Disease Modifying Anti-Rheumatic Drugs

NSARs have quite rightly for a long time been the main stronghold for curing rheumatoid arthritis: they are very efficient at suppressing inflammation, and the destructive force which can cause strong pains and damage to the joints. However, in the last few years, the choice of treating rheumatoid arthritis has spread to new types of drugs known as disease-modifying anti-rheumatic drugs.

The NSAR drugs remain important at treating RA, but rheumatologists do not rely on them as much anymore, for several reasons:

  • High doses of NSAR needed to remedy the inflammation may sometimes lead to severe complications
  • Experts have concluded that people often experience worse damage to the joints, despite taking NSAR which relieve pain
  • DMARD also offer some advantages over NSARs. DMARD not only relieve the inflammation, but also slow down the degradation of the joints, which can with NSAR continue on, even if the inflammation has been appeased.

DMARD, which were once used only if other methods of treatment had not been successful or when the joint damage was obvious, are strong medicaments which can cause severe side effects. However, a major turnaround in the methods of treating rheumatoid arthritis has occurred, so nowadays many doctors prescribe DMARD as soon as the condition has been diagnosed, as an aggressive method of trying to stop the condition from progressing, and preventing the damage which it could cause to the joints and internal organs.

Older types of DMARD - are they still as efficient?

Methotrexate

Even though used for centuries in treating cancer and severe psoriasis, methotrexate has not until 2002 been approved to be used in treating rheumatoid arthritis.

Its potential was discovered when dermatologists were prescribing it to patients suffering from psoriasis, but who were also suffering from rheumatoid arthritis - they noticed that their condition concerning arthritis had greatly improved. Using methotrexate to treat rheumatoid arthritis is on the rise, so in the UK and the USA it takes up first place among the most commonly prescribed DMARD.

How it works

Rheumatoid arthritis appears when the immune system starts attacking the joints of its own body, causing a chronic inflammation which can ultimately destroy the cartilage and the bone. Like many DMARD, methotrexate is an immunosuppresant, which means that it reduces the immune system's reaction to the joints; by doing that, the painful destructive inflammation connected to the condition is alleviated. Methotrexate is not only extremely efficient for many patients suffering from rheumatoid arthritis, but it also works much faster than other DMARD, showing results sometimes already in 2 weeks. It is also good concerning the safety of using it; less than 5 percent of patients were forced to stop using it due to side effects. Methotrexate is usually taken orally, once a week.

Side effects

Due to the fact that methotrexate can cause liver damage, patients must take regular liver function tests, to check for the possibility of damage, and should not drink much alcohol while taking the drug. Pregnant women should never take methotrexate, because it can cause severe damage to the fetus, in some cases even its death. Methotexate may also decrease the sperm count in men.

Methotrexate can affect folic acid and in that way cause a deficiency of that important vitamin. That is why some doctors recommend that their patients take a small amount of folic acid every day as an addition to their diet, as to prevent the possibility of its deficiency.

Gold

Ever since the twenties, treatments using gold have been an important method of treating rheumatoid arthritis, and it had remained a common choice all until methotrexate appeared in the USA in the 80s. It can be applied orally (by daily ingestion during an indefinite time period), or by injections. The ordinary method is injecting it into the muscle once a week during four or five months. After that, injections to maintain its level are given for an indefinite amount of time, every two to four weeks.
Gold for oral intake (Ridaura) is easier to take and causes less side effects; however, gold in injections is usually more efficient. Some doctors start the treatment by prescribing the method of oral intake, and in case no improvement occurs, they switch to gold in injections which they apply for the next six months.

How it works

Gold operates slow, but it helps at preventing joint inflammation, even though experts are not sure how that occurs. Gold must be applied for several months for improvement to happen. After taking gold for two or three months, the patients may notice the morning stiffness being milder, and the joint inflammation, together with the pain and sensitivity, may start improving after four to six months.

Side effects

On average 10 percent of children and adults being treated with gold develop anemia, their white cell blood count lowers, or their liver function test shows deviations from the normal results. Gold may damage the kidneys and cause skin rash which disappears upon lowering the dose.

Sulfasalazine

Developed in the thirties, this drug has not been widely used, but impressive results from new research have awakened new interest in it. The drug has a good effect on many patients suffering from rheumatoid arthritis, and with it also rarely causes severe side effects. It seems to be very efficient when used together with methotrexate.


How it works

Experts still do not know exactly the way in which sulfasalazine functions. It seems to suppress the inflammatory effect of rheumatoid arthritis. It has been approved in the UK and there it is widely used for RA, and in Europe also to alleviate arthritic pain. Even though still not approved in the US, many rheumatologists there prescribe it when other medication fail to succeed.

Side effects

The most common are nausea, headaches, vertigo, allergic reactions such as rashes, and stomach-bowel problems. In rare cases the drug may cause toxic damage to the blood and liver. People allergic to sulfa drugs should avoid sulfasalazine, which can cause severe harmful reactions.

Hydroxychloroquine

Hydroxychloroquine, for a long time used to treat malaria (it is present on the market under the name of Plaquenil), became a drug for rheumatoid arthritis when patients suffering from malaria noticed that it had also helped them with arthritis. Hydroxychloroquine helps in relieving pain for people suffering from rheumatoid arthritis; however, arthritis experts have a divided opinion on it: some recommend its use only in the case other drugs have proved inefficient, and other consider it an effective drug which rarely causes side effects. To achieve improvement, many months of treatment are needed.

How it works

The drug is taken orally and almost always in a combination with other drugs. Even though experts are not entirely sure how it works, it can significantly help some patients. Taking hydroxychloroquine can also lead to reducing the amount of corticosteroids needed to help alleviate the pain and inflammation.

Side effects

Include nausea, skin rash, the appearance of blood or protein in the urine, liver functions deviating from normal and damage to the fundus of the eye. Patients should have their eyes examined every three to six months.

Penicillamine

Penicillamine, a synthetic metabolite of penicillin, is most efficient among two groups of patients suffering from arthritis - those with the gene marker HLA-DR2 and those not reacting to treatment using other DMARD. Penicillamine, always taken combined with an NSAR or sometimes with a steroid, is given as a last option of treatment, because some people suffering from arthritis react only to penicillamine.

How it works

Its use as a drug for arthritis was discovered accidentally. Penicillamine ties itself onto heavy metals such as gold and removes them from the patient's body. When used to treat a gold overdose in patients suffering from RA, it also helped them with the arthritis. It would seem that penicillamine has some unknown effect on the immune system and suppresses the mentioned condition.

Side effects

Mild side effects include loss in the sense of taste, the appearance of blood in the urine, and liver functions deviating from normal. In rare cases there is a possibility of developing a muscular condition called miastenia gravis, which causes muscles to weaken. Patients should in the course of the treatment have regular blood and urine tests conducted.

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