How Do DMARDs Treat Rheumatoid Arthritis?

Question: How do DMARDs work for treating rheumatoid arthritis?
— Salt Lake City, UT

Answer: Disease-modifying anti-rheumatic drugs (DMARDs) are prescribed as long-term maintenance medications to help suppress inflammatory activity caused by  rheumatoid arthritis (RA) and to limit your exposure to steroids.

The goals of therapy are:

  • Pharmacist filling a prescriptionrelieve pain
  • preserve functional status
  • reduce joint inflammation
  • control systemic involvement and disease progression
  • avoid complications related to therapy

Over-the-counter medications, such as non-steroidal anti-inflammatory drugs (NSAIDs) (eg, ibuprofen), are not enough to use alone to treat rheumatoid arthritis. In general, a combination of medications, such as steroids and DMARDs are needed (especially upon initial diagnosis) to control RA.

A few examples of traditional DMARDs prescribed by rheumatologists are methotrexate, leflunomide, sulfasalazine, azathioprine, and hydroxychloroquine.

Rheumatoid arthritis is an autoimmune disorder, and a complex interaction of genes and the environment predisposes people toward developing RA. People who smoke have an increased risk of developing RA, and they may also have a more aggressive disease course.

If you have RA, your white blood cells, which are supposed to help fight infection, become overactive and start to attack your synovium (healthy tissue) in your joints, creating inflammation.

DMARDs work to treat your RA symptoms by slowly "modifying" your disease. They suppress your body's immune and inflammatory responses—2 systems responsible for the progression of RA. In general, they inhibit the T cells and B cells of your immune system. Because DMARDs suppress white blood cell over-activity, taking them may eventually lead to less inflammation.

Although DMARDs are powerful drugs, it may take several weeks before you feel their effects. For example, methotrexate may take up to 6 to 8 weeks to reach its maximum efficacy. Usually, to get the benefits as quickly as possible, your doctor will prescribe DMARDs within 1 to 3 months of diagnosing you with RA.

But DMARDs can improve your quality of life. For many people taking DMARDs, RA may still be present, but at a lower activity level.

It's also important to note that DMARDs are typically initially taken with an NSAID or a steroid, such as prednisone. That's because both help treat your immediate symptoms—mostly inflammation and pain—while the DMARDs help prevent long-term joint damage and work on modifying the disease.

Like other medications, DMARDs can have serious side effects and interactions with other medications you take. Most of the side effects involve blood-producing cells, your liver, and your kidneys, so your doctor will need to frequently monitor how your body is responding to the DMARD. You'll also need to have routine blood tests and check-ups when taking these medications.

If traditional DMARDs don't work for you, then your doctor may prescribe a biologic medication—a drug made from human cells instead of chemicals. Biologic medications help restore healthy function of your immune system, and they are often used in combination with traditional DMARDs. One example is TNF-alpha inhibitors.

Like traditional DMARDs, there are side effects associated with taking biologic medications, most notably an increase in infection risk. But since these drugs are so new, long-term side effects are not yet known.

DMARDs are an important part of treating rheumatoid arthritis because they can help ease your pain and stop destructive changes in your joints. Talk to your doctor about any questions or concerns you may have. Your doctor will let you know which DMARDs are right for you.