Disease modifying agents (DMARD) are the most usual treatment for Rheumatoid Arthritis. They are a group of drugs that have been shown to decrease the amount of bone and cartilage damage and improve symptoms. If started in the earliest stages of the disease they can result in disease remission in approximately fifty per cent of cases. These drugs must be used for three months before their effectiveness can be properly evaluated. Most of these drugs are not without some side effects and long term use often requires patients to take certain precautions to protect the liver, gastro-intestinal tract and other organs. As with most drugs they cannot be used in patients who suffer from cetainoher conditions. The most common DMARDs are:
- Methotrexate: this reduces the activity of the immune system and is usually administered as a weekly tablet, although it can also be given as a subcutaneous injection. The most common side effects are abdominal pain, which can be reduced by taking folic acid, but it can also have effects on lungs and liver, where it increases liver enzymes in roughly 15 per cent of people. If you have not had chickenpox and come into contact with someone who has chickenpox or shingles you should inform your doctor immediately.
- Sulfasalazine: dampens down the disease progression. It takes at least six weeks of use to be able to ascertain its anti-inflammatory effects.
- Leflunomide: works in a similar way to the other DMARDs but should not be taken by patients who are pregnant, have ever had tuberculosis, liver disease or a bone marrow disorder. Alcohol should not be drunk while taking this drug due to the increased risk of liver damage.
- Sodium aurothiomalate also known as Myocrisin: this drug is usually given as a weekly injection into muscle, it is important to keep the doses regular and not miss injection appointments. It is especially important to be careful of sun exposure as skin sensitivity is increased with usage. This drug should not be prescribed to patients who are pregnant; have ever suffered from eczema or similar skin conditions; have breathing problems; those with liver or kidney disease; have colitis; have Porphyria; have other autoimmune diseases; have bone marrow disorders.
- Cyclosporin: usually used in conjunction with Methotrexate if it has not been found to be effective on its own. Cyclosporin is used less frequently than other drugs because of the possibility of serious side effects.
Biological agents can be used if DMARDs are not found to be sufficiently effective after three months. They include infliximab, anakinra, abatacept and rituximab. TNF blockers can be used with Methotrexate to achieve better results than when used alone. Problems with these drugs include their association with lung infections and high costs.
Glucocorticoids: are a class of steroid hormones that can help during the short term with flare ups if patients are waiting for slower working drugs to take effect. They can be injected into joints, but this is not recommended long term due to increased incidents of osteoporosis and infections.
NSAIDs: reduce pain and stiffness but do not have long term benefits on the course of RA. They also have undesirable abdominal, cardiovascular and kidney side effects.
COX-2 inhibitors: these have similar usage to NSAIDs but produce fewer gastrointestinal problems in elderly patients, however there is an increased risk of heart attack.
A synovectomy, which removes inflamed tissue from around joints and bones that have not yet been damaged, can give temporary pain relief in patients where conventional drug treatments have not worked. More severely affected joints may need full replacement surgery. In either case, physiotherapy is always a post-operative requirement. Surgery is not a cure for RA but can help reduce pain in some patients.