A big part of managing arthritis is managing the trial-and-error process of finding the right medications to treat your disease. Because arthritis is progressive — and the immune system is mysterious — not all medications work equally well for all patients. Commonly, medications may work for a period of time and then fail to continue to provide relief or control disease activity.
How Patients Feel About Switching Arthritis Medication
“So many of our drugs take months to kick in and we have to deal with the pain, etc. until they do — if they do,” Carole H. shared on our Facebook page. “When they don’t, it’s on to something else. Then after a few years, the effectiveness wears off and you need to change again.”
In other cases, you may be forced to change medications due to changes in your insurance coverage (which is a whole other story).
“After going through all the hurdles to get medication, there is no guarantee it is going to work and in three to six months and I may have to go through it again to get the medication changed,” Lindsay S. told us on Facebook.
Whatever the reason, it’s important to get used to the idea that changing up the medications you take to treat your arthritis — whether osteoarthritis or a form of inflammatory arthritis — is an inevitable part of the patient journey.
Though that doesn’t make it any less stressful.
“I’m just about to switch yet again and it’s scary because of the [potential] side effects and reactions,” Carrie G. told us on Facebook. She is about to switch from an injectable biologic to an infused drug and is nervous about the change.
Val A. told us on Facebook that she’s “concerned that the biologic only has me 70 percent controlled — and what will happen if or when the meds stop working?”
The good news is that there are more medications than ever to treat inflammatory arthritis — from various DMARDs and biologics to forthcoming JAK inhibitors. It’s a whole different world than it was 20 or even 10 years ago.
“We’re in a good age of rheumatic medication,” says Masoom Modi, MD, a board-certified rheumatologist at UCLA Health and assistant clinical professor at the David Geffen School of Medicine at UCLA. “There are so many options for patients now.”
But having more choice also creates more potential confusion. With all these options, you may wonder which medication is best for you. Should you need to switch medication, whether to an entirely new class or a different drug within the same class, you may have concerns over which specific medication may be best for your needs.
“Patients’ main concerns are pain relief and resuming quality of life,” says Dr. Modi. “The physician’s job is to keep that in mind when discussing medication changes with patients. I base any decision to switch on objective markers, like looking at the individual patient, their labs, and their imaging results.”
Deciding to Switch Arthritis Medication or Stay the Course
In many cases, both doctors and patients feel most comfortable maintaining whatever drug regimen is working.
“I think most patients are happy to stick with what they know works for them,” says Lindsay S. Lally, MD, a rheumatologist at the Hospital for Special Surgery in New York City. “There is always anxiety around trying something new and not knowing if it will control your disease. I do not recommend switching to new therapies just because they are ‘new;’ there needs to be a compelling reason medically.”
But if your regimen is not working as well as it could be, don’t hesitate to ask your doctor about a change — or be surprised if your doctor suggests a more aggressive strategy.
Under a “treat-to-target” philosophy that’s espoused by rheumatologists for many different forms of arthritis, such as rheumatoid arthritis, you and your doctor should agree on a target — such as remission or low disease activity, as measured by imaging and blood tests — and adjust your treatment if necessary until you achieve it.
This may mean changing your medication from a conventional disease-modifying drug (DMARD) such as methotrexate to adding additional DMARDs, such as sulfasalazine and hydroxychloroquine. It could mean switching your arthritis medication from a conventional DMARD to adding a biologic drug, such as a TNF inhibitor. Or trying another biologic drug with a different mechanism of action.
However, research indicates that patients aren’t necessarily changing their arthritis medication regimen even when their symptoms indicate they should consider it. For example, last year, CreakyJoints presented data from our ArthritisPower research registry at the Annual European Congress of Rheumatology that found that only 37 percent of rheumatoid arthritis patients who self-reported having high disease activity were offered a treatment change at their last doctor’s visit. Of those, 72 percent of patients agreed to make a change in their arthritis treatment.
For some patients, as long as they feel well informed about their options, and their doctor includes them in the decision-making process, change is a positive part of the process. Learn more about how to establish shared decision making with your doctor.
“I have been under the care of a rheumatologist for over a year to manage gout,” says arthritis patient Ed R., from Yorktown Heights, New York, who has undergone several switches in medications to address issues with his bloodwork results. “I had no problem with the medication changes as long as I understood the reason for the change and the underlying goal.”
Signs It Might Be Time to Switch Your Arthritis Medication
If you’re on the fence about whether or not to stick with your current arthritis treatment, consider these signs that it might be time for you and your doctor to discuss a prescription switch.
1. You’re noticing new symptoms
The number-one factor that may prompt you or your rheumatologist to consider a change in medication is if you’re experiencing different symptoms, says Dr. Modi. For example, if patients come to her saying they’re bothered by more morning stiffness, more swollen joints, or more fatigue, it may be time to think about another option.
Unfortunately, many patients with arthritis take a “tough-it-out” approach to their symptoms. They may believe that things won’t get any better and this is just the way they have to feel now.
It’s never a good idea to keep these thoughts to yourself. If you’re feeling bad or worse, tell your doctor about it and push them to help you find a treatment plan that can start making you feel better.
2. The medication isn’t working
Inefficacy is another big reason your physician may recommend a change. “If after several months on a medication, a patient has ongoing or worsening joint pain, swelling, and stiffness, that tells us switching medications is warranted,” says Dr. Lally.
Sometimes a patient may start a medicine and never respond to it, which is a situation called primary non-response. “Other times a medication that has been working for a long time starts to become less effective for a patient; we consider this a secondary non-response.”
3. You can’t tolerate the medication’s side effects
“Every medication is a drug and will have side effects, but the disease has to be treated,” says Dr. Modi. “We have to consider if the side effects outweigh the benefit of the medication.”
For her part, Dr. Lally sees side effects from arthritis drugs that run the gamut, including nausea and upset stomach, itchy injection site reactions for patients taking injectable biologic medications, and even serious allergic responses.
If a side effect is life threatening, the drug must be immediately discontinued. “But if the side effects are not dangerous or life-threatening, we see if there are other measures we can take to minimize them. Sometimes lowering a dose, sometimes adding a medication like an antihistamine in the case of injection site reactions, sometimes splitting a dose,” Dr. Lally explains. If side effects persist, you need to have a conversation with your doctor to weigh risks and benefits and discuss alternatives.
Finding the right dosage that addresses symptoms with minimal side effects is part of the trial and error process. For some patients, this can be difficult. “Some of the worst times of my life were when doctors were trying to figure out the dosage of a new medicine,” Roz D. shared on Facebook.
“Sometimes the devil you know is better than the devil you don’t, and patients decide to stick with what they are on. But when the side effects are untenable, we switch,” Dr. Lally says. “We are fortunate to have many choices of therapy for RA and other types of arthritis.”
4. Your bloodwork sparks concerns
Some of the medications that treat RA or other inflammatory arthritis can cause laboratory abnormalities like liver test changes or low white blood cell counts, Dr. Lally explains. “These blood test changes may necessitate discontinuation of the medication and switching to an alternative.”
5. You’re coming out of arthritis remission
Remission in inflammatory arthritis is indicated by a number of factors, including lab work (which checks for inflammation markers), imaging studies like X-ray (which look for progressive erosive damage to joints), and a physical exam (which feels for swollen and tender joints).
“When a patient is in remission, we tend to be conservative and keep them on their current medication regimen,” says Dr. Modi, though sometimes medications can be tapered, adjusted, or stopped once a patient is in remission. “But if a patient who has been in remission — even for years — starts to develop symptoms, or if you notice a change in their labs, imaging, or physical exam, you have to consider a change in medication.”
6. Your initial diagnosis changed
Because many kinds of arthritis are tricky to diagnose, it’s common for a diagnosis to change — perhaps you were diagnosed with fibromyalgia, but later learn that you have ankylosing spondylitis — or to get an additional diagnosis, such as having rheumatoid arthritis and spondyloarthritis at the same time. This could necessitate adding new medications or swapping what you take for a new drug that can treat multiple diseases at the same time.
7. You’re having other health problems — and taking other prescriptions
Beyond arthritis, a patient may develop other health issues that require their own medications, which could prompt a change in your arthritis medication regimen. “If I have a patient who develops congestive heart failure or if someone starts a blood thinner, I may have to adjust the dosage of their arthritis medication or re-evaluate the prescription entirely,” says Dr. Modi.
Other times, a change in arthritis medication may prompt a switch in your prescription from another specialist. Ed R. had been taking a particular statin for years to control cholesterol. “It appears that this statin adversely interacts with a new drug I was prescribed for gout, so a different statin is being tried,” he says.
Tips for Transitioning to a New Arthritis Medication
Rheumatologists like Dr. Modi see a range of patient preferences, from those who prefer sticking with familiar medications to those who are eager to try new things. When it comes to broaching the topic of switching prescriptions, she says, “It’s always a joint decision we make together, with quality of life leading the decision-making process.”
If you and your doctor conclude a new prescription makes sense, starting a new drug means more than just popping a new pill (or getting a new injection or infusion). The transition involves many steps, such as tapering the old medication and educating patients on the new — including any training they may need for unfamiliar methods of medication delivery, such as injectables. (Here are tips for dealing with injectable medication.)
“Education about medication is a huge part of what we do as rheumatologists,” says Dr. Lally. “We talk about what to expect with the new medication, how long it will take to see an effect, and what side effects they may experience.”
Different medications require different monitoring in terms of frequency of laboratory testing and office visits, she adds. “We try to lay that all out upfront to make the transition as smooth as possible.”
If you’re about to start a new medication, it’s a good idea to make sure you have answers to the following questions:
- Why am I taking this medication — how is it expected to help me feel better?
- How soon should the medication start working?
- How will you monitor whether or not it is working?
- What side effects should I watch out for?
- What long-term side effects or risks should I be aware of?
- Why do the benefits of taking this medication outweigh the risks for me?
- Does this medication interact with any other drugs or supplements I use?
- How often do I take this medication? What is the dose?
- Are there any other tips I should know about using this medication safely?
- Is there anything I need to avoid eating, drinking, or doing while taking this medication?
- Is there anything I can do to help manage potential side effects?
- If I have a concern or question about this medication, who should I call?
Track Your Medications with ArthritisPower
Join CreakyJoints’ patient-centered research registry and log your medications to track side effects and impact on disease activity. Learn more and sign up here.