RA Medicine Treatment Primer

For those who have only been recently diagnosed with RA, the treatment options can be overwhelming.  There are Biologics, DMARDs, NSAIDs, steroids, and snozzwangers.  Not the last one.  They expect you to research them all or take them on faith, and either way, it’s an insane amount of information for anyone to have to learn in a short period of time. Even after thirty years of RA myself, I’m finding there are still a few things to learn.  So, let’s break it down.

The RA treatments of my youth

It was the golden age of the landline and cable television had just been rolled out, overwhelming us with twenty-nine whole channels to choose from (plus the naughty one).  Imagine that.  I had been suffering for two years with a mystery illness, and right as we were about to give up, bam!  A doctor said I had JRA (now JIA).  At age 11, you don’t really process something as complex as the implications of having a lifelong illness. You just feel the same as if someone smashed all your Legos – crappy.  Fortunately, but ultimately, unfortunately, there weren’t many people in our treatment neighborhood.  There was Indomethacin and Tolectin (NSAIDs), the well-meaning but spineless brothers, Gold Salts, the nouveau riche neighbor everyone love to hate, and corticosteroids, the morally bankrupt but attractive couple everyone wants to be friends with.  In the end, without much research available, we went with the doctor’s advice to start with Indocin and Tolectin and work our way up as needed.  Turns out, that’s exactly the opposite of what we should have done.

A change to the RA treatment algorithm

Nowadays, doctors tend to hit the disease hard and fast, like a veteran linebacker on a rookie quarterback.  Or Eli (dude!).  They start with biologics almost immediately and usually add methotrexate.  If this doesn’t work, then they add more meds until they have a delicious 7-layer medicine cake with an icing of acceptable quality of life.  The faster they stop the joint damage and inflammation, the better.  That’s why it’s important to know the differences between the types of medicines used for RA, so this quick guide should help.

NSAIDs are Non-Steroidal Anti-Inflammatory Drugs which are the granddaddy of them all, some of the oldest medicines available for treating, well, pretty much everything.  Aspirin, ibuprofen, Celebrex, and naproxen fall into this category.  Acetaminophen (Tylenol) is not an NSAID, but pretty much acts the same way.  Without getting too technical, let’s just say NSAIDs help to inhibit the production of “stuff” in your body that makes things “swell.”  Not swell like your grandpa’s new lawnmower, but swell like inflamed.  Years ago when the doctors knew little and people were still dying of dysentery on The Oregon Trail (the computer game, not the actual trail), NSAIDs were the drug of choice for RA, even for children.  There was a whole host of nasty side effects, though,  so alternatives had to be found.

Steroids are the “S” in NSAID, and their clinical name is corticosteroids.  Corticosteroids are what the body produces in times of stress and injury, and they are sort of the duct-tape of adrenal system.  They are used to hold things together until a proper fix by suppressing the body’s inflammation immune response.  When rheumatologists give patients steroids, it’s either for one or two big, short, blasts, or for a prolonged period of time.  The former isn’t too bad, but the latter can cause some serious side effects and is more of a napalm carpet than a laser-guided missile.  Also, they weren’t specifically developed to fight RA, so, again, we needed more.

Some of the first drugs specially made to fight RA and its cousins were called DMARDs – disease-modifying anti-rheumatic drugs. This group includes sulfasalazine (Azulfidine), hydroxychloroquine (Plaquenil), leflunomide (Arava), azathioprine (Imuran), cyclosporine, and the big honkin’ King Kong of them all – methotrexate.  These drugs, in a nutshell, work to suppress the body’s immune response en masse.  Like adding Britney Spears to a night of Pearl Jam, nobody shows up.  They act unilaterally, beating down your immune system like an over-confident MMA fighter, and they don’t discriminate which part of the immune system gets pummeled.  It’s an all or none buffet, and your immune system is the only thing on the menu.  That’s why they created the next group of “drugs.”

Biologics for RA treatments

Biologics are the natural evolution of DMARDs and are the treatment par excellence for today’s RA patient on the go.  If we went.  Which we don’t.  Biologics include etanercept (Enbrel), tocilizumab (Actemra), certolizumab (Cimzia), adalimumab (Humira), anakinra (Kineret), abatacept (Orencia), infliximab (Remicade), and rituximab, (Rituxin).  Phew.  These compounds work on the body by suppressing one specific type of immune cell, instead of all of them at once.  Kind of like the way your gardener manages to leave everything growing except for the tomato plant you grew from a tiny seed.  Humira suppresses TNF, or tumor necrosis factor, Kineret blocks a molecule called interlueken 1, Actemra blocks interleukin 6, and so on, and so on.  The theory is that everyone’s RA is driven mainly by just one of the molecules in the immune system, and if you restrict production, it should reduce the RA disease activity greatly.  This is a wonderful idea in theory, but in practice, you can’t test to see which specific molecule is responsible for the RA that patient is experiencing.  That means trial and error.  Also, patients who have not yet found relief will have a DMARD added for that extra immunosupressanty goodness (usually Methotrexate).  It takes a long time, though, to find which one works for you, if any.  Personally, it took me almost 20 years, and by then much of the damage was done.  So hang in there, like that cat in the poster at your office, or that chatty guy who always seems to be leaving at the exact same time as you.  No, Brad, I don’t want to hear about your cat.

I hope this helps demystify some of the information that the doctors throw at you when you are first diagnosed.  It can be overwhelming, but hopefully this will help turn the firehose shooting into your face into a nice summer chardonnay that you can sip by the waterside.  Just remember, RA is still a catch-all diagnosis for several conditions caused by different molecules, so be a patient patient.  I know it can get intolerable, but it’s worth the time when you finally hit the RA jackpot.  Well, actually, it’s less of a jackpot and more of a gift basket from the local charity auction which has tickets to community theater, but it’s something.