Rheumatoid Arthritis Medications
DMARDs (Disease-Modifying Anti-Rheumatic Drugs)
DMARDs are the most widely used and studied drugs used as therapy for RA. A DMARD is an RA medication that slows down the progression of your disease. DMARD stands for disease-modifying antirheumatic drug. Other than glucocorticoids (steroids), DMARDs have been on the market the longest and have the most evidence to support their use.
- Methotrexate (Rheumatrex®, Trexall®): The most commonly used DMARD is methotrexate. Methotrexate is considered the gold standard in terms of monotherapy treatment of RA with a DMARD, and is generally the first choice.
- Hydroxychloroquine (Plaquenil) is often used alone in mild RA or in combination with other medications in people with more severe RA. It can reduce your joint pain and swelling. In the long term, hydroxychloroquine (Plaquenil) may help prevent joint damage or lower your risk of joint disability. We don’t really know why this drug works to control RA symptoms or complications. One theory is that hydroxychloroquine (Plaquenil) interferes with communications between the cells of your immune system.
- Leflunomide (Arava®): Leflunomide (Arava) is used to treat moderate to severe RA. It can lower joint damage and disability that RA can cause. It can also help ease your symptoms. It may be used alone or in combination with other DMARDs. Leflunomide (Arava) blocks the development of certain cells in your immune system. By doing this, leflunomide (Arava) works to suppress your immune system and reduce inflammation that causes pain, swelling, and other symptoms.
- Sulfasalazine (Azulfidine): Sulfasalazine (Azulfidine) is used to treat RA symptoms like pain or swelling. Over time, it can help slow down the progression of your disease. It may be used alone or in combination with other DMARDs. We don’t know exactly why sulfasalazine (Azulfidine) eases RA symptoms like pain, swelling, or joint stiffness. It may prevent joint damage and over the long term, loss of your joint function.
TNFi biologics work by targeting something called tumor necrosis factor proteins, or TNF. TNF is a protein that sends signals to your body, eventually leading to inflammation that causes swelling, pain, and stiffness. By inhibiting, or stopping, TNF, these medications can reduce inflammation. That’s why they’re often called TNF inhibitors (or TNFi).
Some common TNFi biologics are:
- Adalimumab (Humira®)
- Certolizumab pegol (Cimzia®)
- Etanercept (Enbrel®)
- Golimumab (Simponi®, Simponi Aria®)
- Infliximab (Remicade®)
These biologics are molecules that are specially designed to target TNF and block it at the source. They can cool down your immune response that’s out of control in RA.
Your doctor may prescribe TNFi biologics if previous DMARD monotherapy was ineffective. Personal considerations such as out-of-pocket cost, comorbidities, and side effects may make TNFi therapy (often with the addition of methotrexate) the best option.
For individuals with established RA, TNFi biologics could be an addition to your DMARD monotherapy or double therapy, or used alone. Your rheumatologist will determine which option is best for you based on your personal medical history.
There are other biologics that target the immune system in different ways from TNFi drugs. They interact with different kinds of white blood cells, such as T cells or B cells, in your immune system. They can also block chemicals called cytokines that cause inflammation.
White blood cells and cytokines are made by your immune system to fight off infection. But in RA, they may be out of control and cause inflammation. So these drugs can suppress your immune system, ease inflammation, stop RA’s progress, and ease your symptoms.
If disease activity remains moderate or high despite use of DMARD therapy, biologics that target the immune system in different ways from TNFi drugs or a JAK inhibitor may be added to the DMARD or used alone without a DMARD, depending on the drug.
Some common biologics that work differently than TNFi biologics:
- Abatacept (Orencia®): Abatacept works by blocking signaling to a special kind of white blood cell called a T cell. It is available in two forms: a subcutaneous (SC) injection that is a shot that is given just under your skin. It is available as a pre filled syringe or a ClickJect™Autoinjector or as an intravenous (IV) infusion is given by your healthcare provider through a vein in your arm.
- Rituximab (Rituxan®): Rituximab (Rituxan®) works by blocking a special kind of white blood cell known as B cells. Rituximab is given by IV infusion.
- Tocilizumab (Actemra®): Tocilizumab (Actemra®) works by blocking a cytokine known as Il-6 that can cause inflammation. It can be given by IV infusion or self-injected.
- Sarilumab (Kevzara®): Sarilumab works by blocking IL6, a pivotal cytokine that drives inflammation. It is available as subcutaneous injections every 2 weeks.
Janus Kinase (JAK) Inhibitors
JAK inhibitors are a new class of arthritis drugs that treat RA. They’re not biologics. They are known as small molecule medications.
JAK inhibitors come in pill form. They decrease your immune system’s ability to make certain enzymes that can lead to RA symptoms. The first JAK inhibitor is tofacitinib (Xeljanz®). Tofacitinib (Xeljanz) works by decreasing the effectiveness of the immune system to reduce pain, swelling, and inflammation. Many others JAK inhibitors are being developed now, and may be approved soon.
JAK inhibitors can be used with or without methotrexate. Your rheumatologist may even prescribe this drug before you try a biologic if he or she thinks it’s the right option for you.
Glucocorticoids are medications can reduce RA symptoms very quickly. They may also be called corticosteroids or even “steroids” for short. The most commonly prescribed glucocorticoids are prednisone and methylprednisolone (Medrol®).
They’re often used as a “bridge therapy” while you’re waiting for your DMARD or biologics to kick in. They can also be used if you have a flare and need quick symptom relief.
There’s another new option that will soon be available to treat RA: biosimilar drugs. These are very similar copies of the various biologics that are already on the market. You may have seen this term in the news, or even heard your doctor or nurses mention it. Biosimilars are drugs that are made to be very similar to existing biologic drugs like TNF inhibitors.
In 2016, three biosimilars to biologics used to treat RA have been approved by the FDA so far:
- Infliximab-dyyb (Inflectra®)
- Etanercept-szzs (Erelzi®)
- Adilimumab-atto (Amjevita)