Aug 9, 2011 9:52 PM
Severe joint pain and stiffness in rheumatoid arthritis (RA) are hard to ignore and often send people looking for help.
But pain, swelling, and stiffness are not the only problems for joints affected by RA. A destructive army assembles, drawn from a person's own immune system. If not put in check, a faulty immune system can attack cartilage and bone within the joint as well as other healthy tissues in the body.
Controlling inflammation is key to controlling RA. Douglas Conaway, MD, a rheumatologist with Carolina Health Specialists in Myrtle Beach, uses the analogy of a wildfire that becomes more difficult to contain the longer it burns.
"Inflammation is at the root of all problems in RA, including most of the joint pain and all of the swelling and stiffness. It's also why people feel so tired," says Conaway. "Patients want these things fixed fast, which is understandable. I want them fixed, too. Above all, we both want to keep the joints functioning. To do this, we need to do more than just control symptoms. We need to control the disease."
As recently as 20 years ago, doctors waited until a person with RA showed evidence of joint damage on an X-ray to begin treating with high-powered drugs to control inflammation.
Today, RA treatment is guided by the principle of early and tight control. That means achieving the lowest possible level of disease activity as soon as possible, and keeping it low. Research shows that such tight control can slow the progression of RA and reduce damage to joints.
Says Seth Berney, MD, Director of the Center of Excellence for Arthritis and Rheumatology at Louisiana State University Health Sciences Center in Shreveport, "My goal is to get patients back to feeling the way they did before RA. That's what I tell patients. It may not always be realistic, but that's my goal and that's what we'll work together to try to achieve."
The outlook for people living with RA is brighter today than ever before, thanks to a growing range and number of treatments.
RA medicines generally fall into two groups:
Joint replacement and other surgical options are used to treat some forms of advanced joint damage.
Rheumatologists today tend to use DMARDs and biologics as the leads in RA therapy, with steroids and NSAIDs playing supporting roles.
DMARDs are a diverse group of drugs that all act in some way to suppress an overactive immune system in RA. These drugs can slow or stop progression of joint damage. They may take from four to six weeks to a few months to begin working and may take longer to reach full effect.
"DMARDs are the current drugs of first choice when starting RA therapy," says Thomas Hardin, MD, vice president of research at the Arthritis Foundation. American College of Rheumatology guidelines say that anyone diagnosed with RA should be started on at least one DMARD immediately, no matter how mild their disease.
"It's better to err on the side of overtreating early on and then be able to withdraw the drug after getting complete control of the disease," says Hardin.
If you have severe RA and signs that indicate very active disease, the treatment approach is even more aggressive. Some people with RA may start on a single DMARD while others may take a combination of DMARDs in order to get the disease under control.
The most commonly used DMARDs are methotrexate, sulfasalazine, hydroxychloroquine, and leflunonomide. All can be taken orally, although methotrexate is sometimes given by injection.
Most DMARDs were developed to treat other diseases but since have been found to be effective for RA. For example, methotrexate was originally used for cancer.
"I tell patients right away that the drug I use most often for RA is a cancer drug," says Conaway. "But, I emphasize that the dose of methotrexate used for cancer is 100 times what I use for RA. It's important for patients to understand that the doses for cancer and the doses for RA are not the same, so the risk for side effects is also not the same."
Because DMARDs work in different ways to suppress the immune system, side effects vary with each medicine. Serious potential risks include infection and kidney or liver damage. Methotrexate and leflunomide can cause serious birth defects. Women or men being treated with one of these drugs should talk with their doctor before planning pregnancy.
Biologics are newer treatments that target specific parts of the immune system to help turn down the inflammatory response. These drugs can work quickly to reduce joint pain and swelling. Longer term, biologics have been shown to slow the pace of joint damage and to improve physical function.
Biologics are used to treat moderate to severe RA that cannot be controlled by DMARDs. "These are the people for whom a biologic makes a big difference," says Hardin. "If people don't respond within six to eight weeks of starting traditional DMARDs, it's very appropriate to move on to biologics."
Biologics can be used alone but often are combined with one or more DMARDs or other RA drugs to control symptoms and disease activity. However, you should not take two biologics together, because of the risk of serious infection. All biologics are taken either by injection (shot) or by infusion (IV).
A number of biologics are available to treat RA.
Biologic drugs work by targeting immune triggers that cause joint inflammation and damage in rheumatoid arthritis. 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 the immune system, biologics lower your ability to fight infection. They can cause some conditions that aren't active to flare (such as tuberculosis). Some people may also have reactions at the infusion or injection site.
Some people may have more widespread infusion reactions. Thought they are usually mild, they can cause chest pain, difficult breathing, and hives, among other things. While injections can be done at home, infusions are always done at a medical facility so your condition can be monitored.
In addition, each drug has its own set of potential side effects that you should talk about with your doctor.
Corticosteroids are strong inflammation fighters that can rapidly improve symptoms and reduce swelling. They are less effective at slowing the disease itself. Your doctor may prescribe them initially to get inflammation under control, or when you have a flare.
Your doctor may also recommend an injection of steroids into a painful joint when you're having a flare. And for some people, says Hardin, a very low dose of oral steroids in combination with DMARDs and/or biologics seems to control their RA.
Steroids can cause weight gain and bone loss, raising the risk of osteoporosis. They also may worsen diabetes and increase the risk of infections. Generally, the lower the dose and the shorter the course of steroids, the fewer side effects.
Nonsteroidal anti-inflammatory medications, such as ibuprofen, naproxen, or celecoxib (Celebrex) reduce inflammation and help relieve pain. NSAIDs do not slow joint damage.
"I use less and less NSAIDs every year in my practice," says Hardin. "I don't rely on them for much except minor symptom control. I would certainly never treat RA with an NSAID alone."
NSAIDs can cause stomach problems, including bleeding. Some also have been associated with an increased risk of heart disease and should be used with caution in people who have preexisting heart, liver, or kidney disease.
Joint replacement surgery is an important treatment option for some people with RA whose joint damage causes pain and limits function and mobility. "It is very clear that these surgeries can reduce pain and restore function," says Hardin. "Right now, the technology for joint replacement is best for the knee and hip, but we're also moving into joint replacement surgery for elbows, shoulders, and ankles, which is great."
Hardin predicts that fewer joint replacements will be done in the future. "Because we can control the disease process so much better with medications now, we should be able to significantly lower the number of people with RA who come to joint replacement surgery," he says.