Jul 14, 2011 6:12 PM
Rheumatoid arthritis is no longer the disabling condition it was in the past, thanks in large part to combination therapy - taking more than one RA medicine at a time.
For example, combining two disease-modifying antirheumatic drugs (DMARDs) or combining the DMARD methotrexate with a biologic agent can lessen symptoms such as joint pain as well as slow joint damage -- greatly improving quality of life for people with RA.
Combination therapy has produced a sea change, says James R. O'Dell, MD, Larson professor of internal medicine and chief of rheumatology and immunology at the University of Nebraska Medical Center in Omaha, Neb. "It is very gratifying to go to clinic now," he says. Instead of counting the number of people in wheelchairs, Larson says, "You see the majority of your patients doing great and living a normal life."
If your doctor recommends combination therapy, work with him to tailor a treatment plan that is right you. Here are answers to some of the questions you may have about combination therapy for RA.
It's not yet possible to know in advance which combinations of drugs will work for a specific patient. So you can expect some trial and error and tailoring to get the best result for you.
After you are diagnosed, you may start on monotherapy, which means taking a single drug, usually the DMARD methotrexate. Methotrexate can suppress an overactive immune system and slow or stop joint damage. It is used in combination with virtually every other drug, says Mark C. Genovese, MD, professor of medicine and co-chief of immunology and rheumatology at Stanford University Medical Center in Palo Alto, Calif.
Then your rheumatologist may increase the dose, as needed, to evaluate its effectiveness and any side effects. If your disease does not respond well to the first drug, the doctor may add a biologic. Biologics can work quickly to reduce joint pain and swelling. They also help turn down the inflammatory response and improve physical function.
Finding the biologic that works best for you can take some time. Genovese says that patient and physician preferences, as well as cost and insurance coverage, are also a part of the decision-making process.
Although many doctors combine methotrexate with a biologic, that's not necessarily better than combining two DMARDs. O'Dell lists methotrexate, sulfasalazine, hydroxychloroquine, and leflunomide among the DMARDs that have been used together. "Work with a rheumatologist to find a therapy or combination that will get your disease to a low level of activity," O'Dell says.
Rheumatologists don't combine two biologics because of the higher risk of infections.
Although methotrexate doesn't often cause liver toxicity, your doctor will carefully monitor your liver function. Many RA medications can also cause bone marrow problems. Doctors closely watch for these potential risks.
In the past, it was more common to use one drug at a time for rheumatoid arthritis. Over the last 15 years, though, combinations have shown much better results than using a single drug.
The benefits of combination therapy go beyond lessening joint pain, morning stiffness, and inflammation. It can help slow or stop progression of the disease, meaning joint damage doesn't get worse. And it can help people live active lives and be able to do the activities they like to do. And a good response to combination therapy also means you are able to prevent further joint damage from rheumatoid arthritis.
The goal is to prevent disease and damage by shooting for a low level of disease activity, O'Dell says. Some people may achieve remission, meaning they don't have any signs or symptoms of RA. Even if your symptoms go away, you will still need to take medication for RA.
Combination therapy can't reverse joint damage that's already happened. But it can prevent further damage. And it can help reduce the risk of health problems that may accompany rheumatoid arthritis. Knocking down disease activity and ridding the body of inflammation can lower the risk of heart attack and stroke, for example, which is higher in people with RA.
Currently, rheumatologists start treating people with RA with a DMARD as soon as they are diagnosed. Methotrexate is most commonly prescribed.
Rheumatologists are trying to sort out whether people with RA should start on combination therapy right after they are diagnosed or only step up to it as needed. O'Dell says that clinical trials show that when people need to step up to combination therapy, 70% do as well within a few months as those who start on combination therapy.
"The big question remains -- what is happening in the person's life during that three-month period?" he adds. Is RA causing problems at home? Keeping a worker off the job? Producing significant joint changes? These are the kinds of things to talk over if you and your doctor choose to start with a single medication.
These medications are still used, but not as much as in the past. Nonsteroidal anti-inflammatory drugs (NSAIDS) treat symptoms of pain and inflammation. But they don't slow down joint damage, O'Dell says. Corticosteriods, such as prednisone, can slow down joint damage, but using them long term causes serious side effects.
"Steroids are cheap and effective for quick relief," O'Dell says. "But our goal is to get patients off them as quickly as possible. They are more often used as a bridge to more effective disease-modifying therapies with less long-term toxicity."