Without treatment, joint
inflammation can cause permanent damage. Doctors know that it is wise to
prescribe a disease-modifying antirheumatic drug (DMARD) before such
damage occurs. People newly diagnosed with an inflammatory form of
arthritis, such as RA, may be prescribed a DMARD upon their diagnosis.
Another reason DMARDs should
be started early is that, although they are generally effective, they
take a long time to show results. For example, hydroxychloroquine (Plaquenil)
and sulfasalazine (Azulfidine) may take up to three or four
months before effects are noticed. Other drugs, such as methotrexate,
work more quickly, but often not quickly enough. For that reason,
doctors frequently prescribe an additional drug – such as a
corticosteroid or an NSAID – to help control pain and inflammation while
the DMARD starts to work.
DMARDs are most commonly used
for RA, but some are also used for juvenile RA, ankylosing spondylitis,
psoriatic arthritis and lupus. Some, such as chlorambucil (Leukeran),
mycophenolate mofetil (CellCept) or cyclosphosphamide (Cytoxan),
are used mainly to treat severe organ disease, such as kidney disease
caused by lupus or vasculitis. The dosages listed in this chart are for
those with RA; your dosage may vary depending on your specific condition
and factors like disease severity, age, body weight and other
medications you are taking.
Only three DMARDs – auranofin
(Ridaura), leflunomide (Arava) and Azulfidine –
were actually developed for RA. The others were borrowed from different
areas of medicine: Hydroxychloroquine (Plaquenil) is a malaria
drug, chlorambucil (Leukeran) and methotrexate are cancer
medications and cyclosporine (Neoral) originally was developed to
keep the body from rejecting transplanted organs.
Because DMARDs suppress the
immune system, always watch for signs of infection – chills, fever, sore
throat or cough – and report them to your doctor. And check with your
doctor before getting any vaccinations.
Biologics BIOLOGIC RESPONSE
MODIFIERS
The “biologics” (or biologic
response modifiers) technically are a subset of DMARDs. Like DMARDs, the
biologics stop disease progression; sometimes they initiate a
long-lasting remission. Moreover, these drugs often work for people in
whom other therapies have failed. In fact, studies show that two-thirds
of people with RA respond favorably to a biologic, with most of them
achieving remission. In many cases, biologics are used together with
standard DMARDs, such as methotrexate.
Unlike DMARDs, which may be
used in combination with one another, two biologics are not used
together. For instance, abatacept (Orencia), anakinra (Kineret)
and rituximab (Rituxan) should not be used with TNF-a inhibitors,
and TNF-a inhibitors should not be combined.
Although the biologics work
in different ways, all block specific steps in the inflammation process.
Adalimumab (Humira), etanercept (Enbrel) and infliximab (Remicade)
block a cytokine called tumor necrosis factor-alpha (TNF-a). Kineret
blocks a cytokine called interleukin-1 (IL-1). Abatacept (Orencia)
blocks the activation of T cells. Rituximab (Rituxan) blocks B
cells.
Like many
drugs, biologics have a downside, most often, expense. Also, the drugs
must be infused intravenously or injected. Researchers say that future
agents may be less expensive and taken orally.