Jun 23, 2011 6:05 PM
Medications called biologic response modifiers have given new hope to people with rheumatoid arthritis (RA) and the doctors who treat them. Until the late '90s, people with RA looked at a future of pain, lost function, and eventual disability. Biologics have changed that outlook.
Many people now live with significantly less pain and more function, but may worry about side effects. Here's a look at the risks and benefits of biologics.
Ed Clough's story demonstrates how biologics have changed the RA picture. He was first diagnosed in the early '90s and advised to take ibuprofen for pain. "It didn't do much," he says.
Then, for no apparent reason, his RA went into remission. A few years later, it came back with a vengeance. "The pain in my fingers and wrists got so bad I couldn't button my shirt or lift a gallon of milk without dropping it," he says. "Things I never used to think about."
The return of Clough's RA coincided with the FDA's 1998 approval of the first two biologic agents on the U.S. market. The drugs were so new that Clough's doctor had to put him on a special list to qualify for the treatment. "Within weeks of the first injection, I could manage everyday activities again," Clough says. "I played golf without pain for the first time in years."
Biologics are a class of drug that target specific parts of the immune system. With RA, the immune system goes into overdrive and attacks healthy cells. So bringing the immune system under control is key to managing the disease.
This approach is not new, exactly. Some disease-modifying antirheumatic drugs (DMARDs) that have been around for decades. But many work by suppressing the whole immune system, rather than specific parts of it.
"Biologics are the first agents developed specifically with RA in mind," says Theodore R. Fields, MD, clinical director of the Early Arthritis Initiative at the Hospital for Special Surgery. "Some were originally developed as chemo drugs, others to treat tuberculosis. The new agents target specific chemicals in the immune system so you see more benefits without as much collateral damage."
"Biologics have elevated the goals of treatment," says Arthur Kavanaugh, MD, professor of clinical medicine in the Rheumatology Division at the University of California, San Diego. "We're treating the disease earlier and more aggressively with much higher expectations for patient outcomes."
Researchers now recognize that the first year is a critical time to treat RA. Often much of the bone and joint damage occurs early, within a few weeks of onset. Biologics do not reverse existing damage, but can protect the joints against continued damage and have been shown to slow the progression of the disease. They are considered a possible treatment for patients who have uncontrolled RA despite the use of DMARDs.
The most serious risk of taking biologics is infection. A suppressed immune system doesn't go after viruses, bacteria, or other intruders as well. So people who take biologics are more susceptible to infections, including pneumonia and some food-borne illnesses. People with serious or active infections such as tuberculosis should not take biologics. Other precautions should be taken in those with heart failure or problems of the nervous system such as multiple sclerosis as biologics may exacerbate these conditions.
Injection site reactions can occur around the site where biologics are injected or infused. The area around injection sites sometimes become red, bruised, and painful, and you may need time off the biologic until the infection clears up.
Infusion reactions can be more serious, causing chest pain, difficult breathing, and hives, among other things. For this reason, infusions are always done at a medical facility where they can be closely monitored.
A small number of biologics have the potential for more serious side effects. Some are only recommended when other biologics have failed.
Because each drug has its own set of potential side effects, you should talk about them with your doctor.
Unfortunately, every treatment carries risk, no matter what the condition. Patients and doctors need to weigh the side effects of available treatments against what could happen with no treatment. Though many people with RA experience periods of remission, the disease often becomes active again.
Without treatment, RA reduces life quality and expectancy for most people. As RA progresses, it destroys cartilage and bone within the joint, then moves to the surrounding muscles, ligaments, and tendons.
For people with uncontrolled RA, fatigue, pain, and disability become a way of life. One study found a higher than normal rate of depression in people with RA, particularly those with poorly managed disease. People who had RA and who suffered from depression were more than twice as likely to die as RA patients without depression symptoms.
Chronic inflammation can damage other organs in the body as well. RA doubles the risk for heart disease. Approximately 30%-60% of people with RA develop anemia. In rare cases, RA can lead to tissue damage, nerve damage, and eye problems.
As relative newcomers to the RA treatment scene, biologics come with many questions that have not yet been answered. For instance, what biologics work best for which person? Do biologics work better when used in combination with other drugs?
Though questions remain, biologics are part of a trend of significant improvements in RA treatment. The shift from "wait and see" to early, aggressive treatment has had a big impact on people's lives. Review of a database of more than 3,000 people with RA found that the average level of disability has declined 40% since 1977 at a steady rate of about 2% each year.
"It's better to have RA in 2010 than any time in the past thanks to advances in treatment," Elena M. Massarotti, MD, at Brigham and Women's Hospital Department of Rheumatology in Boston, tells WebMD. "I expect we'll be even further along at this time next year."