Drugs and Prescription Medications For RA
Medications are an essential part of managing rheumatoid arthritis (RA), both for pain management and to slow or stop the disease process. Without treatment, the chronic inflammation in the joints can lead to permanent damage and disability.
There are several different classes of drugs that are used to treat RA, including:
- Disease-modifying anti-rheumatic drugs (DMARDs)
- Biologic DMARDs, also just called biologics
- Target-specific DMARDs
- Non-steroidal anti-inflammatory drugs (NSAIDs)
- Glucocorticoids, or corticosteroids
- Pain medications, or analgesics
Drug treatment generally fall into two categories, symptomatic treatments (those drugs whose main focus is relief of symptoms) and disease-modifying treatments (those drugs that can modify the course of RA and slow or prevent joint destruction in addition to providing relief of symptoms). DMARDs, including traditional, biologics, and target-specific, have been shown to slow and prevent damage to joints, thereby preserving function and improving quality of life.1
DMARDs (disease-modifying anti-rheumatic drugs) are effective at reducing inflammation associated with RA and slowing or preventing damage to joints and enabling a patient to maintain function and quality of life. This is why they are called “disease-modifying,” because they can interrupt the processes that cause damage in rheumatic diseases. The introduction of DMARDs for the treatment of RA has significantly changed and improved the prospects for patients with RA. Before the availability of DMARDs, damage to joints and related structures from chronic inflammation associated with RA was inevitable for many patients.1
One limitation associated with traditional DMARDs is the time it takes for them to achieve full effect. For instance, methotrexate may take 4 to 6 weeks to improve RA symptoms and hydroxychloroquine 2 to 3 months. This is why other medications like glucocorticoids are often used in concert with DMARDs during RA flares for acute (short-term) control of inflammation and associated symptoms.2
DMARDs are associated with a range of side effects, which is why your doctor will work closely with you to adjust the dose of whichever DMARD you use to balance the therapeutic effect with safety concerns or side effects.1
The introduction of biologics revolutionized the treatment of RA and has significantly broadened and improved the drug treatment options for people living with RA. These treatments also fall under the category of DMARDs, because they can change or modify the disease course in RA and slow or prevent damage to joints and related structures.1
The term “biologics” is used for these treatments because they are designed to target specific molecules on immune system cells, such as receptors on T- or B-cells, to block the actions of these cells and, thereby, dampen the out-of-control inflammatory process that characterizes an autoimmune disease like RA. There are several types of biologics available to treat RA, including tumor necrosis factor (TNF)-inhibitors (also called anti-TNF agents), B-cell inhibitor, T-cell inhibitor, and interleukin-6 (IL-6) inhibitor. These medications can be used in combination with traditional DMARDs and are often used with NSAIDs and short-term glucocorticoid treatment.3
Biologic DMARDs include:
- Actemra® (tocilizumab)
- Cimzia® (certolizumab pegol)
- Enbrel® (etanercept)
- Humira® (adalimumab)
- Kineret® (anakinra)
- Orencia® (abatacept)
- Remicade® (infliximab)
- Rituxan® (rituxumab)
- Kevzara® (sarilumab)
- Simponi® (golimumab)
- Rinvoq® (upadacitinib)
Biologics take somewhat less time to achieve full effect than traditional DMARDs, with time to effect ranging from 2 to 6 weeks, depending on the specific drug. All biologics must be taken by injection or infusion. Some are available for injection through the skin and may be taken at home. Others must be infused at your doctor’s office, with an infusion taking anywhere from 1 to 6 hours.2,4
Biologics are associated with several side effects. The most important and potentially dangerous have to do with their effect on the immune system. Because biologics are designed to dampen the immune response, they can increase your risk of developing infections or certain cancers.4
Biosimilars are medications that are a type of biologic therapy. Biosimilars are named for the fact that they are highly similar to an already approved biological product. Like biologics, biosimilars have bioengineered proteins that mimic certain functions in human genes or cells, and they are made from living organisms.5
Biosimilars are not generics, although they are generally cheaper than the medicine they are similar to, called a reference medicine. Biosimilars approved for RA include Amjevita™ (adalimumuab-atto), Cyltezo® (adalimumab-adbm), Erelzi™ (etanercept-szzs), Inflectra® (infliximab-dyyb), and Renflexis™ (infliximab-abda).5
First in a new class of treatment, tofacitinib (Xeljanz®), is a Janus kinase (JAK) pathway inhibitor available as an oral pill taken twice daily. The JAK pathways play an important role in the inflammatory process. Xeljanz was approved by the FDA in November 2012 and like other DMARDs, works to relieve inflammation by interrupting the disease process of RA.2
Olumiant® (baricitinib), is another Janus kinase (JAK) pathway inhibitor that has been approved by the FDA in June 2018. It has been approved for the treatment of moderate-to-severe rheumatoid arthritis (RA) in people who have not had an adequate response to one or more anti-TNF (tumor necrosis factor) therapies. Olumiant is available as an oral pill of 2 mg. to be taken once daily.
NSAIDs, which include ibuprofen (Advil, Motrin), naproxen (Aleve), or indomethacin (Indocin), as well as Celebrex (celecoxib), can be very useful in providing fast relief of RA symptoms such as pain and minor inflammation. However, NSAIDs have no effect on the long-term damage to joints that can result from chronic inflammation associated with RA. To have an effect on inflammation, an NSAID must be taken continuously (at a specified dose) and must be taken for a couple of weeks for the anti-inflammatory effect to be fully achieved. Talk to your doctor about the appropriate dose to use for whichever NSAID you are taking. Remember that two NSAIDs should not be taken at the same time, and like all medications, NSAIDs also can cause side effects.2,4
Glucocorticoids (also called corticosteroids or just steroids) are very effective at controlling inflammation. They may be taken orally, by injection into a vein, or by direct injection into a joint cavity. Steroids (examples include prednisone, prednisolone, and methylprednisolone) have been shown to provide rapid improvement of RA symptoms, including pain and tenderness, stiffness, swelling, and inflammation. However, unlike DMARDs, they do not slow or prevent RA-related damage to joints and other structures.2
Steroids are typically used during an RA flare, when disease activity is at its highest and causes the most disruption to functioning normally. Because steroids take effect rapidly, they are often used in combination with RA drugs that act more slowly, such as methotrexate, which may take a month to achieve full efficacy, or biologics, which may take a couple weeks to achieve full efficacy. Steroids are typically used at the lowest dose possible and only for a limited period of time because of the potential for a variety of side effects, including exacerbation of diabetes, weight gain, bone loss (osteopenia and osteoporosis), increased risk of infection, and increased risk for cataracts.2,4
Several different classes of drugs provide pain relief in RA but do not have any effect on inflammation. These include analgesics such as acetaminophen (Tylenol), the narcotic-like pain medication tramadol (Ultram), capsaicin cream or ointment, and narcotic pain relievers, such as codeine, oxycodone, and hydrocodone.2,6
Use of the narcotic pain relievers in patients with RA is generally discouraged due to the potential for addiction with long-term use and because of the fact that they have no effect on inflammation. However, narcotic pain relievers may be useful in certain circumstances, such as in RA patients with joints that are badly damaged and who are not candidates for joint replacement surgery. Use of narcotics in these patients must be closely monitored by a rheumatologist or pain specialist.6
Choosing the right medication
Choice of drug treatment, as well as intensity of treatment (whether one or more drugs are used and drug dosages), will depend on individual factors including how severely RA affects you and any side effects associated with treatment. Your doctor will work closely with you to strike the right balance in suppressing RA-related inflammation (and symptoms), while keeping side effects to a minimum. This is the key challenge of drug treatment in RA. To get the balance right, your doctor may adjust the dose of your RA medication or switch to another that has a different track record for efficacy or side effects.
RA isn’t the same for every person, and not every drug works for everyone. It’s currently impossible to predict which drugs will work best for an individual person, and your doctor may try several medications, one at a time or in combination, before determining what works best for you.
- Kahlenberg JM, Fox DA. Advances in the medical treatment of rheumatoid arthritis. Hand Clin. 2011 Feb;27(1):11-20. doi: 10.1016/j.hcl.2010.09.002.
- Rheumatoid arthritis clinical presentation. Medscape. Available at https://emedicine.medscape.com/article/331715-clinical. Accessed 6/1/18.
- Scott DL. Biologics-based therapy for the treatment of rheumatoid arthritis. Clin Pharmacol Ther 2012;91:30-43.
- Rheumatoid arthritis: how to treat. Cleveland Clinic. Available at https://my.clevelandclinic.org/health/drugs/4750-rheumatoid-arthritis-how-to-treat. Accessed 6/1/18.
- What you should know about biosimilars. Arthritis Foundation. Available at https://www.arthritis.org/living-with-arthritis/treatments/medication/drug-types/biologics/arthritis-biosimilars.php. Accessed 6/1/18.
- Rheumatoid arthritis treatment. Johns Hopkins Medicine. Available at https://www.hopkinsarthritis.org/arthritis-info/rheumatoid-arthritis/ra-treatment/. Accessed 6/1/18.