Treating RA: Is It Time for a Biologic?

Medically Reviewed by Brunilda Nazario, MD on June 26, 2011
6 min read

Since they were first introduced in 1998, biologic response modifiers -- or biologics -- have made a huge difference in the lives of people with rheumatoid arthritis.

These powerful drugs don't just treat the symptoms of RA. Biologics for rheumatoid arthritis can target the underlying cause, relieving pain and saving the joints from damage.

"Biologics can have side effects, no question," says Eric L. Matteson, MD, chair of the rheumatology department at the Mayo Clinic in Rochester, Minn. "But in the long run they can help control the disease. That will lower your risk of surgery and allow you to keep working, live better, and live longer."

If you have RA, are biologics right for you? How can you make sense of their benefits and their risks? Here are things to consider about biologics for rheumatoid arthritis.

RA is an autoimmune disease. For reasons we don't understand, the body's immune system becomes too aggressive. It attacks healthy tissue in the joints and elsewhere in the body.

Biologics can't cure RA. They work by blocking the effects of the immune system, protecting the body from itself.

In the past, doctors could only treat the symptoms of RA. This usually meant painkillers, steroids, and multiple surgeries. Biologics -- and other disease-modifying antirheumatic drugs (DMARDs) -- have revolutionized the approach.

Rheumatologists now start with a DMARD as soon as a person is diagnosed with RA. The most commonly prescribed is methotrexate.

The faster a person gets this treatment, the sooner she can slow down or stop the damage to her joints. In most people who use them, biologics can push the disease into remission, relieving pain and stiffness.

"We're in a new era now," says Clifton Bingham, MD, associate director of the Johns Hopkins Arthritis Center in Baltimore. "Using biologics and other DMARDs, we're having much better outcomes and avoiding surgeries that used to be routine."

Methotrexate is usually the first drug that a person will try after getting diagnosed. Typically, biologics are reserved as the next step.

When might a rheumatologist turn to biologic therapy? Here are few reasons.

  • Treatment with methotrexate alone isn't working well enough. This is the most common reason for taking biologics. Your doctor will regularly examine your joints and test your blood for signs of RA. If methotrexate isn't helping enough, he or she might add a biologic. Studies suggest that the combination of drugs is more powerful than either on their own.
  • You have side effects from methotrexate. Some people don't tolerate methotrexate well. Some health conditions -- like liver problems -- rule out the use of methotrexate. In these cases, a rheumatologist might move directly to a biologic.
  • You are pregnant or want to become pregnant. Women with RA should talk to their doctors if they're considering pregnancy. Evidence suggests that some -- not all -- biologics might be safer for pregnant women than methotrexate. However, biologics can pose risks as well.

There are a number of biologics to choose from. They work in different ways. TNF-blockers target a chemical messenger that triggers swelling. Other biologics affect different molecules involved in the immune response.

It can take a few tries before finding the biologic that works best for you. Sometimes, a drug that used to work stops helping and a new one needs to be substituted.

While it can be disappointing when a drug doesn't work, take heart.

"Switching biologics is common," says Matteson. "In the vast majority of patients, we can find a medication strategy that gets the disease under control and keeps it that way."

Biologics and other DMARDs work by blocking attacks from the immune system. That's their drawback, too. By suppressing the immune system, you become more vulnerable to infection and other problems.

The exact side effects depend on the specific drug. Some biologics can cause:

  • Skin irritation at the injection site
  • An increased risk of infections, including tuberculosis
  • An increased risk of some cancers
  • An increased risk of neurologic and heart problems

Biologics are not safe for everyone. If you have a condition like multiple sclerosis, hepatitis, or heart failure, your doctor might not recommend biologics.

Whatever you do, don't manage side effects on your own without your doctor's help by skipping doses or cutting down the amount of medicine you get. That's a bad idea, Bingham says. It could allow your RA to worsen. It could also mislead your doctor into thinking your medicine isn't working.

When you have RA, it's important to be an informed and active patient. If your rheumatologist recommends a biologic, here are a few things to ask:

  • Why are you choosing this biologic medication? Doctors generally can't predict how well a medicine will work in a person. There's often some trial and error in settling on a drug. Still, it's good to ask why your doctor is choosing this medicine instead of another.
  • What other medicines will I need? A biologic is often used in combination with methotrexate. You might also need other medicines, like prednisone or painkillers. Doctors generally don't use two biologics for rheumatoid arthritis together. Why? They increase the risks without seeming to increase the benefit.
  • Will I receive it by injection or intravenously? Some biologics are only available intravenously at the doctor's office. Others can be injected at home.
  • How often will I need it? The dosage schedules vary widely. They range from twice a week to once every eight weeks.
  • Is the biologic therapy you're prescribing covered by my insurance? Biologics are expensive drugs. Insurance companies differ in which drugs they cover and when they will cover them.
    Matteson says it's not uncommon for a person's treatment to be guided by an insurance company's policies as much as the doctor's recommendations. Some people run into problems when changing jobs. A treatment covered by their old insurer might not be covered by a new one. Talk directly about the costs with your doctor, Bingham says.
  • What will my co-pay be? Even the co-pays for biologics can be expensive. Make sure you know if you have to pay a separate co-pay for the injection or infusion as well.
  • Am I eligible for financial assistance from the drug manufacturer? Many drug companies offer programs to help people pay for biologics.
  • What should I do if I have side effects? You need to know when to get help. Worsening symptoms, a fever, or weight loss are all signs that you should get checked out right away.
  • How often will I need checkups? At first, you will probably need to see your doctor every four weeks. If your treatment is helping and your disease is well controlled, you might only need checkups every three to six months, Matteson says.

When you first get diagnosed with RA, you might have doubts about treatment. If you're only having mild joint pain right now, are the risks of biologics and other DMARDs worth it? Can't you wait and see how it goes?

But a wait-and-see approach can have serious consequences.

"We know what will happen if we don't treat someone with rheumatoid arthritis," says Bingham. "They will get worse." In some cases, the damage may become so severe that even surgery won't help.

Matteson compares RA to other chronic conditions like diabetes and high blood pressure. At first, they might not seem like a problem. But untreated, they can lead to serious disease and even early death.

While the side effects from biologics might look scary, Bingham points out that the risks of untreated RA go far beyond achy joints. They include debilitating pain, heart problems, infections, and cancer.

We still don't have a cure for RA. But biologics offer hope to people who once had no good options.

"Biologics and other DMARDs are more successful than anything we could have imagined 15 years ago," Bingham tells WebMD. "These treatments have reshaped the face of the disease."