Rheumatoid Arthritis (cont.)
"Second-line" or "slow-acting" drugs
(Disease-modifying anti-rheumatic drugs or DMARDs)
While "first-line" medications (NSAIDs and corticosteroids) can relieve joint inflammation and
pain, they do not necessarily prevent joint destruction or deformity. Rheumatoid arthritis requires
medications other than NSAIDs and corticosteroids to stop progressive damage to cartilage, bone, and adjacent soft tissues. The medications needed for ideal management of the disease are also referred to as
disease-modifying antirheumatic drugs or DMARDs. They come in a variety of forms and are listed below. These
"second-line" or "slow-acting" medicines may take weeks to months
to become effective. They are used for long periods of time, even years, at
varying doses. If maximally effective, DMARDs can promote remission, thereby retarding the
progression of joint destruction and deformity. Sometimes a number of
DMARD second-line medications are used together as combination therapy. As with the first-line medications, the doctor may need to
try different second-line medications before treatment is optimal.
Recent research suggests that patients who respond to a DMARD with control of the rheumatoid disease may actually decrease the known risk (small but real) of
lymphoma that exists from simply having rheumatoid arthritis. The
various available DMARDs are reviewed next.
Hydroxychloroquine (Plaquenil) is related to quinine and is also used in the
treatment of malaria. It is used over long periods
for the treatment of rheumatoid arthritis. Possible side effects include upset
stomach, skin rashes, muscle weakness, and vision changes. Even though vision
changes are rare, patients taking Plaquenil should be monitored by an eye doctor
(ophthalmologist).
Sulfasalazine (Azulfidine) is an oral medication traditionally used in
the treatment of mild to moderately severe inflammatory bowel diseases,
such as ulcerative colitis and Crohn's colitis.
Azulfidine is used to treat rheumatoid
arthritis in combination with antiinflammatory medications. Azulfidine is
generally well tolerated. Common side effects include rash and upset stomach. Because
Azulfidine is made up of sulfa and
salicylate compounds, it should be avoided by patients with known sulfa allergies.
Methotrexate has gained popularity among doctors as an
initial second-line drug because of both its effectiveness and relatively
infrequent side effects. It also has an advantage in dose flexibility (dosages can be adjusted according to needs). Methotrexate is an immune-suppression drug. It can
affect the bone marrow and the liver, even rarely causing cirrhosis. All patients taking methotrexate require regular blood tests
to monitor blood counts and liver function blood tests.
Gold salts have been used to treat rheumatoid arthritis throughout most
of the past century. Gold thioglucose (Solganal) and gold thiomalate
(Myochrysine) are given by injection, initially on a weekly basis, for
months to years. Oral gold, auranofin (Ridaura), was introduced in the 1980s. Side effects of gold (oral and injectable) include skin rash, mouth
sores, kidney damage with leakage of protein in the urine, and bone
marrow damage with anemia and low white cell count. Patients receiving
gold treatment are regularly monitored with blood and urine tests. Oral
gold can cause diarrhea. These gold drugs have lost favor because of the availability of more effective treatments, and many companies no longer manufacture them.
D-penicillamine (Depen, Cuprimine) can be helpful in
selected patients with progressive forms of rheumatoid arthritis. Side effects
are similar to those of gold. They include fever, chills, mouth sores, a
metallic taste in the mouth, skin rash, kidney and bone marrow damage,
stomach upset, and easy bruising. Patients on this medication require routine
blood and urine tests. D-penicillamine can rarely cause symptoms of other
autoimmune diseases and is no longer commonly used for the treatment of rheumatoid arthritis.
Immunosuppressive medicines are powerful medications that suppress the
body's immune system. A number of immunosuppressive drugs are used to treat rheumatoid arthritis. They include methotrexate (Rheumatrex, Trexall) as described above, azathioprine (Imuran), cyclophosphamide (Cytoxan), chlorambucil (Leukeran), and
cyclosporine (Sandimmune). Because of potentially serious side effects,
immunosuppressive medicines (other than methotrexate) are generally reserved for patients with very
aggressive disease or those with serious complications of rheumatoid
inflammation, such as blood vessel inflammation (vasculitis). The exception is methotrexate, which is not frequently associated with serious side effects and can be carefully monitored with blood testing. Methotrexate has become a preferred second-line medication as a result.
Immunosuppressive medications can depress bone-marrow
function and cause anemia, a low white cell count, and low platelet counts. A
low white count can increase the risk of infections, while a low platelet count
can increase the risk of bleeding. Methotrexate rarely can
lead to liver cirrhosis and allergic reactions in the lung.
Cyclosporine
can cause kidney damage and high blood pressure. Because of potentially
serious side effects, immunosuppressive medications are used in low doses,
usually in combination with antiinflammatory agents.
Next: Newer treatments »
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