Most people who have rheumatoid arthritis take some type of medication. Medications for RA typically fall into five categories: Non-steroidal anti-inflammatory drugs (NSAIDs); steroids; disease-modifying anti-rheumatic drugs (DMARDS); biologics; and janus kinase (JAK) inhibitors.
When prescribing a medication, a physician will take into account the patient’s age, disease activity, and other medical conditions, but each patient is unique. Figuring out which medication or combination of medications work best for an individual can be challenging and often requires a process of trial and error.
Most people with RA are advised to take a non-steroidal anti-inflammatory drug to decrease pain and inflammation. NSAIDs are sold over-the-counter, under such names as Advil and Aleve, as well as by prescription, under names such as Mobic and Celebrex.
2. Steroids (Corticosteroids)
Fast-acting steroids, such as prednisone, are particularly useful during initial treatment, before other RA medications have had a chance to take effect (often 12 weeks or more).
One advantage of steroids is that they can be injected into joints. Injected steroids can provide targeted pain relief to one or two painful joints with limited side effects.
Experts recommend taking the lowest possible dose of steroids and advise against relying on them longer than necessary. Steroids’ effectiveness often diminishes over time—meaning the longer a person takes a steroid, the less likely it is to relieve symptoms. In addition, people who take steroids continuously for several months or years can experience side effects such as weight gain, increases in blood pressure, diabetes, and heart disease.
3. Methotrexate and Other Traditional DMARDs
Disease-modifying antirheumatic drugs (DMARDs) are used used to slow or stop rheumatoid arthritis by suppressing the immune system. The generic names for commonly used DMARDs include:
Methotrexate is often the first drug prescribed for people newly diagnosed with rheumatoid arthritis. RA patients take this medication weekly, alone or in combination with other medications.
High dose methotrexate is also used to treat some cancers. RA patients take significantly lower doses than cancer patients.
4. Biologics for Rheumatoid Arthritis
This class of medications, called biologic response modifiers, is technically a subset of DMARDs. They may be used with traditional DMARDs or as an alternative to them. Biologics:
- Disrupt certain parts of the cascade of events that lead to RA inflammation and have the potential to stop the disease process.
- Increase a person’s risk of infection and tend to be expensive. Because of these potential downsides, biologics are used when methotrexate or other DMARDs prove insufficient or cause unacceptable side-effects.
- May become less effective and/or cause worsening side effects over time. The doctor and patient can work together to monitor changes and decide if and when switching medication is advisable.
Biologics fall into four categories: Tumor necrosis factor (TNF) inhibitors; Interleukin (IL) inhibitors; B-cells inhibitors; and T-cells inhibitors. These medications are administered by injection or infusion. Examples include Remicade, Enbrel, and Humira.
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Testing for Tuberculosis
Before taking any type of biologic medication, a person must be tested for tuberculosis. People who have latent tuberculosis carry the Mycobacterium tuberculosis bacterium without having tuberculosis symptoms. If a person with latent tuberculosis takes immune-suppressing biologic medications the bacterium can multiply and cause symptomatic tuberculosis.
5. Janus Kinase (JAK) Inhibitors
JAK enzymes are essential messengers in the immune system’s inflammatory process. When JAK enzymes bind with other cells, called X cells, they trigger inflammation. JAK inhibitors bind to JAK enzymes, preventing them from binding with X Cells and stopping the inflammatory process.
The first FDA-approved JAK inhibitor is called Tofacitinib, and it is sold under the names Xeljanz and Xeljanz XR (extended release).
As with biologic mediations, people considering taking JAK inhibitors must have a tuberculosis test.
People taking JAK inhibitors are advised to work with their doctors to monitor risks and side effects.