Rheumatoid Arthritis Medications: Understanding Your Options

Helping You to Manage Rheumatoid Arthritis

Woman taking rheumatoid arthritis medication.
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Medications are the mainstay of traditional treatment for rheumatoid arthritis. As soon as you are diagnosed with rheumatoid arthritis, your doctor will recommend and prescribe a course of treatment.

There are quite a few medications used to treat rheumatoid arthritis which are divided into drug classifications based on how they work. It is important for you to understand your options, as well as understand why a particular medication has been chosen for you.

In other words, what is the drug doing in the body?

If a particular course of treatment doesn’t seem to be effective after a period of time, it is common for your doctor to make changes to your regimen. Let’s consider the rheumatoid arthritis medications. You may be prescribed one or more of the following.

NSAIDs

NSAIDs (nonsteroidal anti-inflammatory drugs) prevent COX 1 and COX 2 (the cyclooxygenase enzymes) from making prostaglandins, hormones which contribute to inflammation in the body. There are a couple of dozen NSAIDs from which to choose. The most commonly prescribed NSAIDs are Motrin (ibuprofen), Naprosyn (naproxen), Mobic (meloxicam), and Voltaren (diclofenac). Celebrex (celecoxib) is the only COX-2 selective inhibitor available in the U.S. Also, Advil (ibuprofen) and Aleve (naproxen) are available at over-the-counter strength.

NSAIDs have been linked to an increased risk of heart attack or stroke, so it was ultimately determined that the drugs should be taken at the lowest dose possible and for the shortest duration possible.

Also, you should never take more than one NSAID product at a time. Read labels carefully as NSAIDs can be a component of various over-the-counter medications for cough, cold, allergy, sleep, and stomach upset.

Analgesics

Analgesic medications work by relieving pain. Acetaminophen is a popular over-the-counter pain medication; actually it is the only analgesic medication available over the counter.

It, too, can be in various over-the-counter products, so it is imperative to read labels and be aware of the cumulative effect of acetaminophen.

Stronger analgesics are available only with a prescription. They are called opioids or narcotics. Opioids act on the central nervous system to block pain signals. Opioid medications do come with a risk of dependency, but if used as directed and with vigilance regarding potential side effects and adverse events, these drugs can be effective pain relievers for people with rheumatoid arthritis. In 2016, the Centers for Disease Control and Prevention (CDC) released guidelines for prescribing opioidsHydrocodone/acetaminophen (brand Norco) and Tramadol (brand Ultram) are two of the most commonly prescribed opioid analgesics. Others include oxycodone and MSContin.

Corticosteroids

Corticosteroids, also known as glucocorticoids or steroids, mimic the effects of the hormone cortisol in the body and play a role in the immune response. Corticosteroids are available is several forms including pills, injectable solution, drops, and topical creams.

Corticosteroids are potent anti-inflammatory medications. While their effectiveness can seem miraculous, they are associated with potentially severe side effects, not the least of which is an increased risk of infection. To reduce the risk of side effects, corticosteroids should be taken at the lowest dose possible and for the shortest duration possible.

Some people with rheumatoid arthritis are prescribed a low dose corticosteroid as part of their routine medication regimen. Others only use corticosteroids to tame a flare of rheumatoid arthritis symptoms. People who have taken a corticosteroid for a long time may experience withdrawal symptoms if they stop the drug without tapering. Prednisone and methylprednisolone are the most common oral corticosteroids. Triamcinolone is a popular injection and cream.

DMARDs

Disease-modifying anti-rheumatic drugs (DMARDs) are slow-acting drugs that work to slow disease progression and reduce joint damage. There are traditional DMARDs, the original and oldest options. There are also biologic DMARDs—the first of which appeared on the scene in 1998. And, most recently, another sub-class of DMARDs known as targeted small molecule medications.

Of the traditional DMARDs, methotrexate is the most commonly prescribed. It is actually considered the gold standard treatment for rheumatoid arthritis. Other traditional DMARDs include Arava (leflunomide), Plaquenil (hydroxycholorquine), and Azulfidine (sulfasalazine)Gold and Imuran (azathioprine) are available but no longer commonly prescribed for rheumatoid arthritis. Traditional DMARDs impact the immune system, consequently it may be more difficult to fight an infection and there is possibly an increased risk of developing certain cancers. You must pay careful attention to potential side effects and warnings associated with DMARDs. Typically, periodic blood tests are ordered to check liver function and complete blood counts.

Biologic DMARDs

Biologic drugs, also referred to as Biologic DMARDs or Biologic Response Modifiers, are medications that were created to prevent or reduce inflammation which damages joints. Biologics specifically target molecules on immune system cells and products secreted in the joint which are involved in causing inflammation and joint destruction.

There are several types of biologics, each with a specific target. Targets include tumor necrosis factor (TNF), interleukins (IL-1, IL-6, IL-12, and IL-23), B cells, and T cells.  Biologic drugs are quite expensive, but financial help is available for people who qualify. The drugs are administered by infusion or injection. Because of the effect of biologics on the immune system, certain undesirable and severe side effects are possible.

Targeted Small Molecule DMARDs     

The newest drug class for rheumatoid arthritis is "targeted small molecule DMARDs" which interrupt intracellular signaling. By interrupting specific intracellular signals, it is possible to modulate specific cell functions, including surface receptors, signaling proteins, and transcription of nuclear proteins. By doing so, the behavior of the cell types targeted can be influenced or impacted.

The targets of greatest interest to researchers, for the purpose of treating autoimmune and inflammatory diseases, include Janus-associated kinase, spleen tyrosine kinase, phosphodiesterase-4, Bruton’s tyrosine kinase, and phosphatidylinositol-3 kinase. Human trials are needed to determine the potential of each target. JAK (Janus kinase) inhibitors are the most developed and one is FDA-approved, Xeljanz (tofacitinib).

A Word From Verywell

Some people with rheumatoid arthritis fear the medications, primarily because of the potential side effects, some of which can be severe. It is certainly important to weigh the benefits and risks of the medications with your doctor.

Consider your current level of disease activity and decide on treatment goals with your doctor. Likely, you will be prescribed some combination of the available options described above. Keep a symptom diary after starting the medications to help assess if they are working well for you. Be knowledgeable about potential side effects and report anything unusual to your doctor.

Sources:

Arthritis Today. Drug Guide 2016. Published by the Arthritis Foundation.

Kelly, V. and Genovese, M. Novel small molecule therapeutics in rheumatoid arthritis.  Rheumatology (Oxford) (2013) 52 (7): 1155-1162.

Kelley's Textbook of Rheumatology. Ninth edition. Elsevier.

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