Why Aren’t My RA Meds Working? (And Other Top Treatment Qs)
No one wants to hear that they have to take medications regularly, especially if it might be for the rest of their life. But if you have rheumatoid arthritis (RA), treating it swiftly can provide symptom relief and fundamentally change the course of the disease, preventing permanent joint damage, says Anca Askanase, M.D., director of rheumatology clinical trials at Columbia University Irving Medical Center. So, definitely worth it—but as with all meds, not without concerns about issues like safety, efficacy, and more. Wherever you are in your treatment journey, here are answers to questions that often crop up.
How long will it take to start feeling better?
“One of the fastest acting [medications] is prednisone, so we use it when someone has a flare—we know it can bring down inflammation in days,” says David Pisetsky, M.D., professor of medicine and immunology at Duke University Medical Center in Durham, NC. JAK inhibitors also work relatively quickly, within days to weeks. Methotrexate, however—an older disease-modifying antirheumatic drug (DMARD) and typically the first line of treatment—can take weeks to even a few months. Docs typically combine long- and short-acting meds so you can get relief sooner and later.
Is it okay to take over-the-counter pain relievers, too?
For the most part, yes. Taking NSAIDs like ibuprofen or naproxen alongside meds like methotrexate appears to be a safe, so long as you’re sticking to the recommended doses, says Dr. Pisetsky. The one he warns strongly against: aspirin. “I get concerned because there are medications with aspirin in them that don’t say ‘aspirin’—Goody’s Powders, some headache medicines—and too much has real safety issues.” One review of 17 studies in Cochrane Systematic Review found that combining high doses of aspirin with methotrexate may increase liver and kidney problems in people with RA. Check ingredients lists: acetylsalicylic acid is another name for aspirin.
Will vaccines still work for me if I’m on immunosuppressants?
Yes, and they’re important for people with RA, who are up to twice as likely to acquire a severe infection as the general population—which is partly due to immunosuppressive therapies like DMARDs and biologics. But research in Current Rheumatology Reports suggests the flu vaccine’s level of protection might be reduced, and live vaccines like the flu nasal spray, measles, mumps, rubella, and yellow fever should be avoided by people taking immunosuppressants, says Dr. Askanase. Timing—ideally, taking vaccines before beginning RA therapy—is key.
Are RA medications safe during pregnancy?
“It depends on the medication, how severe your disease is, and the level of risk you’re willing to take,” says Dr. Askanase. For instance, it’s clear that methotrexate is not safe for pregnancy, but the evidence suggests that hydroxychloroquine, biologics, and prednisone at certain levels are safe for the baby, she says. “There are generally enough options that if the disease needs to be treated, the woman and her doctor can make the correct choice.” Men, this affects you, too. Some RA treatments like sulfasalazine can affect your fertility, reducing sperm count and function. The bottom line: Plan ahead if you can and keep your doctor in the conversation.
Why do people of color have a worse treatment outcome?
Genetics may play some role, says Dr. Pisetsky, but that’s only part of the story. New research presented at the American College of Rheumatology found significant differences in the treatments prescribed to Black and White patients. The study found that 74% of White patients were given a biologic—a newer, more expensive, and more effective option than conventional DMARDs—compared to just 67% of Black patients. Other studies suggest minority RA patients have higher rates of pain and disability compared to others. A few possible reasons for these disparities, which often stem from systemic racism in healthcare, include lack of access to RA specialists, distrust in physicians, and high medication costs.
What does “treat to target” mean?
An approach to treating RA that’s gaining a lot of traction, the goal of treat-to-target or T2T is to reach a state of low disease activity or remission using a fast-paced strategy: Test frequently to monitor progress, and if progress stalls, change courses quickly. “Progress can be assessed by the number of tender and painful joints, as well as some objective measure of inflammation, which you can get from a blood test,” Dr. Pisetsky explains. Ultimately, this approach encourages physicians—and patients—to be more aggressive, nimble and, if necessary, to fail fast to get to what works. Not every doctor uses T2T, but some research suggests it’s particularly effective at improving remission rates and function in early RA patients.
Can I drink alcohol while on RA medications?
Methotrexate, one of the most common RA medications, is the most worrisome when it comes to alcohol. It’s known to damage the liver when taken in high doses or long term, and alcohol is toxic to the liver, too, so combining the two can have an additive effect, says Dr. Askanase. NSAIDs like ibuprofen and aspirin are also a concern: They increase the risk of bleeding in the upper gastrointestinal tract, as does alcohol. And heavy drinking when you take acetaminophen regularly can cause liver damage. Basically, when in doubt, pour it out—at least until you can talk to your RA specialist about it.
Why aren’t my meds working anymore?
There could be a few different things at play here, says Dr. Pisetsky. If you’ve been on the medication for a while, you might have developed antibodies to the therapy and so your response is diminishing. Sometimes people have a flare where, for some reason—an infection, extra stress, a jump in physical activity levels—the arthritis gets worse for days or even months until the inflammation is addressed. Or it’s possible the disease is progressing, and you need a new approach. “The question we have to ask is if it's something temporary, or is it really a sustained change in disease activity that’s going to require thinking about a medication change,” says Dr. Pisetsky.
I feel good—can I stop taking my meds?
Possibly, but not without some serious discussions with your doctors. “Because we have more effective drugs and we start therapy earlier, there’s a pretty good chance of hitting remission,” says Dr. Pisetsky. Remission rates range between 5% and 45%, according to one research review, with higher rates trending in those who receive early intervention. The definition of remission is hazy though—there’s no standard measure—and stopping medications abruptly or without medical guidance could backfire with a massive flare. So work closely with your rheumatologist to see if how you’re feeling could translate to taking fewer or no drugs, says Dr. Anaskase. You don't want to go this one alone.
Are the potential side effects of meds worth the benefits?
It’s easy—and totally human—to feel some nervousness around taking medications. After all, no prescription drug is 100% risk-free. But Dr. Askanase suggests you’ll be better served by flipping your perspective. “As a culture, we have this major fear of side effects. We spend a lot of time talking about all the rare things that may happen with a drug, and very little time on why we’re using it,” she says. “I think it's important to remember that we prescribe a medicine because we think the benefit of taking it outweighs the risks. We're not expecting the side effects—we’re expecting it to work and make you better.”
- Aspirin and Methotrexate Risks: Cochrane Systematic Review. (2011). “Safety of non‐steroidal anti‐inflammatory drugs, including aspirin and paracetamol (acetaminophen) in people receiving methotrexate for inflammatory arthritis (rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, other spondyloarthritis).” cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008872.pub2/full
- Vaccines Efficacy With RA meds: Current Rheumatology Reports. (2015). “Vaccinations for Rheumatoid Arthritis.” ncbi.nlm.nih.gov/pmc/articles/PMC4080407/
- COVID-19 Vaccines Aren’t Live: Centers for Disease Control and Prevention. (2020). “Facts About COVID-19 Vaccines.” cdc.gov/coronavirus/2019-ncov/vaccines/about-vaccines/vaccine-myths.html
- Double Risk of Infection: Rheumatology. (2006). “Vaccinate your immunocompromised patients!” academic.oup.com/rheumatology/article/45/1/9/1788779
- Sulfasalazine and Male Fertility: Gut. (1981). “Sulphasalazine and male infertility: reversibility and possible mechanism.” pubmed.ncbi.nlm.nih.gov/6114897/
- Racial and Ethnic Differences in RA: American College of Rheumatology Meeting Abstracts. (2020). “Characterization of Racial Disparities in Rheumatoid Arthritis Treatment Choice and Location of Care.” acrabstracts.org/abstract/characterization-of-racial-disparities-in-rheumatoid-arthritis-treatment-choice-and-location-of-care/
- Health Disparities in RA: The Journal of Rheumatology. (2007). “Health status disparities in ethnic minority patients with rheumatoid arthritis: a cross-sectional study.” pubmed.ncbi.nlm.nih.gov/17552045/
- Treat to Target History: Annals of the Rheumatic Diseases. (2011). “Treating rheumatoid arthritis to target: recommendations of an international task force.” ard.bmj.com/content/69/4/631
- Alcohol and Methotrexate Risks: LiverTox. (2020). “Methotrexate.” ncbi.nlm.nih.gov/books/NBK548219/
- Combining NSAIDs and Alcohol: Drug, Healthcare and Patient Safety. (2015). “Gastrointestinal injury associated with NSAID use: a case study and review of risk factors and preventative strategies.” ncbi.nlm.nih.gov/pmc/articles/PMC4310346/
- Alcohol, NSAIDS, and Stomach Bleeding: American Family Physician. (2000). “Alcohol and NSAIDs Increase Risk for Upper GI Bleeding.” aafp.org/afp/2000/0501/p2863.html
- Acetaminophen Dangers: Harvard Health Letter. (2009). “Overdoing acetaminophen.” health.harvard.edu/staying-healthy/overdoing-acetaminophen
- Remission: Therapeutic Advances in Musculoskeletal Disease. (2017). “Sustained remission in rheumatoid arthritis: latest evidence and clinical considerations.” ncbi.nlm.nih.gov/pmc/articles/PMC5613855/