Because the severity of Rheumatoid Arthritis varies significantly, treatment is tailored to the individual patient. A mild case of RA will be treated very differently to a severe case. Current treatments for Rheumatoid Arthritis focus on relieving pain, reducing inflammation, slowing or stopping joint damage, and improving a person’s day to day functioning and sense of well-being.
It’s often necessary to try several medications or combinations of medications to find the treatments that deliver the best results. Each patient is different, and it can be a long and frustrating journey looking for the ‘magic’ combination that works the best.
There are four main classes of medications for RA:
• Non-steroidal anti-inflammatory drugs (NSAIDS)
• Corticosteroid medications and injections
• Disease modifying Anti-rheumatic drugs (DMARDS)
• Biological DMARDS, such as Tumour Necrosis Factor (TNF) medications
Pain relievers, either over the counter or prescription, may also be prescribed. People with severe Rheumatoid Arthritis often rely on narcotic pain relief, such as morphine or oxycodone.
Non-steroidal anti-inflammatory drugs (NSAIDs)
NSAIDs reduce inflammation, joint swelling and stiffness. They can also relieve pain that is not controlled by analgesics (pain killers) alone. Some NSAIDs are available without a prescription, while others must be prescribed by a doctor.
NSAIDS work by stopping the body producing substances (prostaglandins) that cause inflammation. This reduces the symptoms of rheumatoid arthritis, such as pain and swelling. NSAIDs are not a cure, or even have any long term effect on RA – its merely symptom control.
There are several NSAIDS available, and different drugs work better for different people. Most patients will try a few before they find the most effective medication. The older NSAIDs, such as naproxen and ibuprofen tend to be harder on the stomach. There is a newer group of NSAIDs called COX-2 inhibitors (Celebrex and Mobic) that are slightly less likely to cause stomach problems.
Most people with Rheumatoid Arthritis would take an NSAID daily, in combination with other drugs. They can, however cause side effects and must be taking in close consultation with a doctor. For people with RA these side effects are generally far less than the effects of the disease.
Corticosteroids are have a powerfiul anti-inflammatory effect and can reduce pain and swelling very quickly. However, like NSAIDS, their effect is only symptom control, and they do not do anything to improve the underlying disease.
Corticosteroids can be taken orally as tablets or a liquid. The drug can be also be injected directly into a joint to quickly relieve inflammation at the source.
Rheumatologists will prescribe the lowest possible dose that will control the symptoms, and corticosteroids shouild only be taken short term. Patients often use a steriod ‘taper’ where they start on a higher dose of corticosteriods then gradually taper the dose down to help control a disease ‘flare’.
Taken long term or in high doses, Corticosteroids can have serious side effects. Common side effects include weight gain, thinning of the bones (osteoporosis), high blood pressure and increased susceptibility to infection. Corticosteroids can also affect moods, inducing severe mood swings, and/or depression.
Corticosteroid injections into a joint usually produce fewer side effects than tablets.
DMARDS and Biological DMARDS
DMARDS are slower acting, immune suppressing medications. Most take 3-6 months to have any effect, and it may be even longer before their full effect is felt. Most DMARDS are very powerful medications, that can have dangerous side effects and as such they are only prescribed by a rheumatologist experienced in their use.
Again tho, the risk of not treating Rheumatoid Arthritis is often worse than the risk the medications pose, however this is very individual. Mild cases of Rheumatoid arthritis are treated with milder DMARDS like Plaquenil whereas more severe cases are usually treated with methotrexate, a cytotoxic agent.
DMARDs act on the immune system to cause ‘immunosuppression’. This reduces the activity of the immune system which is attacking and damaging healthy joints.
In Australia the first choices for rheumatoid arthritis treatment are methotrexate, sulfasalazine and leflunomide. They are usually begun as individual drugs or in combination with hydroxychloroquine (plaquenil). Hydroxychloroquine alone is only prescribed for very mild, seronegative disease.
There is also a newer group of DMARDs available, known as ‘biological DMARDs’. These block certain substances in the blood and joints that cause inflammation. This reduces inflammation and halts joint damage. Due to their expense, these biological DMARDs are not readily available in some countries and are very tightly controlled.