Controlling inflammation is key to controlling rheumatoid arthritis (RA).
“Inflammation is at the root of all problems in RA, including most of the joint pain and all of the swelling and stiffness,” says rheumatologist Douglas Conaway, MD, of Carolina Health Specialists in Myrtle Beach, S.C. “Above all, we both want to keep the joints functioning. To do this, we need to do more than just control symptoms. We need to control the disease.”
The sooner that starts, the better. Early treatment is key, even if you have mild RA.
RA Treatment Options
Rheumatoid arthritis medicines fall into two groups:
- Drugs that help control disease and limit joint damage, which include DMARDs (disease-modifying antirheumatic drugs) and biologics.
- Drugs that treat pain and inflammation but do not limit joint damage, which include corticosteroids (aka steroids), NSAIDS (nonsteroidal anti-inflammatory drugs), and other pain medicines.
Joint replacement and other surgical options are used to treat some forms of advanced joint damage.
Rheumatologists tend to use DMARDs and biologics as the first treatment in RA therapy, with steroids and NSAIDs playing supporting roles.
DMARDs for Rheumatoid Arthritis
The most commonly used DMARDs are hydroxychloroquine, leflunonomide, methotrexate, and sulfasalazine. All can be taken as a pill, although methotrexate is sometimes given by injection.
These drugs can slow or stop progression of joint damage. They may take from four to six weeks to a few months to begin working and may take longer to reach full effect.
“DMARDs are the current drugs of first choice when starting RA therapy,” says Thomas Hardin, MD, vice president of research at the Arthritis Foundation. American College of Rheumatology guidelines say that anyone diagnosed with RA should be started on at least one DMARD immediately, no matter how mild their disease.
Because DMARDs work in different ways to suppress the immune system, side effects vary with each medicine. Serious risks include infection and kidney or liver damage. Methotrexate and leflunomide can cause serious birth defects. Women taking any of these drugs should talk with their doctor before planning pregnancy.
Biologics for RA
Biologics target specific parts of the immune system to help turn down the inflammation process. These drugs can work quickly to reduce joint pain and swelling. In the longer term, biologics have been shown to slow the pace of joint damage and to improve joint use and movement.
Biologics are used to treat moderate to severe RA that cannot be controlled by DMARDs. “These are the people for whom a biologic makes a big difference,” says Hardin. “If people don’t respond within six to eight weeks of starting traditional DMARDs, it’s very appropriate to move on to biologics.”
Biologics can be used alone but often are combined with one or more DMARDs or other RA drugs to control symptoms and disease activity. Doctors don't prescribe two biologics together.