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Rheumatoid Arthritis Drugs

Rheumatoid Arthritis Drugs - Disease modifying anti-rheumatic drugs (DMARDs)


The term Disease Modifying Anti-Rheumatic Agent was originally introduced to indicate a drug that reduced evidence of processes thought to underly the disease, such as a raised erythrocyte sedimentation rate, reduced haemoglobin evel, raised rheumatoid factor level and more recently, raised C-reactive protein level. More recently, the term has been used to indicate a drug that reduces the rate of damage to bone and cartilage. DMARDs can be further subdivided into traditional small molecular mass drugs synthesised chemically and newer 'biological' agents produced through genetic engineering.

Traditional small molecular mass drugs:

azathioprine
ciclosporin (cyclosporine A)
D-penicillamine
gold salts
hydroxychloroquine
leflunomide
methotrexate (MTX)
minocycline
sulfasalazine (SSZ)


The most important and most common adverse events relate to liver and bone marrow toxicity (MTX, SSZ, leflunomide, azathioprine, gold compounds, D-penicillamine), renal toxicity (cyclosporine A, parenteral gold salts, D-penicillamine), pneumonitis (MTX), allergic skin reactions (gold compounds, SSZ), autoimmunity (D-penicillamine, SSZ, minocycline) and infections (azathioprine, cyclosporine A). Hydroxychloroquine may cause ocular toxicity, although this is rare, and because hydroxychloroquine does not affect the bone marrow or liver it is often considered to be the DMARD with the least toxicity. Unfortunately hydroxychloroquine is not very potent, and for most patients hydroxychloroquine alone is insufficient to control symptoms.

Many rheumatologists consider methotrexate to be the most important and useful DMARD, largely because of lower rates of stopping the drug through toxicity. Nevertheless, methotrexate is often considered by patients and even other doctors as a very "toxic" drug. This reputation is not entirely justified, and at times can result in patients being denied the most effective treatment for their arthritis. Although methotrexate does indeed have the potential to suppress the bone marrow or cause hepatitis, these effects can be monitored using regular blood tests, and the drug withdrawn at an early stage if the tests are abnormal, before any serious harm is done (typically the blood tests return to normal after stopping the drug). In clinical trials in which patients with RA were treated with one of a range of different DMARDs, patients who were prescribed methotrexate were those who stayed on their medication the longest (the others stopped theirs because of either side-effects or failure of the drug to control the arthritis). Lastly, methotrexate is often preferred by rheumatologists because if it does not control arthritis on its own then it works well in combination with many other drugs, especially the biological agents. Other DMARDs may not be as effective or safe in combination with biological agents.

Biological agents
Biological agents include:

tumor necrosis factor alpha (TNFα) blockers - etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira)
interleukin-1 blockers - anakinra
anti-B cell (CD20) antibody - rituximab (Rituxan)[16]
blockers of T cell activation - abatacept (Orencia)

Anti-inflammatory agents and analgesics
Anti-inflammatory agents include:

glucocorticoids
Non-steroidal anti-inflammatory drug (NSAIDs, most also act as analgesics)
Analgesics include:

acetaminophen (Paracetamol outside US)
opiates
diproqualone
lidocaine topical

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