Traditional Disease-Modifying Anti-Rheumatic Drugs (DMARDs)

Reviewed by: HU Medical Review Board | Last reviewed: March 2022 | Last updated: April 2022

Traditional disease-modifying anti-rheumatic drugs (DMARDs), also called conventional synthetic DMARDs (csDMARDs), are a treatment option for rheumatoid arthritis (RA). They are used to reduce inflammation and slow or prevent damage to joints.1

There are several types of DMARDs, including traditional, targeted, or biologic. Traditional DMARDs are sometimes also called conventional synthetic DMARDs.1

How do traditional DMARDs work?

RA is an autoimmune condition. This means that the body's immune system cannot tell the difference between healthy cells and invaders like viruses, fungi, or bacteria. Because it cannot tell the difference, the body begins to attack and damage healthy cells.

Traditional DMARDs work by restricting the immune system. This can reduce the inflammation caused by RA.1,2

These drugs are called “disease-modifying” because they interrupt the processes that cause damage in RA. The use of DMARDs for the treatment of RA greatly changed and improved outcomes for people with RA.

DMARDs both reduce symptoms and prevent damage caused by RA. Because of this, it is important to start DMARDs soon after diagnosis to reduce the long-term effects of joint damage.1,2

Because of the way they work, it can take more than a month for people to notice any benefits from DMARDs. It can take up to 12 weeks or more to see the full effect.1,2

Examples of traditional DMARDs

DMARDs used to treat RA include:2,3

MethotrexateMethotrexate is a very common RA treatment. It is given at a low dose and has been shown to be effective in controlling inflammation and related symptoms. Methotrexate has a strong safety record when properly monitored.

SulfasalazineSulfasalazine is made up of 2 components that work together to treat RA.

LeflunomideLeflunomide works by reducing the production of immune system cells. Some research shows it may improve quality of life more than methotrexate.

HydroxychloroquineHydroxychloroquine was first used as a malaria drug. It helps treat RA by regulating the immune system response. Hydroxychloroquine has been shown to reduce RA symptoms, including pain, swelling, and tenderness. It has low side effects but may cause stomach or intestinal problems.

Azathioprine – Azathioprine works by preventing immune cells from growing and promotes cell death. Studies show it may not be as effective as other DMARDs. It may cause stomach or intestinal problems. It is not used as frequently as the other traditional DMARDs and it is no longer mentioned in current guidelines.

Possible side effects

Side effects can vary depending on the specific drug you are taking. Common side effects of traditional DMARDs include:2,3

  • Increased risk of infections
  • Increased risk from receiving live vaccines
  • Headache
  • Nausea

DMARDs work by restricting the immune system. While this helps treat RA, it can increase the risk from other infections. Because of this, it is important to tell your doctor about any signs of infection while on DMARDs. Signs of infection include chills, fever, sore throat, cough, or unusual tiredness.1

These are not all the possible side effects of DMARDs. Talk to your doctor about what to expect when taking DMARDs. You should also call your doctor if you have any changes when taking DMARDs.

Things to know

It may take time for your doctor to determine the right DMARD for your RA. They may even suggest a combination of multiple DMARDs for some people.3

DMARDs are linked to side effects and safety concerns. You will likely have to take certain precautions before and during DMARD treatment. Before starting, your doctor may perform screening tests. This might include a tuberculosis or hepatitis test. You may also have to get vaccinations before starting DMARDs.1,2

During treatment, your doctor may recommend periodic checkups. The goal of these checkups is to check for health concerns and determine if the DMARD is working as it should. The results of these checkups may determine if you should try an alternative DMARD or treatment option.1,2

Before beginning treatment for RA, tell your doctor about all your health conditions and any other drugs, vitamins, or supplements you are taking. This includes over-the-counter drugs.

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