What Is the Best Treatment for Your Rheumatoid Arthritis?
Your rheumatologist has just rattled off at the names of a number of medications. All these multisyllabic words sound like a foreign language -- how will you know what is the best treatment option for you? Let’s demystify RA meds, so you can make better decisions.
Nonsteroidal anti-inflammatory drugs (NSAIDs) treat the symptoms of RA, not the underlying disease. As the name indicates, they work to reduce inflammation and pain, and that can feel like a huge relief. Examples of NSAIDs include naproxen, Voltaren, meloxicam, and Celebrex.
Like all medications, they have potential for side effects and you need to be especially aware of two: One is that NSAIDs can be hard on the stomach. This includes the risk of gastric bleeding, although most don’t experience this. The more common stomach-related side effects are acid reflux and heartburn.
NSAIDs may also increase the risk of heart attack. Have a conversation with your doctors about how to manage this risk, and whether another pain killer would be better for you.
To treat the disease itself, you need DMARDs or Biologics.
DMARDs (disease modifying antirheumatic drugs) aim to do just that: modify your disease. These include steroids, Plaquenil, sulfasalazine, Arava, and methotrexate. The latter is considered the “gold standard” of rheumatoid arthritis treatment and is often the first course of treatment.
DMARDs get a little trickier than painkillers and NSAIDs. For instance, although steroids can be very helpful in treating a flare, they may have some undesirable side effects when used long term. They may lead to weight gain, osteoporosis, or affect the adrenal gland. So your doctor may be cautious about prescribing them on an ongoing basis.
Both Arava and methotrexate may also cause liver toxicity. Unless you already have liver disease, that shouldn’t deter you from taking them as you will be closely monitored. Should anything happen with your liver, the meds will be stopped quickly, which often reverses side effects. As well, both of these medications may cause severe birth defects, so it’s important to be very careful about contraception while taking them. If you are planning to have a family in the near future, you may want to discuss other options with your physician.
Biologics are a relatively new class of drugs, having only been available since 1999. They are genetically engineered to block different inflammatory processes. There are currently ten biologic medications on the market, including Infliximab, Etanercept, Adalimumab, Certolizumab pegol, golimumab, abatacept, tocilizumab, rituximab. Most biologics are administered either by weekly or biweekly self-injection, or via bimonthly IV infusion in a clinic. The latest medication used for Rheumatoid arthritis belongs to a class called targeted synthetic DMARDs and these medications have a smiliar safety and efficacy profile to the biologics. The only available targeted synthetic DMARD in the USA is Tofacitinib, which is a tablet. Studies have shown that patients who don’t respond to one medication, may respond well to another medication. Therefore, your doctor may try a few different medications or combinations of medicaionts before finding the best regimen for you.
All biologics and targeted synthetic DMARDs are immunosuppressants. Therefore, one of the most common side effects of biologics is an increased risk of infection, such as upper respiratory tract infections (sinus infections). Other common side effects include fatigue and queasiness after taking the medication. They also have the potential for serious side effects, which led the FDA to give them a so-called black box warning. This scares a lot of people, but it’s important to know that the serious side effects are rare. Most people take biologics without any major side effects.
Rheumatologists will often start with Etanercept, as it can work fast, whereas most of the other biologics may take about three months to really kick in. Rituximab is often used as a last resort, but has been known to be quite effective for people who don’t respond to the other biologics. Tofacitinib is also showing promise when other biologics fail.
The choice of biologics can also depend on the method of administration. Although self-injection can be very easy to do, especially with autoinjector pens, you might get queasy at the thought. On the other hand, some people prefer the ease of injecting themselves at home as opposed to spending hours in a clinic once a month.
In the past, the approach to treatment was to “go low and go slow,” starting with NSAIDs, and only very slowly moving on to DMARDs. While treatment was going low and slow, the disease was left to rampage through the body and most individuals with RA ended up with serious disabilities.
The biologics created a revolution in the lives of people with RA and the approach to treatment. Since remission from RA is now possible, it is recommended to treat early and aggressively. There is a window of opportunity early in RA that increases the chance for remission. Instead of moving slowly, treatment now follows the treat-to-target approach, whereby you and your doctor continue to tinker with medication until you find one that works.
Unfortunately, biologics are extremely expensive, and most insurance companies require individuals to have tried other medications first. There are also a number of other ways to get financial assistance for these medications. If you have trouble getting funding, you may want to talk to your doctor about triple therapy, a combination of several DMARDs that have been shown to potentially be as effective as Biologics.
What medication will work best for you?
It’s difficult to predict which biologic will work best for you. We all respond differently to medication, so what works well for me might not work for you at all, and vice versa. It can therefore involve some trial and error while you and your doctor work to find what’s best.
When I was growing up with this disease, there were no treatments and the prognosis was therefore pretty grim. Conditions are totally different now, with many options for treatment, and a real potential for remission. Unfortunately not everyone responds to the medications currently on the market, but many more are in development.
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