatment, though not all patients will get side effects. 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 on their own, but there can sometimes be serious effects 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. Quite often side-effects can be sorted out by adjusting the dose of your medication, but if that does not work there are usually other medicines that you could try instead. The DMARDs all work in different ways and affect the body differently, so just because you’ve had side-effects from one medicine doesn’t mean that the same thing will happen with other DMARDs. If you don’t respond well to the first DMARD you’re given, your rheumatologist may want you to try a different one. They are also often used in combination.

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. If you are taking methotrexate or leflunomide, you should avoid alcohol to reduce your risk of serious liver damage. For more information on drinking and alcohol see: http://www.nhs.uk/livewell/alcohol/Pages/Alcoholhome.aspx.

Do I need to have any tests when taking DMARDs?

DMARDs can affect the blood, liver or kidneys so you probably will need to have regular blood tests. These are usually taken at your GP surgery. Results of all blood tests are reviewed by the rheumatology team and are also copied to your GP. If problems occur you may be advised to stop the DMARD, or to reduce the dose to prevent more serious side effects occurring. Some of the DMARDs can rarely cause lung problems, so before you start treatment you may need to have a chest x-ray and some breathing tests (Lung Function Studies) to make sure it is safe for you to start treatment. If you develop any problems with your breathing while taking DMARDs, you should seek advice from your GP urgently (or from the Out-of-Hours service if your GP surgery is closed). Lung problems are a rare side effect of these medicines but it is important to be aware of them.
Some drugs have other potential side effects, for example hydroxychloroquine rarely causes eye problems so an eye check is usually carried out when you first start treatment and repeated every year by your optician while you are taking it. Some people get some blurred vision when they first start taking hydroxychloroquine but this usually settles down. Leflunomide can cause your blood pressure to rise so you should have your blood pressure checked when you have your blood tests.

Can I take DMARDs if I want to get pregnant or father a child?

Whilst on treatment with methotrexate or leflunomide you must not become pregnant or father a child, as both of these medicines can harm an unborn child. If you wish to start a family, become pregnant, or father a child, and are taking either of these medicines, please contact the Rheumatology department for advice. Sulfasalazine can cause a temporary and reversible reduction in a man’s sperm count, which may make it harder for him to have children. This will wear off after stopping treatment but may take up to two years.
If you are taking another DMARD and wish to have children, please discuss this with your Rheumatologist.

How do I balance the benefits of DMARDs with the side-effects?

Although patients often worry about potential side effects of treatment, it is important to realise that if left untreated, your rheumatic condition may cause you greater harm than the drugs prescribed to control it. Most patients feel much better with treatment without many side effects.

What are the different types of DMARD?

There are different types of DMARD which are classified according to that the way they work to reduce the activity of the arthritis and so improve the symptoms of pain, swelling and stiffness. DMARDS can be divied into “conventional DMARDs” and the new “Biologics”. There are various different types of biologic which target different cells.
Conventional DMARDS
This group of 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.
The most widely used conventional DMARDS are listed below. Click the name of the drug to find out more about it:

For further information about specific conventional DMARDs and their side effects see:
http://www.arthritisresearchuk.org/arthritis-information/drugs/dmards.aspx#sthash.FDGJNVSr.dpuf

Biologic Drugs

What are Biologics?

Biological therapies (also known as biologics) are newer drugs that have been developed in the last ten to fifteen years. They target individual molecules and tend to work more quickly than conventional DMARDs. There are several different biologics, which target different molecules involved in carrying messages between the immune system cells responsible for causing your disease. The first biologic therapies targeted a protein called TNF, which causes inflammation. Other biologics target different molecules.

Is there any criteria for receiving Biologics?

Biological therapies are only given to people who haven’t responded to conventional DMARDs or who have had serious side-effects from them. Biological therapies are often given in combination with a conventional DMARD such as methotrexate . as this makes them work better, but they can be used on their own if necessary. Some Biologics such as Anti-TNF drugs are extremely expensive, and it costs about £10,000 to treat one person with them for one year. These drugs can only be prescribed by a consultant rheumatologist and strict criteria must be fulfilled in order to qualify for treatment. If you do not attend your clinic appointments then your consultant will not be able to issue further prescriptions for your treatment.

How are these drugs given?

They are given as injections, which you give yourself at home, or by infusion (through a drip into a vein in your arm). You can be taught to give yourself these injections, or your partner or another family member or friend can be taught how to give you the injections. If this is not possible your practice nurse or district nurse might be able to give the injections.
These medicines generally start to work within a few weeks, but your consultant would usually wait 12 weeks before deciding if they were working or not.

What tests do I need before starting Biologics?

Biologics can increase the risk of infections, and this can cause problems if you’ve had certain infections in the past. Before starting biologics, you will need to have a chest x-ray and blood tests, including tests to check for latent (hidden) infection with tuberculosis (TB), hepatitis B and hepatitis C. Your consultant might recommend that you are vaccinated against other diseases such as chickenpox or shingles before starting treatment.
Once you have started treatment, you will need to have blood tests every three months (or more often if you are also taking methotrexate and leflunomide). You will usually be seen by your consultant three months after starting treatment and then at least once every six months, even if you are well. If the biologic you are prescribed is not working, you may be switched to a different one.

Do Biologics have side-effects?

As with all medicines, the biologics can cause side effects. The most common side effects are a blocked or runny nose, headache, dizziness, flushing, rash, abdominal pain or indigestion. They may cause a decrease in certain types of blood cells which are important to fight infection and control bleeding. It is therefore very important that you inform your GP (or out-of-hours service) immediately if you develop a fever, sore throat or other infection, or if you suddenly bruise or bleed easily or become very pale. With the biologics that are self-injected you may also have inflammation around the site of the injection, which should be reported if it is severe. These drugs can rarely cause an allergic reaction, in which case they will have to be stopped.

What effect do Biologics have on fertility?

The biologics do not appear to have any effect on fertility. If you decide to start a family or become pregnant whilst on biologic therapy, please contact the Rheumatology department urgently.

Can I have vaccinations when I am taking Biologics?

‘Live’ vaccinations such as polio, rubella (German measles) and yellow fever should be avoided whilst on biologic therapy. An inactivated polio vaccine may be given instead if needed; this should also be used for household members and other close contacts. You should avoid close contact with children or otherswho have received the ‘live’ polio vaccine for 4-6 weeks after vaccination. Annual flu and pneumonia vaccines are both safe and recommended. However, the shingles vaccine is not recommended for people taking biologics.

Are there different types of Biologic drug?

There are a number of different types of Biologic and they are classified according to the different ways in which they work. Below is some information on the different types:

Anti-TNFs: Infliximab, Etanercept, Adalimumab, Certolizumab pegol and Golimumab

These drugs work by blocking a substance called TNF, which is involved in sending signals between cells in your immune system. TNF is produced by some of the cells which attack your joints in RA, and encourages other cells to start attacking joints as well. By blocking the effect of TNF we can stop these other cells from attacking joints and this reduces the pain and inflammation of RA.

Adalimumab (brand name Humira)
Adalimumab can be prescribed for rheumatoid arthritis, psoriatic arthritis and some other types of arthritis. It is given by fortnightly injection.
To find out more information go to:
http://www.arthritisresearchuk.org/arthritis-information/drugs/adalimumab.aspx
Certolizumab pegol (brand name Cimzia) 
Certolizumab pegol is given once a fortnight.
To find out more information go to:
http://www.arthritisresearchuk.org/arthritis-information/drugs/certolizumab-pegol.aspx

Etanercept (brand name Enbrel)
Etanercept can be prescribed for rheumatoid arthritis, psoriatic arthritis, juvenile idiopathic arthritis (JIA) and ankylosing spondylitis. Etanercept is given by injection once or twice weekly.
To find out more information go to:
http://www.arthritisresearchuk.org/arthritis-information/drugs/etanercept.aspx

Golimumab (brand name Simponi)
Golimumab is given once every month.
To find out more information go to:
http://www.arthritisresearchuk.org/arthritis-information/drugs/golimumab.aspx

Infliximab (brand name Remicade, given by 8-weekly infusion)
Infliximab can be used for rheumatoid arthritis, and psoriatic arthritis. It is also used for Crohn’s disease (a bowel condition) and psoriasis. It is given by intravenous infusion (drip) into a vein in your hand or arm, and is administered by the nurses in the Medical Day Unit. The dose is based on your weight. The second infusion will be given 2 weeks after the first, and the third infusion 4 weeks after that, with further infusions given every 8 weeks. You will need to have a blood test at your GP surgery 10-14 days before each infusion to make sure it is safe for your treatment to go ahead.
To find out more information go to:
http://www.arthritisresearchuk.org/arthritis-information/drugs/infliximab.aspx

Rituximab(trade name MabThera)
Rituximab is a different type of biologic which works by removing certain types of cells from the blood called B-cells. Usually B-cells produce antibodies, a type of protein which fights off germs, viruses or other substances that the body considers ‘foreign’ or potentially dangerous. In people with rheumatoid arthritis some B-cells produce harmful ‘autoantibodies’ which attack the tissue in your joints. By reducing the number of B-cells in your blood, this reduces the amount of autoantibodies and interrupts the disease process. Rituxumab can be prescribed for people with rheumatoid arthritis and some other autoimmune diseases such as lupus.
Rituximab is given by intravenous infusion or a ‘drip’ into a vein in your hand or arm and is administered by a nurse in the medical day unit. Two doses are given, a fortnight apart. Further courses are given after at least six months, but can be given at longer intervals if your disease is still well-controlled.
To find out more information go:
http://www.arthritisresearchuk.org/arthritis-information/drugs/rituximab.aspx

Tocilizumab(brand name Roactemra)
Tocilizumab is another type of biologic, which works by in a similar way to the anti-TNF medications but blocks a different signal, called Interleukin-6. It is given as an infusion at the hospital once every four to five weeks. It can affect your white blood cells, platelets, and liver function, so you will need to have blood tests 10-14 days before each infusion to check it is safe for your infusion to go ahead.
To find out more information go to:
http://www.arthritisresearchuk.org/arthritis-information/drugs/tocilizumab.aspx

Abatacept(brand name Orencia)
Abatacept is another type of biologic, which works by preventing a type of immune system cell (a T-cell) from being switched on to attack the joints. It is given as a once-weekly injection, which you can self-administer at home. It is usually used along with methotrexate or another DMARD so you will need to have monthly blood tests while using it.
To find out more information go to:

http://www.arthritisresearchuk.org/arthritis-information/drugs/abatacept.aspx

To find out more about individual DMARDS see   http://www.arthritisresearchuk.org/arthritis-information/drugs/dmards.aspx