All the drugs used to treat rheumatoid arthritis have been tested and have been proven useful in patients who have the disease. However, they all work on a different aspect of the inflammatory process seen in rheumatoid arthritis and their use – as well as their side effects — depends on the current disease status of each patient and any associated medical problems that a patient may have.
The effectiveness and the risks of drugs are considered when your rheumatologist plans your treatment.
If a drug is very effective in treating an illness but causes a lot of side effects, it is not an ideal treatment for long-term use. For example, high doses (15 to 20 mg or more per day) of corticosteroids can make people with rheumatoid arthritis feel dramatically better. However, high doses of corticosteroids may cause serious side effects when taken over many months or years. Steroids have many possible side effects, including weight gain, worsening diabetes, promotion of cataracts in the eyes, thinning of bones (osteopenia and osteoporosis), and an increased risk of infection. Thus, when steroids are used, the goal is to use the lowest possible dose for the shortest period of time.
NSAIDs. All of the NSAIDs are similarly effective, making it difficult for doctors to strongly recommend one over the other. These drugs can cause irritation of the stomach and cause kidney damage as side effects. Therefore their use in people with severe stomach and kidney problems should be closely supervised by doctors.
Cox-2 anti-inflammatory agents work by inhibiting a certain enzyme in the body (cyclooxygenase 2, i.e. COX-2), which in turn, reduces the amount of bad prostaglandins. Thus, inflammation is reduced leaving the other good prostaglandins alone that protect the stomach and kidneys. COX-2 inhibitors are sometimes used in patients who cannot take ordinary NSAIDs – such as those who are concerned about stomach ulcers and gastric irritation.
DMARDs. The “traditional” DMARDs work by a different mechanism than NSAIDs and work well. For example, methotrexate is among the drugs that are widely used and most effective in providing benefits for people with rheumatoid arthritis. It is often referred to as the “cornerstone of therapy” and is used alone or in combination with other drugs. However, traditional DMARDs act slowly after starting the drug for several weeks.
Biologic agents. The biologic agents are newly developed effective drugs. Biologic agents are more specifically targeted at the inflammatory process seen in rheumatoid arthritis. This high specificity leads to another big advantage of using the biologics. They tend to be better tolerated and sometimes able to work faster than traditional DMARDs. However, all of the biologic agents can have side effects and will need to be used under the supervision of your rheumatologist.
DMARDs and biologic agents interfere with the immune system’s ability to fight infection and should not be used in people with serious infections.
Testing for tuberculosis (TB) is necessary before starting anti-TNF therapy. People who have evidence of prior TB infection should be treated because there is an increased risk of developing active TB while receiving anti-TNF therapy.
Anti-TNF agents such as infliximab, etanercept, adalimumab, certolizumab and golimumab are not recommended for people who have lymphoma or who have been treated for lymphoma in the past; people with rheumatoid arthritis, especially those with severe disease, have an increased risk of lymphoma regardless of what treatment is used. Anti-TNF agents have been associated with a further increase in the risk of lymphoma in some studies but not others; more research is needed to define this risk.