Ultimate Guide: Rheumatoid Arthritis Treatments

Rheumatoid Arthritis Medications

What rheumatoid arthritis medications are available and how do I know which one is right for me?

Most people who have rheumatoid arthritis take medications. Some rheumatoid arthritis drugs are used only for pain relief; others are used to reduce inflammation. Still another rheumatoid arthritis medication is often called disease-modifying antirheumatic drugs (DMARDs), which are used to try to slow the course of the disease. The person’s general condition, the current and predicted severity of the illness, the length of time he or she will take the drug, and the drug’s effectiveness and potential side effects are important considerations in prescribing drugs for rheumatoid arthritis. The Table in this article shows currently used rheumatoid arthritis medications, along with their uses and effects, side effects, and monitoring requirements.

Biologic response modifiers are new drugs used for the treatment of rheumatoid arthritis. They can help reduce inflammation and structural damage to the joints by blocking the action of cytokines, proteins of the body’s immune system that trigger inflammation during normal immune responses. Three of these drugs, etanercept (Enbrel*), infliximab (Remicade), and adalimumab (Humira), reduce inflammation by blocking the reaction of TNF-α molecules. Another drug, called anakinra (Kineret), works by blocking a protein called interleukin 1 (IL-1) that is seen in excess in patients with rheumatoid arthritis.

For many years, doctors initially prescribed aspirin or other pain-relieving drugs for rheumatoid arthritis, as well as rest and physical therapy. They usually prescribed more powerful drugs later only if the disease worsened.

Today, however, many doctors have changed their approach, especially for patients with severe, rapidly progressing rheumatoid arthritis. Studies show that early treatment with more powerful drugs, and the use of drug combinations instead of one medication alone, may be more effective in reducing or preventing joint damage. Once the disease improves or is in remission, the doctor may gradually reduce the dosage or prescribe a milder medication.

Medications	Uses & Effects	Side Effects	Monitoring
Analgesics and Nonsteroidal Anti-inflammatory Drugs (NSAIDs)	Analgesics relieve pain; NSAIDs are a large class of medications useful against pain and inflammation. A number of NSAIDs are available over the counter. More than a dozen others-including a subclass called COX-2 inhibitors-are available only with a prescription.	NSAIDs can cause stomach irritation or, less often, can affect kidney function. The longer a person uses NSAIDs, the more likely he or she is to have side effects, ranging from mild to serious. Many other drugs cannot be taken when a patient is being treated with NSAIDs because they alter the way the body uses or eliminates these other drugs. NSAIDs sometimes are associated with serious gastrointestinal problems, including ulcers, bleeding, and perforation of the stomach or intestine. People over age 65 and those with any history of ulcers or gastrointestinal bleeding should use NSAIDs with caution.	Check with your health care provider or pharmacist before you take NSAIDs. Before taking traditional NSAIDs, let your provider know if you drink alcohol or use blood thinners or if you have any of the following: sensitivity or allergy to aspirin or similar drugs, kidney or liver disease, heart disease, high blood pressure, asthma, or peptic ulcers.
Acetaminophen	Nonprescription medications used to relieve pain. Examples are aspirin-free Anacin*, Excedrin caplets, Panadol, Tylenol, and Tylenol Arthritis.	Usually no side effects when taken as directed.	Not to be taken with alcohol or with other products containing acetaminophen. Not to be used for more than 10 days unless directed by a physician.
Aspirin Buffered Plain	Aspirin is used to reduce pain, swelling, and inflammation, allowing patients to move more easily and carry out normal activities. It is generally part of early and ongoing therapy.	Upset stomach; tendency to bruise easily; ulcers, pain, or discomfort; diarrhea; headache; heartburn or indigestion; nausea or vomiting.	Doctor monitoring is needed.
* NOTE: Brand names included in this RA Medication Guide are provided as examples only. If a particular brand name is not mentioned, this does not mean or imply that the product is unsatisfactory.
Traditional NSAIDs Ibuprofen Ketoprofen Naproxen	NSAIDs help relieve pain within hours of admin-istration in dosages available over-the-counter (available for all three medications). They relieve pain and inflammation in dosages available in prescription form (ibu-profen and ketoprofen). It may take several days to reduce inflammation.	For all traditional NSAIDs: Abdominal or stomach cramps, pain, or discomfort; diarrhea; dizziness; drowsiness or light-headedness; headache; heartburn or indigestion; peptic ulcers; nausea or vomiting; possible kidney and liver damage (rare).	For all traditional NSAIDs: Before taking these drugs, let your doctor know if you drink alcohol or use blood thinners or if you have or have had any of the following: sensitivity or allergy to aspirin or similar drugs, kidney or liver disease, heart disease, high blood pressure, asthma, or peptic ulcers.
Corticosteroids	These are steroids given by mouth or injection. They are used to relieve inflammation and reduce swelling, redness, itching, and allergic reactions.	Increased appetite, indigestion, nervousness, or restlessness.	For all corticosteroids, let your doctor know if you have one of the following: fungal infection, history of tuberculosis, underactive thyroid, herpes simplex of the eye, high blood pressure, osteoporosis, or stomach ulcer.
Methyl-prednisolone Prednisone	These steroids are available in pill form or as an injection into a joint. Improvements are seen in several hours up to 24 hours after administration. There is potential for serious side effects, especially at high doses. They are used for severe flares and when the disease does not respond to NSAIDs and DMARDs.	Osteoporosis, mood changes, fragile skin, easy bruising, fluid retention, weight gain, muscle weakness, onset or worsening of diabetes, cataracts, increased risk of infection, hyper-tension (high blood pressure).	Doctor monitoring for continued effectiveness of medication and for side effects is needed.
Disease-modifying antirheumatic drugs (DMARDs)	These are common arthritis medications. They relieve painful, swollen joints and slow joint damage, and several DMARDs may be used over the disease course. They take a few weeks or months to have an effect, and may produce significant improvements for many patients. Exactly how they work is still unknown.	Side effects vary with each medicine. DMARDs may increase risk of infection, hair loss, and kidney or liver damage.	Doctor monitoring allows the risk of toxicities to be weighed against the potential benefits of individual medications.
Azathioprine	This drug was first used in higher doses in cancer chemotherapy and organ transplantation. It is used in patients who have not responded to other drugs, and in combination therapy.	Cough or hoarseness, fever or chills, loss of appetite, lower back or side pain, nausea or vomiting, painful or difficult urination, unusual tiredness or weakness.	Before taking this drug, tell your doctor if you use allopurinol or have kidney or liver disease. This drug can reduce your ability to fight infection, so call your doctor immediately if you develop chills, fever, or a cough. Regular blood and liver function tests are needed.
Cyclosporine	This medication was first used in organ transplantation to prevent rejection. It is used in patients who have not responded to other drugs.	Bleeding, tender, or enlarged gums; high blood pressure; increase in hair growth; kidney problems; trembling and shaking of hands.	Before taking this drug, tell your doctor if you have one of the following: sensitivity to castor oil (if receiving the drug by injection), liver or kidney disease, active infection, or high blood pressure. Using this drug may make you more susceptible to infection and certain cancers. Do not take live vaccines while on this drug.
Hydroxy-chloroquine	It may take several months to notice the benefits of this drug, which include reducing the signs and symptoms of rheumatoid arthritis.	Diarrhea, eye problems (rare), headache, loss of appetite, nausea or vomiting, stomach cramps or pain.	Doctor monitoring is important, particularly if you have an allergy to any antimalarial drug or a retinal abnormality.
Gold sodium thiomalate	This was one of the first DMARDs used to treat rheumatoid arthritis.	Redness or soreness of tongue; swelling or bleeding gums; skin rash or itching; ulcers or sores on lips, mouth, or throat; irritation on tongue. Joint pain may occur for one or two days after injection.	Before taking this drug, tell your doctor if you have any of the following: lupus, skin rash, kidney disease, or colitis. Periodic urine and blood tests are needed to check for side effects.
Leflunomide	This drug reduces signs and symptoms and slows structural damage to joints caused by arthritis.	Bloody or cloudy urine; congestion in chest; cough; diarrhea; difficult, burning, or painful urination or breathing; fever; hair loss; headache; heartburn; loss of appetite; nausea and/or vomiting; skin rash; stomach pain; sneezing; and sore throat.	Before taking this medication, let your doctor know if you have one of the following: active infection, liver disease, known immune deficiency, renal insufficiency, or underlying malignancy. You will need regular blood tests, including liver function tests. Leflunomide must not be taken during pregnancy because it may cause birth defects in humans.
Methotrexate	This drug can be taken by mouth or by injection and results in rapid improvement (it usually takes 3-6 weeks to begin working). It appears to be very effective, especially in combination with infliximab or etanercept. In general, it produces more favorable long-term responses compared with other DMARDs such as sulfasalazine, gold sodium thiomalate, and hydroxychloroquine.	Abdominal discomfort, chest pain, chills, nausea, mouth sores, painful urination, sore throat, unusual tiredness or weakness.	Doctor monitoring is important, particularly if you have an abnormal blood count, liver or lung disease, alcoholism, immune-system deficiency, or active infection. Methotrexate must not be taken during pregnancy because it may cause birth defects in humans.
Sulfasalazine	This drug works to reduce the signs and symptoms of rheumatoid arthritis by suppressing the immune system.	Abdominal pain, aching joints, diarrhea, headache, sensitivity to sunlight, loss of appetite, nausea or vomiting, skin rash.	Doctor monitoring is important, particularly if you are allergic to sulfa drugs or aspirin, or if you have a kidney, liver, or blood disease.
Biologic Response Modifiers	These drugs selectively block parts of the immune system called cytokines. Cytokines play a role in inflammation. Long-term efficacy and safety are uncertain.	Increased risk of infection, especially tuberculosis. Increased risk of pneumonia, and listeriosis (a foodborne illness caused by the bacterium Listeria monocytogenes).	It is important to avoid eating undercooked foods (including unpasteurized cheeses, cold cuts, and hot dogs) because undercooked food can cause listeriosis for patients taking biologic response modifiers.
Tumor Necrosis Factor Inhibitors Etanercept Infliximab Adalimumab	These medications are highly effective for treating patients with an inadequate response to DMARDs. They may be prescribed in combination with some DMARDs, particularly methotrexate. Etanercept requires subcutaneous (beneath the skin) injections two times per week. Infliximab is taken intravenously (IV) during a 2-hour procedure. It is administered with methotrexate. Adalimumab requires injections every 2 weeks. Long-term efficacy and safety are uncertain.	Etanercept: Pain or burning in throat; redness, itching, pain, and/or swelling at injection site; runny or stuffy nose. Infliximab: Abdominal pain, cough, dizziness, fainting, headache, muscle pain, runny nose, shortness of breath, sore throat, vomiting, wheezing. Adalimumab: Redness, rash, swelling, itching, bruising, sinus infection, headache, nausea.	Long-term efficacy and safety are uncertain. Doctor monitoring is important, particularly if you have an active infection, exposure to tuberculosis, or a central nervous system disorder. Evaluation for tuberculosis is necessary before treatment begins.
Interleukin1 Inhibitor Anakinra	This medication requires daily injections. Long-term efficacy and safety are uncertain.	Redness, swelling, bruising, or pain at the site of injection; head-ache; upset stomach; diarrhea; runny nose; and stomach pain.	Doctor monitoring is required.