WebMD Health - Rheumatoid Arthritis

Jun 23, 2011 6:02 PM

Treating RA: Choosing The Right Biologic for You

In the late '90s, biologic response modifiers changed expectations for patients with rheumatoid arthritis. People with RA-related pain, inflammation, and possible disability had a new and better way to control the condition.

Since the first biologics' success, new ones have continued to enter the market at a steady pace. If you have RA, you may wonder what the difference is and how to choose.

Biologics Basics

Biologics target specific parts of the immune system. Since RA happens when the immune system goes into overdrive and attacks healthy joints, bringing the immune system under control is key to managing the disease.

Biologics fall into several classes, based on the part of the immune system they help control.

Many of them work by blocking TNF, a type of protein called a cytokine that triggers inflammation. Some target other cytokines such as interleukin-1 (IL-1) or interleukin-6 (IL-6), or B cells, another type of immune cell. Another inactivates immune cells called T cells.

Because they suppress your immune system, biologics lower your ability to fight infection. Also, each drug has its own set of potential side effects that you should talk about with your doctor.

Biologic Choices

"The differences between biologics is minor," Fred Kantrowitz, MD, a rheumatologist on staff at Beth Israel Medical Center, tells WebMD. "The real question is whether a patient will benefit from biologics, which are an aggressive form of treatment. Once that question is answered, the majority of physicians prescribe one of the TNF-blockers."

Two of the first biologics to become available in 1998 were TNF blockers. Thanks to the positive impact they had on RA symptoms, doctors became familiar with this class of drug. As a result, 12 years later, the long-term impact of TNF blockers is better understood than that of some other biologics.

Less Pain, Less Stress

Amy Botvin has been taking a TNF blocker to manage her RA since 2001 and has seen it impact all aspects of her life. The most obvious impact is pain relief; another is convenience.

Botvin used to pack an army of pill bottles whenever her family went on a trip. Now she gives herself an injection once a week. "It's nice not having to worry about all of my drugs. If we go away for a long weekend, I bring a bottle of ibuprofen and that's it," Botvin says.

Biologics by Injection or Infusion

In choosing a biologic, you may want to consider how it's taken. Some biologics are injected under the skin, which you can do at home. Others are infused --given by IV -- at a medical facility. Currently there aren't any oral biologics for RA.

People can give themselves injections or have a friend or family member do it for them. In general, injections need to be done more often than infusions -- anywhere from daily to every two weeks -- depending on the biologic.

Botvin gives herself injections using an auto-injector, which lets her inject herself without seeing the needle. Although Botvin likes the precision -- the auto-injector comes prefilled with exactly the right amount of medication -- she says the injections do tend to sting.

If you take a biologic by infusion, how often you take it can range from once every four to eight weeks. For each infusion, you would spend from 30 minutes to several hours in the doctor's office, clinic or hospital.

Some people get serious infusion reactions, including chest pain, a change in blood pressure, difficulty breathing, and hives. One of the most serious risks of biologics, however, is that they pose an increased risk of the body's vulnerability to infections and other diseases. In addition, patients need to be screened for tuberculosis before starting most biologics and then monitored for disease activation during treatment.

Working With Your Doctor On a Biologic

Choosing which biologic to take may take a lot of doctor-patient cooperation because so much is still unknown about them. "Selecting the right drug for a patient is a matter of trial and error," Theodore Fields, MD, clinical director, Early Arthritis Initiative, at Hospital for Special Surgery tells WebMD. "Researchers are looking for ways to predict the best match. For now, we try one and if that doesn't work, we try another."

For this and many other reasons, your relationship with your doctor can make a big difference in RA treatment. "Find a rheumatologist you can talk with openly about your condition, medications, risks, and side effects," says Elena Massarotti, MD, co-director of the Center for Clinical Therapeutics at Brigham and Women's Hospital. "Your doctor can tell you what's new so you always know what options are available."

Questions to Ask Your Doctor

If your doctor suggests you try a biologic agent, here are some questions you can ask:

  • How long has this drug been available in the U.S.?
  • How much experience do you have prescribing this drug?
  • How much is know about its side effects? What are they?
  • Is it given by infusion or injection?
  • How often do I need to take it?
  • Are there different ways to take this drug in case one method doesn't work well for me?
  • Do I need to take it in combination with another drug?
  • What are the side effects of that drug?

RA: Balancing Hope With Reality

Coping with RA and staying on top of new treatments can be a daunting challenge. It's also often an emotional one.

"Many patients ask me, 'Are you sure I can't get better myself?'" Fields says. "And yes, there is some variability, but for the vast majority of people, RA is a long-term, chronic condition."