Medications

DMARDs do not have any common properties other than their ability to slow down the progression of rheumatoid arthritis. Many were used for other diseases and were found accidentally to help RA. DMARDs include:

• Methotrexate (considered to be the current standard of care. Newer drugs called biologic modifiers, however, are proving to be as effective with fewer side effects when used alone, and even more effective when used in combination with methotrexate.)
• Hydroxychloroquine
• Sulfasalazine
• Gold
• D-penicillamine
• Cyclosporine
• Leflunomide

Unfortunately, all DMARDs tend to lose effectiveness over time, even methotrexate. Patients rarely use one drug for more than 2 years. Combining DMARDs with each other or with drugs in other categories offers the best approach for many patients. The addition of a corticosteroid to any combination may be important.

All DMARDs may produce stomach and intestinal side effects, and, over the long-term, each poses some risk for rare but serious reactions. (In some cases, however, they may be less harmful than long-term NSAID treatment.)

Methotrexate. Methotrexate (Rheumatrex, Trexall) acts as an anti-inflammatory drug and is now the most frequently used DMARD, particularly for severe disease. It has the following advantages over other DMARDs:

• A faster mode of action than other DMARDs (starts working within a few weeks).
• The best record to date for long-term use.
• A 2002 study suggested that it reduced mortality rates from heart disease by 70% compared to other DMARDs. (Death rates from other causes were also lower, although less significantly.)
• A 2005 study indicated that methotrexate may be more effective than leflunomide for treatment of juvenile rheumatoid arthritis.

Even this drug loses effectiveness, however, when used alone. It may be more effective when used in combination with other DMARDs or drugs. Recent studies have focused on combining methotrexate with various biological response modifier drugs, especially for treatment of patients with early aggressive arthritis. Study results from 2006 suggested that combining methotrexate with either adalimumab or infliximab could help lead to remission in these patients. The combination appears to work better than single drug therapy.