The truth about living with Rheumatoid Arthritis


DMARD choices – Management of Rheumatoid Arthritis

There are many medications prescribed for Rheumatoid Arthritis.  No two cases are exactly the same, and the treatment approach will depend on the severity of symptoms.  Most people will need to try several different medications, or combinations of medications to find a cocktail that works best for them.

The most important class of medications in the treatment of Rheumatoid arthritis are DMARDs (Disease Modifying Anti-Rheumatics) and bDMARDs (Biological Disease Modifying Anti-Rheumatics).  bDMARDs are very expensive medications, and in Australia there is a strict criteria and you will need to try and fail several DMARDs before being allowed to try bDMARDs The chart below is taken from the Australian Prescriber website, and lays out the criteria that your rheumatologist will use to choose the appropriate medication.

Management of Rheumatoid Arthritis – Criteria for selecting a DMARD


Management of Rheumatoid Arthritis


Hydroxychloroquine (Plaquenil) – medications for Rheumatoid Arthritis (RA)

Hydroxychloroquine (Plaquenil) is primarily used in combination with other drugs, including methotrexate and/or sulfasalazine for moderate to severe Rheumatoid Arthritis.  It is only prescribed alone in patients with very mild symptoms, who are RF negative and have non-erosive disease.   It is slow acting, and  usually takes 2-6 months for any benefits to be felt.

How does it work?

From Australian Prescriber – “Hydroxychloroquine interferes with antigen presentation and the activation of the immune response by increasing the pH within macrophage phagolysosomes.”

In plain English, this means the drug interferes with communication of the cells in the immune system, thereby reducing inflammation.

Hydroxychloroquine dose

Patients usually start by taking 400mg daily.  Once a response is achieved, the dose may be lowered to 200mg daily.

Hydroxychloroquine  side effects

Hydroxychloroquine, as one of the milder DMARDs is generally very well tolerated and serious side effects are rare.  The most common side effects are gastric – nausea and diarrhoea.  This usually improves over time, and it should be taken with food to minimise these effects.

Rashes are quite common, and some hair thinning.  Patients may also develop hyper pigmentation when exposed to the sun, and patients should always wear sunscreen. The most serious potential side effect is retinal toxicity with macular damage.  When starting hydroxychloroquinine patients should have an eye exam, and repeat this every two years, of if they notice any visual changes.

For a complete list of side effects, click here.

Monitoring recommended

Patients taking hydroxychloroquine should have a baseline ophthalmologic exam, especially if they have pre-existing eye disease or diabetes, and then every two years. No specific laboratory monitoring is required.


Patients with pre-existing maculopathy should not take hydroxychloroquine.

Advice in pregnancy/breastfeeding

Hydroxychloroquine is not safe to take in pregnancy. Low concentrations are found in breast milk, therefore caution is recommended if the patient is breastfeeding.

Leflunomide (Arava) – Medications for Rheumatoid Arthritis (RA)

Leflunomide (Arava) is the newest of the commonly used DMARDs.  Its effectiveness is similar to Methotrexate and Sulfasalazine, but in practice it is usually used as a second line treatment, if the response to methotrexate hasn’t been good.  It is usually prescribed on its own, but sometimes it is prescribed in conjunction with methotrexate.  This increases the risk of liver damage though, which is the major side effect of concern.

How does Leflunomide work?

From Australian prescriber – “Leflunomide primarily inhibits replication of activated lymphocytes by blocking the de novo synthesis of pyrimidines and hence DNA. It also has a weak anti-inflammatory action.”

What does that mean?  In RA, an increased number of lymphocytes move into the joints and produce substances that cause inflammation and attack the joints, causing pain and swelling.  Leflunomide reduces these lymphocytes, thereby reducing inflammation and damage.

Leflunomide dose

The standard dose is 20 mg/day, however if the patient experiences side effects, it can be started at 10 mg/day.  Sometimes a loading dose is given, 100mg/day for the first three days.  This results in benefits being seen from the drug quicker, but also results in increased side effects, mostly gastrointestinal adverse effects.

Side effects

The most common side effects are nausea and diarrhoea, but this often settles over time.  A very itchy skin rash is less common, as is hair loss.  The most serious side effect is liver toxicity, and therefore alcohol should be avoided while taking leflunomide.  Rarer side effects include bone marrow suppression and infections.

For a complete list of side effects, click here.

Monitoring recommended

Patients need to have their liver function monitored while on leflunomide, usually tested monthly for the first six months.  After that liver function is sometimes checked 2 monthly, but some rheumatologists prefer monthly blood tests.  Blood tests are essential to detect any damage before it is irreversible.


As with methotrexate, leflunomide should not be given to patients with severe immunodeficiency, impaired bone marrow function, or severe uncontrolled infections. As mentioned,  excessive alcohol consumption should be avoided.

Advice in pregnancy/breastfeeding

Leflunomide is not safe in pregnancy or breastfeeding.  Because leflunomide stays in the body for several months, women should not fall pregnant for at least a year after stopping leflunomide.  Men wishing to father a child should discontinue leflunomide and have the drug ‘washed out’ of their system.

Sulfasalazine – Medications for Rheumatoid Arthritis (RA)

Sulfasalazine (azulfidine, salazopyrin) belongs to a class of drugs called sulfa drugs.  It’s a combination of salicilate (the main ingredient in aspirin)  and a sulfa antibiotic.  Sulfasalazine works by slowing the radiographic progression (damage to the joints) of rheumatoid arthritis, and reducing pain and swelling.  It is one of the first line treatments for moderate to severe rheumatoid arthritis, along with methotrexate and leuflunomide (arava).

Its efficacy is similar to that of methotrexate, but the choice of sulfasalazine may be made if the patient is a heavy drinker, or may become pregnant.

It is sometimes prescribed by itself or maybe prescribed in combination with hydroxychloroquine (Plaquenil) or with methotrexate, it usually takes 6-12 weeks to start to feel the benefits.

How does Sulfasalazine work?

From ‘Australian Prescriber’ – the method of action is unclear but may involve the transcription factors which are increases in inflammation’.  Confidence inspiring, no?

So no one is quite sure how it works.  Just that, for a lot of people, it does work.  It reduces inflammation and inhibits joint damage.  Which is the aim!

Sulfasalazine dose

Patients usually take 1 – 1.5 grams per day.  Because Sulfasalazine can cause unpleasant gastric side effects, it is usually tapered up slowly, starting with 500 mg in the mornings for a week.  Then 500 mg in the morning and night for a week.  Gradually adding 500mg per week until the optimum dosage is reached.  If side effects are severe, it can be tapered more slowly.

Side effects

The most common side effect is stomach upset – nausea, vomiting, loss of appetite,  and diarrhoea.  Headache and dizziness are also common, as is depression.

Sulfasalazine can also cause liver problems, and a reduced white cell count. This leads to a higher chance of infections, and must be monitored closely with regular blood tests.  Full blood count and liver function are tested month for the first for three months, then three monthly thereafter.

Sulfasalazine can also turn your tears or your urine orange.  Even your skin!  This is usually harmless and goes away once the medication is stopped.

For a complete list sulfasalazine side effects click here


Sulfasalazine should not be prescribed for patients who are hypersensitive to salicylates or sulfa drugs. It is also should be monitored carefully in patients with decreased kidney function, or decreased liver function.

Advice in pregnancy/breastfeeding

Sulfasalazine can be used in pregnancy. Very small amounts are found in breast milk, so it can be used cautiously by breastfeeding mothers.


Methotrexate – Medications for Rheumatoid Arthritis (RA)

Methotrexate (mtx) is the current ‘gold standard’ of Rheumatoid Arthritis treatment.   While it comes with a whole host of unpleasant side effects, it has the highest rate of continued long-term treatment.  In short, the side effects are worth it to most people, because it reduces their joint pain and inflammation effectively.

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