When you have rheumatoid arthritis, your immune system attacks your joints. This can make them swollen, stiff, and painful.
When you’re first diagnosed with RA, your doctor probably will start you on a disease-modifying antirheumatic drug (DMARD), like methotrexate, sulfasalazine, hydroxychloroquine, or leflunomide.
"It's been around for years, it's cheap, we know its characteristics really well, and we know it's effective," says Steven Vlad, MD, PhD, a rheumatologist at Tufts Medical Center.
The goal with DMARDs is to control your symptoms and prevent damage to your joints or, better yet, put you into remission. "You still have the disease, but you don't have active joint pain," says Jonathan Samuels, MD, associate professor of medicine at the NYU Langone Medical Center Division of Rheumatology.
"You don't have the swelling and stiffness, and you hopefully don't have the joint damage that would lead to disability."
If methotrexate hasn't worked after a couple of months, your doctor may talk with you about a biologic drug. Biologics block substances in your body that inflame and damage your joints. They can bring down joint swelling quickly and ease pain.
Types of Biologics
There are a few kinds of biologic drugs.
TNF inhibitors block a substance called tumor necrosis factor. They include:
- Adalimumab (Humira)
- Adalimumab-atto (Amjevita)
- Certolizumab (Cimzia)
- Etanercept (Enbrel)
- Etanercept-szzs (Erelzi)
- Golimumab (Simponi)
- Infliximab (Remicade)
- Infliximab-abda (Renflexis)
- Infliximab-dyyb (Inflectra)
Biologics that target molecules other than TNF include:
- Anakinra (Kineret)
- Baricitinib (Olumiant)
- Rituximab (Rituxan)
- Tocilizumab (Actemra)
- Tofacitinib (Xeljanz)
Which drug you get might depend on your health insurance. Most insurance companies ask doctors to use a TNF inhibitor first, Vlad says. "If you try it and have a reaction to the medication or it doesn't work, you can move to another [biologic]."
How to Start Taking a Biologic
Instead of switching you to a biologic, your doctor might keep you on methotrexate and add a biologic to it. That can help prevent an immune reaction.
"Our immune system sees [biologics] as foreign," Samuels says.
Methotrexate lowers the chance that your body will react to the new medicine.
Before you start on a biologic, your doctor will test you for tuberculosis (TB) and hepatitis B. If you were infected with these viruses in the past, they can lie dormant in your body for years. Some biologics can reactivate them and make you sick.
You'll also need to get up to date on all your vaccines. Make sure you've had your flu, pneumonia, and shingles shots.
With some biologics, your doctor will start you on a low dose, then raise it over time. With other drugs, you'll start on a loading dose. This means you'll get a higher amount of the drug the first few times you take it, and then drop to a lower dose.
Forms of Biologics
You can take newer biologics as pills, but you’ll need your doctor’s help for others.
They’ll either teach you how to give yourself a shot, or you’ll get it through an IV into your vein. You'll have to visit your doctor's office or a medical center for those.
Handling Side Effects
Many of Vlad's patients are nervous about side effects of biologics. "They've usually seen television ads where there's a whole huge list. Some drugs have black box warnings about the risk of cancer," he says. "I spend time reassuring them that these drugs are very effective -- and very safe."
Biologic drugs can cause side effects, but often they're mild -- like a rash, redness, or itching where the needle went in your skin. Because biologics dampen your immune system, they can make you more likely to get an infection. Rarely, they might raise your chances of certain types of cancer, like lymphoma.
Tell your doctor if you do get sick so you can get treated. You might have to stop taking your biologic for a few days until the infection goes away.
Let your doctor know right away if you have any of these more serious side effects after taking a biologic:
- Shortness of breath
- Itchy eyes or lips
- Sudden vision problems
- Numbness or tingling
- Swelling in your ankles or hands
Follow Up With Your Doctor
Once you're on a steady dose of a biologic, you'll see your doctor every few months. They’ll make sure that the drug is working on your RA symptoms and that it isn't causing bothersome side effects.
Make sure to keep all your appointments. Let your doctor know if you have any side effects or if your RA symptoms come back.