RA Treatments: What Are Your Options?

From the WebMD Archives

When you have rheumatoid arthritis (RA), your body’s immune system attacks your joints and organs. Not only could it cause serious joint damage, it might also raise your risk of other problems like heart disease. That’s why it’s important to diagnose your RA early so you can begin treatment as soon as possible.

“The earlier a patient with RA is identified, the earlier they are likely to receive disease-modifying treatments,” says Bella Fradlis, MD, a rheumatologist at Montefiore Medical Center. Treating RA inflammation quickly will keep you and your joints healthy.

Susan Goodman, MD, a rheumatologist at the Hospital for Special Surgery in New York, identifies two short-term treatment goals:

  1. Ease pain, stiffness, and fatigue.
  2. Prevent more damage to the joints from happening.

But the long-term goal for your RA treatment is remission. This means your disease is well controlled and you have no tenderness or swelling. Your doctor will examine you to see if your joints are tender or swollen and test your blood for signs of inflammation. The results will show if your RA is in remission.

How do you get to that point? You and your rheumatologist work together to find a treatment that leads to remission, Fradlis says.

Treatment Options

Your doctor will choose drugs from these groups to treat your inflammation:

  1. DMARDs
  2. Biologics
  3. Corticosteroids
  4. NSAIDs
  5. Analgesics

The first drugs you’ll use to treat inflammation are disease-modifying antirheumatic drugs, or DMARDs, Goodman says. If they don’t work, you may need stronger drugs called biologics.

Your doctor may also suggest you take nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids to ease inflammation, Goodman says. Some people with RA also take an analgesic like acetaminophen to help ease their pain.

DMARDs

You’ll probably start with a DMARD like azathioprine, hydroxychloroquine, leflunomide, or methotrexate to treat your inflammation, Fradlis says. Most people begin with methotrexate. It comes in a pill or a shot you give yourself at home.

Methotrexate is the first choice in RA because it works and it's safe, Fradlis says. “It is also relatively inexpensive.”

Continued

You may need more than one DMARD to control your inflammation or prevent joint damage, Fradlis says.

Your rheumatologist will test your blood for signs of inflammation and take images of your joints to look for damage. These signs tell the doctor if you need to take a combination of DMARDs.

One successful type of combination treatment is triple therapy, which includes methotrexate, hydroxychloroquine (Plaquenil), and sulfasalazine (Azulfidine). They work together to lower inflammation and joint damage, Fradlis says.

DMARDs can have side effects, but most people can handle them, Fradlis says. You could get rashes, diarrhea, nausea, mouth sores, hair loss, and sensitivity to sunlight. Methotrexate and leflunomide may cause severe birth defects and hurt your liver. Both men and women should use birth control while taking these drugs. You’ll get regular blood tests to make sure your liver is healthy.

Biologics

If DMARDs alone don’t put you in remission, the next step, Goodman says, is a biologic.

These are drugs that stop inflammation. They help slow your out-of-control immune system, prevent joint and organ damage, and help you feel better.

Because biologics put the brakes on your immune system, they may make it harder to fight infections like pneumonia. But the tradeoff is usually worth it, Goodman says.

Biologics are available as injections, pills, and by IV. Your doctor will ask you a lot of questions to find out which one will work best to treat your RA or help predict your risk of side effects.

“It is important to remember that serious side effects do not happen to every patient, and that most patients tolerate biologic therapy well,” Fradlis says.

Biologics are more expensive than DMARDs. Many drug manufacturers offer discount cards and other help to offset the high costs, she adds.

Corticosteroids

Corticosteroids, sometimes just called steroids, treat inflammation and pain. These powerful drugs usually are given at low doses and for a short period of time. You may take them if you have a sudden RA flare.

Usually, you’ll start taking corticosteroid pills at a high dose and taper down to a small one to help reduce side effects. Your doctor could inject corticosteroids directly into an inflamed joint. That may be the safest method, Goodman says. “Daily corticosteroid therapy increases risk of infection, diabetes, osteoporosis, and weight gain.”

If you get pregnant, your doctor may put you on corticosteroids for a while. They can control inflammation until you’re able to return to other drugs.

Continued

NSAIDs

NSAIDs are pills used to quickly treat joint pain in RA. There’s a risk of high blood pressure, heart disease, and stomach ulcers with these drugs, Goodman says, "but they’re still a good choice for an overall RA treatment plan.”

NSAIDs are used less than in the past because they don’t change the course of your disease. They only treat its symptoms. In addition, NSAIDs have been found to increase risk of heart attack and stroke

Analgesics

You may sometimes have painful flares of your RA. At these times, your doctor may prescribe analgesic drugs to ease short-term aches. These drugs include everyday pain relievers like acetaminophen and more powerful drugs called opioids.

Analgesics are a good choice if NSAIDs cause serious stomach upset, or if you’ve had ulcers in the past. Your doctor may recommend them for a short while, Fradlis says, “but these medications do not take the place of your DMARDs.”

Analgesics don’t treat RA inflammation or control your disease. They only dull pain. But they can help you get through a flare until your disease is controlled by DMARDs, Fradlis says.

Joint Surgery

If you start taking DMARDs to treat your RA inflammation early, you may be able to avoid joint and tissue damage, Goodman says. But you may need surgery at some point.

The most common surgeries for people with RA are total knee or hip replacements. You may need other operations to align joints or repair soft tissues in joints damaged by RA.

“The good news is that patients with RA are having these operations performed when they are older than in the past, reflecting success in RA treatments,” Goodman says.

WebMD Feature Reviewed by Jennifer Robinson, MD on 8/, 015

Sources

SOURCES:

Bella Fradlis, MD, attending physician, division of rheumatology, Montefiore Medical Center; assistant professor of medicine, Albert Einstein College of Medicine, Bronx, NY.

Susan Goodman, MD, rheumatologist, Hospital for Special Surgery, New York.

American College of Rheumatology: “Rheumatoid Arthritis Researchers Redefine Remission Criteria.”

National Rheumatoid Arthritis Society: “Getting Established on DMARD Therapy.”

Johns Hopkins Arthritis Center: “Rheumatoid Arthritis Treatments.”

American College of Rheumatology: “Biologic Treatments for Rheumatoid Arthritis.”

News release, FDA.

UpToDate:“Rheumatoid arthritis treatment (Beyond the Basics).”

Mayo Clinic: “Rheumatoid Arthritis: Treatments and Drugs.”

UpToDate:“Use of anti-inflammatory and immunosuppressive drugs in rheumatic diseases during pregnancy and lactation.”

Medscape: “Rheumatoid Arthritis Medication: Analgesics, Other.”

FamilyDoctor.org: “Safe Use, Storage, and Disposal of Opioid Drugs.”

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