Rheumatoid Arthritis (cont.)
Newer treatments
Newer "second-line" drugs
for the treatment of rheumatoid arthritis include leflunomide (Arava) and the "biologic" medications etanercept (Enbrel), infliximab (Remicade), anakinra (Kineret), adalimumab (Humira), rituximab (Rituxan), and abatacept (Orencia).
Leflunomide (Arava) is available to relieve the symptoms
and halt the progression of the disease. It seems to work by blocking the action
of an important enzyme that has a role in immune activation. Arava can cause
liver disease, diarrhea, hair loss, and/or rash in some patients. It should not
be taken just before or during pregnancy because of
possible birth defects and is generally avoided in women who might become pregnant.
Newer medications that represent a novel approach to the treatment of rheumatoid arthritis are products of modern biotechnology. These are referred to as the biologic medications or biological response modifiers. In comparison with traditional DMARDs, the biologic medications have a much more rapid onset of action and can have powerful effects on stopping progressive joint damage. In general, their methods of action are also more directed, defined, and targeted.
Etanercept, infliximab, and adalimumab are biologic medications that intercept a messenger protein in the joints (tumor necrosis factor or TNF) that promotes inflammation of the joints in rheumatoid arthritis. These TNF-blockers intercept TNF before it can act on its natural receptor to "switch on" inflammation. This effectively blocks the TNF inflammation messenger from recruiting the cells of inflammation. Symptoms can be significantly, and often rapidly, improved in patients using these drugs. Etanercept must be injected subcutaneously once or twice a week. Infliximab is given by infusion directly into a vein (intravenously). Adalimumab is injected subcutaneously either every other week or weekly. Each of these medications is being evaluated by doctors in practice to determine what role they may have in treating patients in various stages of rheumatoid arthritis. Research has shown that biological response modifiers also prevent the progressive joint destruction of rheumatoid arthritis. They are currently recommended for use after other second-line medications have not been effective. The biological response modifiers (TNF-inhibitors) are expensive treatments. They are also frequently used in combination with methotrexate and other DMARDs. Furthermore, it should be noted that the TNF-blocking biologics all are more effective when combined with methotrexate.
Anakinra is another biologic treatment that is used to treat moderate to severe rheumatoid arthritis. Anakinra works by binding to a cell messenger protein (IL-1, a proinflammation cytokine). Anakinra is injected under the skin daily. Anakinra can be used alone or with other DMARDs. The response rate of anakinra does not seem to be as high as with other biologic medications.
Rituxan is an antibody that was first used to treat lymphoma, a cancer of the lymph nodes. Rituxan can be effective in treating autoimmune diseases like rheumatoid arthritis because it depletes B-cells, which are important cells of inflammation and in producing abnormal antibodies that are common in these conditions. Rituxan is now available to treat moderate to severely active rheumatoid arthritis in patients who have failed
treatment with the TNF-blocking biologics. Preliminary studies have shown that Rituxan was also found to be beneficial in treating severe rheumatoid arthritis complicated by blood vessel inflammation (vasculitis) and cryoglobulinemia.
Orencia is a recently developed biologic medication that blocks T-cell activation. Orencia is now available to treat adult patients who have failed
treatment with a traditional DMARD or TNF-blocking biologic medication.
While biologic medications are often combined with traditional DMARDs in the treatment of rheumatoid arthritis, they are generally not used with other biologic medications because of
the unacceptable risk for serious infections.
The Prosorba
column therapy involves pumping blood drawn from a vein in the arm into an
apheresis machine, or cell separator. This machine separates the liquid part of
the blood (the plasma) from the blood
cells. The Prosorba column is a plastic cylinder about the size of a
coffee mug that contains a sand-like substance coated with a special
material called Protein A. Protein A is unique in that it binds
unwanted antibodies from the blood that promote the arthritis. The
Prosorba column works to counter the effect of these harmful
antibodies. The Prosorba column is indicated to reduce the signs and
symptoms of moderate to severe rheumatoid arthritis in adult patients
with long-standing disease who have failed or are intolerant to
disease-modifying antirheumatic drugs (DMARDs). The exact role of
this treatment is being evaluated by doctors, and it is not commonly used currently.
Next: Other treatments »
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