How is RA treated?
Once your diagnosis is confirmed, there are many treatments that can help to ease your pain and increase your movement. Non-medication therapies such as physiotherapy, occupational therapy, physical activity and relaxation techniques can all be helpful in the treatment of RA. There is, though, a range of prescription drugs that are used to help people manage the disease.
It’s a good idea to keep a diary to include a record of symptoms, questions for clinic appointments, medication, history and blood results. A list of all medication including supplements, over the counter drugs and prescribed drugs by your healthcare team should be included.
Dozens of drugs are used to treat RA and many people are prescribed a combination of them. The general aim when treating RA is to reduce joint inflammation and prevent long-term damage to the joints.
The mainstay of drug therapy for RA is Disease Modifying Anti- Rheumatic Drugs (DMARDS – pronounced dee-mards). They are often used in combination with Non-Steroidal Anti-Inflammatory Drugs (NSAIDs – en-saids) and or Corticosteroids (steroids). Although NSAIDs and steroids reduce the day-to-day inflammation, they don’t tackle the long-term effects of the disease.
A newer class of drugs called ‘biologics’ has revolutionised the treatment of RA. These medications, which can be used in combination with DMARDs, also suppress inflammation and help prevent damage to the joint. These families of drugs are explained below.
Disease-modifying anti-rheumatic drugs (DMARDs)
DMARDs are a class of drugs used to treat inflammatory types of arthritis, such as RA. They help by tackling the causes of inflammation (pain, swelling and stiffness) in the joints. DMARDs are important because they help prevent damage to the joint. They act by altering the underlying disease rather than simply easing the symptoms. In other words, they help to stop the disease from getting worse. In doing this, they reduce pain, swelling and stiffness. Most people with RA will need this type of treatment for many years or for the rest of their life.
DMARDs are a long-term treatment which most people with RA will require. Most DMARDs will start to work in about six to twelve weeks, but some may take longer – up to three or four months. While you are waiting for the DMARD to work, your doctor might prescribe an additional medication, such as a steroid or an NSAID, to help control the symptoms. Occasionally a combination of DMARDs are prescribed. Sometimes DMARDs are given by injection. Taking any medication carries some risk, which must be weighed up against the potential benefits. It is important to recognise that the risk of joint damage and permanent disability is much greater than the risk of side effects from the DMARDs used to control the disease. When properly monitored, the vast majority of side effects are rare and most are reversible by adjusting the dose or switching medications.
Examples of DMARDs (with their brand names) include:
- Methotrexate (Maxtrex®)
- Leflunomide (Arava®)
- Sulfasalazine (Salazopyrin®, Sulazine EC®)
- Hydroxychloroquine (Plaquenil®)
- Azathioprine (Imuran®, Azamune®, Immunoprin®)
When taking almost all DMARDs, you’ll need to have regular blood tests. These tests help your doctor to monitor the effects the drug is having on your condition and also to check for possible side-effects, including problems with your liver, kidneys or blood count.
You can take NSAIDs along with DMARDs, and sometimes you might need to take more than one DMARD.
Biologics are a newer group of drugs that help to prevent joint damage and may be used if other DMARDs aren’t working well enough. These are given either by injection or through a drip into a vein. These drugs target parts of the immune system – in particular the signals that lead to inflammation, and joint and tissue damage.
Some biologics are called ‘anti-TNF’ drugs. These drugs target a protein called ‘tumour necrosis factor’ (TNF). This protein increases inflammation when too much of it is present in the blood or joints. Other biologic therapies target different proteins.
Biologics used for treating RA (with their brand names) include:
- Adalimumab (Humira®)
- Infliximab (Remicade®, Inflectra™, Remsima™)
- Etanercept (Enbrel®)
- Golimumab (Simponi®)
- Certolizumab Pegol (Cimzia®)
- Abatacept (Orencia®)
- Rituximab (Mabthera®)
- Tocilizumab (RoActemra®)
- Anakinra (Kineret R®)
The biologic drug group also includes a category of medicines called biosimilars. These drugs are follow-on versions of original biological medicines. They are independently developed after the patent protecting the original product has expired. Biosimilar medicines are intended to have the same mechanism of action as the original biological medicines, and are designed to treat the same diseases. Two biosimilars currently available in Ireland for RA are Inflectra™ and Remsima™.
If you are prescribed a biologic, you should be aware of the following information.
- Before starting biologic treatments, you may be asked to get a chest x-ray, a tuberculosis (TB) test and a hepatitis test.
- If you suspect that you have an infection of any kind, you should contact your healthcare team. People on this type of treatment are at an increased risk of infection. This is because the biologic can suppress the immune system leaving you susceptible to infections such as sinus, chest or skin infections. If you have an infection, it is important that you seek medical treatment. Also, if an infection is present, it is likely that your doctor will tell you to skip a dose of your biologic or stop it altogether. Do not start taking it again until you have discussed it with your doctor.
- ‘Subcutaneous’ injections (medication received by injection under the skin) can cause redness, itchiness, raised skin or tenderness around the injection site. This will often disappear after a few days and often happens less over time.
- It is important to tell doctors or dentists that you are taking biologic therapy.
- It is recommended that you avoid having live vaccines, e.g. polio or rubella vaccine, while you’re on biologic treatment. Check with your doctor about which vaccines are suitable. If you require these vaccines it’s advised that you have started them before you start your biologic treatment.
- It is recommended that anyone on biologic treatment be immunised against the flu every year and get the pneumonia vaccine once every five years.
- You will have to have regular blood tests when you’re on biologic treatment and it is important that you attend these appointments.
- If you are planning to become pregnant, it is important that you speak with your rheumatologist as many of the treatments require you to stop treatment and remain drug free, from three weeks to one year before you conceive. As with all medications, when planning pregnancy you should link in with your rheumatology team first.
- If you’ve been in contact with someone who has shingles or chicken pox and you haven’t had chicken pox, you should contact your rheumatology team.
Non-steroidal anti-inflammatory drugs (NSAIDs)
NSAIDs are a class of drugs used to treat the pain and inflammation of arthritis. They do not contain steroids, hence the name ‘non-steroidal’. NSAIDs work by interfering with particular enzymes in your body that cause inflammation that occurs in the lining of the joints. They can be very effective in controlling pain and stiffness. Usually, you’ll find your symptoms improve within hours of taking these drugs but the effect will only last for a few hours, so you have to take the tablets regularly. Some people find that NSAIDs work well at first but become less effective after a few weeks. In this situation, it sometimes helps to try a different NSAID.
There are about 20 NSAIDs available, including (with their brand names):
- Ibuprofen (Brufen®, Nurofen® and others)
- Diclofenac (Voltarol®, Diclomax®, Difene®)
- Naproxen (Naprosyn® and others)
Like all drugs, NSAIDs can sometimes have side effects, but your doctor will take care to reduce the risk of these. For example, they might prescribe the lowest effective dose for the shortest possible period of time.
NSAIDs can cause digestive problems (stomach upsets, indigestion or damage to the lining of the stomach) so another type of drug, called a ‘proton pump inhibitor’(PPI), is sometimes prescribed to help protect the stomach. NSAIDs also carry an increased risk of heart attack or stroke. Although the increased risk is small, your doctor will be cautious about prescribing NSAIDs if there are other factors that may increase your overall risk – for example, smoking, circulation problems, high blood pressure, high cholesterol or diabetes.
COXIBs (cyclo-oxygenase 2 inhibitors) are a newer class of NSAIDs that have been developed to reduce the risk of gastrointestinal ulcers and bleeding. Although COXIBs are safer for the stomach, they have all the other side effects of NSAIDs and may still cause indigestion, nausea, stomach cramps and heartburn. All NSAIDs have the potential to cause fluid retention in the body (oedema) and may raise the blood pressure or lead to heart or kidney failure in some individuals. Speak to your doctor about whether you are at risk of these kinds of side effects.
Steroids (properly known as corticosteroids and sometimes referred to as cortisones) can be very effective in reducing inflammation. Most people with RA who need steroids are prescribed prednisolone (brand names include Deltacotril Enteric™, Predsol®) usually only for a short time. Steroids are often prescribed in the early stages of treatment in combination with DMARDs.This helps reduce inflammation until the DMARD takes effect. Steroids are also useful when RA is active, they help bring the disease under control.
Taken long-term and in high doses, steroids in tablet form can cause side effects such as weight gain and osteoporosis, diabetes and high blood pressure. Your doctor will try to give you the lowest effective dose and you will be carefully monitored. You should not alter the dose yourself, or stop taking steroids suddenly.
Steroids can also be injected into an inflamed joint, or into muscles to treat soft tissue conditions, such as tennis elbow. They can be injected directly into the veins during an arthritis flare-up. Injecting doesn’t usually cause the same side effects as tablet steroids.
However, your doctor might recommend steroid injections if your joints are particularly painful or your ligaments and tendons have become inflamed.
Taking drugs can be a worrying business and it’s natural that you may be concerned about side effects. To help ease your mind, you will be carefully monitored for the side effects of certain drugs, with regular blood tests.
Pain killers are drugs that are used to help reduce pain. They are also called analgesics. Painkillers come in varying strengths and types, and are used speciﬁcally to relieve pain. Some are available over the counter, while stronger painkillers are available by prescription only.
There are a number of different types of painkillers:
- Simple non-opioid painkillers:These are the most common type of painkillers, usually available over the counter e.g. paracetamol, ibuprofen
- Compound painkillers: A combination of drugs used in one tablet e.g. co-codamol, which includes parcacetamol and a low dose of codeine
- Opioid analgesics: These are stronger painkillers containing a high dose of opioid than the other painkillers e.g. codeine, tramadol, morphine
How are they taken?
Painkillers are usually taken by mouth or given by injection. However, slow release painkilling patches, known as opioid patches, are also available although not widely prescribed. These are put on the skin and the pain-killing effects last between three and seven days. The patches are used on people whose pain is not managed with non-steroidal anti-inﬂammatory drugs or analgesics.
The internet is a hugely valuable resource for information and support when learning about RA. However, it is important to remember not all the information is reliable. Try to stick to reputable websites, such as arthritisireland.ie, webmd.com and the HSE’s Health A-Z.
People with RA don’t often need surgery. Very occasionally, a damaged tendon may need surgical repair. Sometimes, after many years of disease, a joint that has been damaged by inflammation is best treated with joint replacement surgery. This may help people with severe, advanced RA who have not responded well to other, more traditional pain management plans. Benefits of surgery include less pain and better movement and function. It’s important to remember that surgery is not a treatment for the inflammation of RA.