Treatment for RA
There is no cure for rheumatoid arthritis and the goals of treatment are to relieve symptoms, improve function, slow progression of the disease, and prevent disability. It is important to diagnose RA early and begin aggressive treatment as soon as possible. Patients who have the condition often are treated by a team of physicians and other health care providers, including rheumatologists, nurses, counselors, and physical therapists.
Medications called disease-modifying anti-rheumatic drugs (DMARDs) are often prescribed to treat rheumatoid arthritis. Until these medications take affect, other medications can be used to reduce symptoms.
Analgesics are medications that relieve pain only—they have no impact on inflammation. The most common non-prescription analgesic is acetaminophen (e.g., Tylenol®). For pain that does not respond to acetaminophen, doctors may prescribe opioid analgesics such as tramadol (e.g., Ultram®, Ultracet®), Percocet®, Darvocet®, or codeine. Note: In November 2010, the U.S. Food and Drug Administration (FDA) removed Darvocet from the market in the United States and urged doctors to stop prescribing this medication.
Nonsteroidal anti-inflammatory drugs (NSAIDs) reduce inflammation in addition to relieving pain. There are three types of NSAIDs:
- Traditional NSAIDs include non-prescription ibuprofen (e.g., Advil®) and about 20 different prescription forms. These medications relieve pain and reduce inflammation, but may cause gastrointestinal bleeding, stomach upset, elevated blood pressure, and decreased kidney function.
- COX-2 inhibitors (e.g., Celebrex®) are relatively new to the market and studies continue on their safety and side effects. In general, these drugs are considered to produce fewer gastrointestinal side effects. The biggest advantages of these medicines are that they are less likely to cause ulcers compared to traditional NSAIDs, and they do not increase the risk of bleeding.
- Salicylates include aspirin and non-acetylated salicylates. These medications relieve pain and reduce inflammation. Possible side effects include kidney problems and intestinal bleeding. Aspirin is seldom used to treat RA as the doses required are very high and place patients at too high of a risk for side effects.
In cases where inflammation seriously threatens joints and other tissues, corticosteroids (e.g., prednisone) may be prescribed. These drugs can work quickly and effectively to prevent inflammation from harming the eyes and internal organs in advanced cases of rheumatoid arthritis. Corticosteroids can slow down the worsening of joint damage as well.
Taken in high doses for long periods of time, corticosteroids can cause brittle bones, high blood sugar, and cataracts. However, these drugs currently are prescribed in lower doses and for shorter periods of time to reduce the risks of these side effects.
Disease-modifying anti-rheumatic drugs (DMARDs), such as methotrexate (Rheumatrex®), sulfasalazine (Azulfidine®), leflunomide (Arava®), and hydroxychloroquine (Plaquenil®) may be used alone or in combination to reduce RA symptoms and prevent joint damage.
Biologic response modifiers (BRMs) have been available to treat RA since 1998. These are medications designed to specifically control certain parts of the immune system. The TNF-inhibitors, such as etanercept (Enbrel®), adalimumab (Humira®), and infliximab (Remicade®), were the first to become available. They inhibit a protein that contributes to inflammation, and may be used when other treatments have been ineffective. Newer BRMs include rituximab (Rituxan®), abatacept (Orencia®), and Anakinra (Kineret®). BRMs can slow the progression of RA and can even bring about long periods of remission.
Side effects of these medications may be severe and include nausea, elevated liver enzyme blood tests, bone marrow suppression, lung inflammation (pneumonitis), and oral ulcers. DMARDs and BRMs suppress the immune system and can make the patient more vulnerable to infection. Patients receiving these medications should receive regular physical examinations, as well as regular blood tests and organ function tests.
In September 2013, the FDA approved changes to the prescribing information for Rituxan to include a new Boxed Warning about a risk of reactivation of hepatitis B virus (HBV) infection. Revisions also include recommendations for screening, monitoring, and managing patients to decrease this risk.
Studies have shown that early diagnosis and aggressive treatment for rheumatoid arthritis can help prevent joint damage and maintain function in many patients who have the disease. Recent advancements in treatment have helped more patients with RA to live healthy and productive lives.