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Getting a Grip on Rheumatoid Arthritis Pain

Options for managing the pain and damage of severe chronic RA.

Disease-Modifying Medications for Severe RA continued...

Aggressive treatment for chronic rheumatoid arthritis typically begins with disease-modifying antirheumatic drugs, or DMARDs. These drugs do more than just reduce symptoms, Ruderman tells WebMD. They address some of the root causes of rheumatoid arthritis.

The gold standard DMARD is methotrexate. “We’re going to try to start with methotrexate if we can,” Samuels says, “because it has the longest track record of doing very well.” Methotrexate has a number of distinct advantages:

  • It is relatively inexpensive.
  • It works quickly.
  • It can slow RA damage to the joints.
  • It is generally well tolerated.

If methotrexate doesn’t work, doctors may try another DMARD, such as leflunomide (Arava), hydroxychloroquine (Plaquenil), or sulfasalazine (Azulfidine).

Methotrexate and the other DMARDs are very effective. But they don’t provide instant relief. In fact, they may not start working for weeks or even months. DMARDs aren’t right for every patient. If these drugs don’t relieve symptoms, other drugs are available that also target the processes behind chronic RA.

Other Treatment Options for Chronic Rheumatoid Arthritis: Biologic DMARDs

People with severe rheumatoid arthritis who have a lot of joint damage or who aren’t responding well to the traditional DMARDs may be started on a biologic DMARD. Rheumatoid arthritis is caused by an overactive immune response, Ruderman tells WebMD. Biologic drugs target immune triggers that cause joint inflammation and damage in rheumatoid arthritis. Biologic drugs that may be used include:

  • Tumor necrosis factor (TNF) inhibitors. These drugs include adalimumab (Humira), certolizumab (Cimzia), etanercept (Enbrel), and infliximab (Remicade). They work by blocking TNF, a type of protein called a cytokine that triggers inflammation.
  • Anakinra (Kineret). This drug targets another cytokine called interleukin-1 or IL-1.
  • Abatacept (Orencia). Abatacept inactivates immune cells called T cells.
  • Rituximab (Rituxan). This drug targets B cells, another type of immune cell.

Biologic drugs are often combined with methotrexate to improve their effectiveness. Today, the biologics are administered intravenously or by injection. But the next phase in drug development, Ruderman says, will be oral medications that can achieve the same results.

All of these drugs can have side effects, which is why rheumatologists monitor their RA patients very carefully. For example, methotrexate can cause liver problems. People who take this drug will need to have regular liver function tests.

Infection is one of the biggest concerns with DMARDs. “In a simplistic sense, RA is a disease of an overactive immune system or an immune system that is over-stimulated in certain areas,” says Ruderman. “All of these drugs work by trying to suppress that level of over-activity. But they also suppress normal areas of the immune system.” RA patients who take DMARDs need to be vigilant about hand washing as well as other preventive strategies to avoid getting sick.

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