Rheumatoid Arthritis Treatment:
Despite significant advances in treatment over the past decades,
rheumatoid arthritis continues to be an incurable disease. Treatment of
rheumatoid arthritis has two components:
(1) Reducing inflammation and preventing joint damage and disability and
(2) Relieving symptoms,
especially pain. Although achieving the first goal may accomplish the second,
many people need separate treatment for symptoms at some point in the disease.
Medications:
Disease-modifying antirheumatic drugs (DMARDs): This group of drugs
includes a wide variety of agents that work in many different ways. What they
all have in common is that they interfere in the immune processes that promote
inflammation in rheumatoid arthritis. DMARDs can actually stop or slow the
progression of rheumatoid arthritis. They can also suppress the ability of the
immune system to fight infections. Anyone taking one of these drugs must be
very vigilant to watch for early signs of infection, such as fever, cough, or
sore throat. Early treatment of infections can prevent more serious problems.
Methotrexate (Rheumatrex,
Folex PFS): We do not know exactly how this drug works in the treatment of
inflammatory reactions. It relieves symptoms of inflammation such as pain,
swelling, and stiffness. People taking methotrexate have to have regular blood
tests to measure whether the drug is having any adverse effects on the liver,
kidneys, or blood cells. This drug is not suitable for some people with liver
problems or women who are or may become pregnant.
Sulfasalazine (Azulfidine):
This drug decreases inflammatory responses by an effect similar to that of
aspirin or NSAIDs. People taking sulfasalazine must have regular blood tests to
measure whether the drug is having any adverse effects on blood cells.
Leflunomide (Arava): This drug interferes with cells of the
immune system and reduces inflammation. It reduces symptoms and may even slow
the progression of rheumatoid arthritis. People taking leflunomide must have
regular blood tests to measure whether the drug is having any adverse effects
on the liver or blood cells. This agent is not suitable for some people with
liver or kidney problems or women who are or may become pregnant.
Gold salts (aurothiomalate, auranofin
[Ridaura]): These
compounds contain very tiny amounts of the metal gold. We do not know why they
stop inflammation. Apparently, the gold infiltrates into immune cells and
interferes with their activities. People taking gold must have regular blood
and urine tests to measure whether the drug is having any adverse effects on
blood cells and the kidney.
D-penicillamine: This agent combines with metals in the
bloodstream and cells and removes them from the body. This suppresses certain
actions of the immune system that promote rheumatoid arthritis. People taking
D-penicillamine must have regular blood and urine tests to measure whether the
drug is having any adverse effects on blood cells and the kidney.
Hydroxychloroquine (Plaquenil): This drug was first used against the
tropical parasite malaria. It inhibits certain cells that are necessary for the
immune response that causes rheumatoid arthritis. People taking
hydroxychloroquine must have eye examinations at least yearly to determine
whether the drug is having any adverse effects on the retina.
Azathioprine (Imuran): This drug stops the production of cells that
are part of the immune response associated with rheumatoid arthritis.
Unfortunately, it also stops production of some other types of cells and thus
can have serious side effects. It strongly suppresses the entire immune system
and thus leaves the person vulnerable to infections and other problems. It is
used only in severe cases of rheumatoid arthritis that have not gotten better
with other DMARDs. People taking azathioprine must have regular blood tests to
measure wither the drug is having any adverse effects on blood cells. It is not
used for women who are or may become pregnant.
Cyclosporine (Neoral): This drug was developed for use in people
undergoing organ transplantation or bone marrow transplantation. These people
must have their immune system suppressed to prevent rejection of the
transplant. Cyclosporine blocks an important immune cell and interferes with
the immune response in several other ways. People taking cyclosporine must have
regular blood tests and blood pressure checks to measure whether the drug is
having any adverse effects on blood cells and blood pressure. It is not used
for women who are or may become pregnant.
Biologic response modifiers: These agents act like substances produced normally
in the body and block other natural substances that are part of the immune
response. They block the process that leads to inflammation and damage of the
joints.
Etanercept (Enbrel): This agent blocks the action of tumor
necrosis factor, which in turn decreases inflammatory and immune responses. It
is given by subcutaneous injection twice weekly. People taking etanercept must
have regular blood tests to measure whether the drug is having any adverse
effects on blood cells.
Infliximab (Remicade): This antibody blocks the action of tumor
necrosis factor. It is often used in combination with methotrexate in people
whose rheumatoid arthritis does not respond to methotrexate alone. It is given
by intravenous infusion every six to eight weeks. People taking infliximab must
have regular blood tests to measure whether the drug is having any adverse
effects on blood cells.
Adalimumab (Humira): This is another blocker of tumor necrosis
factor. It reduces inflammation and slows or stops worsening of joint damage in
fairly severe rheumatoid arthritis. It is given by subcutaneous injection every
two weeks. People taking adalimumab must have regular blood tests to measure
whether the drug is having any adverse effects on blood cells.
Anakinra (Kineret): This agent blocks the action of
interleukin-1, which is partly responsible for the inflammation of rheumatoid
arthritis. This in turn blocks inflammation and pain in rheumatoid arthritis.
This agent is usually reserved for people whose rheumatoid arthritis has not improved
with DMARDs. It is given by subcutaneous injection daily. People taking
anakinra must have regular blood tests to measure whether the drug is having
any adverse effects on blood cells.
Abatacept (Orencia): This agent inhibits T-lymphocytes that contribute
to the inflammation and pain associated with rheumatoid arthritis. This drug is
reserved for individuals who do not respond to DMARDs, methotrexate, or TNF
blockers. It is administered by intravenous infusion. Abatacept may increase
the risk of serious infections.
Rituximab (Rituxan): Given by intravenous infusion over four to
five hours, twice, two weeks apart, every four to 10 months, this biologic
response modifier decreases the number of B-cells, a type of immune cell that
plays an integral role in causing rheumatoid inflammation and damage. Rituximab
may increase the risk of serious infections.
Glucocorticoids: These very potent agents rapidly block
inflammation and other immune responses. They are often called steroids. These
agents all work in the same way; they differ only in their potency and in the
form in which they are given. Steroids may be given as pills, intravenously, or
as injections into a muscle or directly into a joint. In high doses, they can
cause many serious side effects and are therefore given only for the shortest
possible periods and under strictly controlled circumstances. These drugs
should never be stopped abruptly.
Prednisone (Deltasone,
Meticorten, Orasone)
Prednisolone (Medrol)
Betamethasone (Celestone)
Nonsteroidal antiinflammatory drugs (NSAIDs): These drugs reduce swelling and pain but do
not stop joint damage and alone are not sufficient to treat rheumatoid
arthritis. These drugs work by blocking an enzyme called cyclo-oxygenase (COX)
that promotes inflammation. There are at least two forms of the enzyme: COX-1
and COX-2. Some people with a history of stomach ulcers or liver problems
should not take these drugs. This group includes aspirin, although aspirin is
rarely used in rheumatoid arthritis because it is not as safe as other agents.
COX-2 inhibitors: These agents block only the COX-2 enzyme
and are often referred to as selective NSAIDs. They have fewer side effects
than the other NSAIDs while still reducing inflammation. Only celecoxib
(Celebrex) currently remains on the U.S. market.
Nonselective NSAIDs: These drugs block both COX-1 and COX-2. They
include ibuprofen (Motrin, Advil, etc.), ketoprofen (Oruvail), naproxen
(Naprosyn), piroxicam (Feldene), and diclofenac (Voltaren, Cataflam).
Analgesics: These agents reduce pain but do not affect
swelling or joint destruction.
Acetaminophen
(Tylenol, Feverall, Tempra):
This drug is often used by people who cannot take NSAIDs because of hypersensitivity, ulcers, liver problems, or
interactions with other drugs.
Tramadol
(Ultram)
Opioids: These drugs may be used to treat moderately
severe to severe pain that is not relieved by other analgesics.
Surgery
Some
people with rheumatoid arthritis need several operations over time. Examples
include removal of damaged synovium (synovectomy), tendon
repairs, and replacement of badly damaged joints, especially the knees or hips.
Some
people with rheumatoid arthritis have involvement of the vertebrae of the neck
(cervical spine). This has the potential for compressing the spinal cord
and causing serious consequences in the nervous system. These people
occasionally need to undergo surgical fusion of the spine.
Other Therapy
No
herb, natural product, or nutritional supplement has been shown definitively to
be helpful in rheumatoid arthritis. Studies are underway to test some herbal products thought to be helpful in
rheumatoid arthritis, but we do not know enough about them to recommend them.
A
variety of complementary approaches may be effective in relieving pain. These
include acupuncture and massage.
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