Rheumatoid Arthritis Drug Therapy

Our Specialty Pharmacy offers pharmacy services to people with rheumatoid arthritis who need long-term biologic response modifier (Enbrel, Humiria, Kineret) drug therapy. Our pharmacy staff can provide the medications for your condition after you return home. Experienced pharmacy professionals work closely with your Mayo Clinic care team to develop a personalized medication management program at no additional cost. We coordinate all billing and claims on your behalf, relieving you of up-front costs and the headaches of completing insurance forms and filing claims.

About Rheumatoid Arthritis
The Role of Medications in Treating Rheumatoid Arthritis
Side Effects, Cautions and Special Requirements
Always Ask Your Pharmacist

About Rheumatoid Arthritis

Unlike osteoarthritis, which results from wear and tear on your joints, rheumatoid arthritis is an inflammatory condition. The exact cause is unknown, but it is believed to be the body's immune system attacking the synovium, the tissue that lines your joints. Rheumatoid arthritis affects about 2 million Americans. It is two to three times more common in women than in men and generally strikes between the ages of 20 and 50. But rheumatoid arthritis can also affect young children and adults older than 50. There is no cure for rheumatoid arthritis. But with proper treatment, a strategy for joint protection and changes in lifestyle, you can live a long, productive life with this condition.

The Role of Medications in Treating Rheumatoid Arthritis

Nonsteroidal anti-inflammatory drugs (NSAIDs). This group of medications helps relieve both pain and inflammation if taken regularly. NSAIDs that are available over-the-counter include aspirin, ibuprofen (Advil, Motrin, others), ketoprofen (Orudis KT) and naproxen sodium (Aleve). NSAIDs only available by prescription include stronger doses of ketoprofen (Oruvail), naproxen (Anaprox, Naprosyn) and ibuprofen (Motrin) as well as tolmetin (Tolectin), diclofenac (Arthrotec, Voltaren), nabumetone (Relafen) and indomethacin (Indocin).

COX-2 inhibitors. This class of NSAIDs may be less damaging to your stomach. Like other NSAIDs, COX-2 inhibitors — celecoxib (Celebrex) and valdecoxib (Bextra) — suppress an enzyme called cyclooxygenase (COX) that is active in joint inflammation. Other types of NSAIDs work against two versions of the COX enzyme that are present in your body: COX-1 and COX-2. However, there is evidence that by suppressing COX-1, NSAIDs may cause stomach and other problems because COX-1 is the enzyme that protects your stomach lining. Unlike other NSAIDs, COX-2 inhibitors suppress only COX-2, the enzyme involved in inflammation.

Corticosteroids. These medications, such as prednisone (Deltasone) and methylprednisolone (Medrol), reduce inflammation and pain, and slow joint damage. In the short term, corticosteroids can make you feel dramatically better. But when used for many months or years, they may become less effective and cause serious side effects.

Disease-modifying anti-rheumatic drugs (DMARDs). Physicians prescribe DMARDs to limit the amount of joint damage that occurs with rheumatoid arthritis. Taking these drugs early in the development of rheumatoid arthritis is especially important in the effort to slow the disease and save the joints and other tissues from permanent damage. Because many of these drugs act slowly — it may take weeks to months before you notice any benefit — DMARDs typically are used with an NSAID or a corticosteroid. While the NSAID or corticosteroid addresses immediate symptoms and limits inflammation, the DMARD works on the disease itself. Some commonly used DMARDs include hydroxychloroquine (Plaquenil), the gold compound auranofin (Ridaura), sulfasalazine (Azulfidine) and minocycline (Dynacin, Minocin). Other forms of DMARDs include immunosuppressants and tumor necrosis factor (TNF) blockers.

Immunosuppressants. These medications act to tame the body's immune system. In addition, some attack and eliminate cells associated with the disease. Some of the commonly used immunosuppressants include methotrexate (Rheumatrex), leflunomide (Arava), azathioprine (Imuran), cyclosporine (Neoral, Sandimmune) and cyclophosphamide (Cytoxan). These medications can have potentially serious side effects such as increased susceptibility to infection.

Tumor Necrosis Factor (TNF) blockers. This class of DMARDs is known as biologic response modifiers. TNF is a cytokine, or cell protein, that acts as an inflammatory agent in rheumatoid arthritis. TNF blockers, or anti-TNF medications, target or block this cytokine and can help reduce pain, morning stiffness and tender or swollen joints — usually within one or two weeks after treatment begins. There is evidence that TNF blockers may halt progression of disease. These medications often are taken with the immunosuppressant methotrexate. TNF blockers approved for treatment of rheumatoid arthritis are etanercept (Enbrel), infliximab (Remicade) and adalimumab (Humira). TNF blockers should not be used if you have an active infection.
Interleukin-1 receptor antagonist (IL-1Ra). IL-1Ra is another biologic response modifier. Interleukin-1 (IL-1) is a cell protein that promotes inflammation; large amounts are found in people who have rheumatoid arthritis or other types of inflammatory arthritis. If IL-1 is prevented from binding to its receptor, the inflammatory response decreases. Anakinra (Kineret) is the first IL-1Ra approved by the Food and Drug Administration for use in people with moderate to severe rheumatoid arthritis who have not responded adequately to conventional DMARD therapy. It may be used alone or in combination with methotrexate. Anakinra is given as a daily self-administered injection under the skin and should not be used if you have an active infection.

Antidepressant drugs. Some people with arthritis also experience symptoms of depression. The most common antidepressants used for arthritis pain and nonrestorative sleep are amitriptyline (Elavil), nortriptyline (Aventyl, Pamelor) and trazodone (Desyrel).

Side Effects, Cautions and Special Requirements

All NSAIDs, including the selective COX-2 inhibitors, can cause kidney problems, hypertension and fluid retention. Traditional NSAIDs, such as ibuprofen, can cause indigestion and stomach bleeding while some reports indicate that COX-2 inhibitors may be associated with an increased risk of heart attack.

Long-term use of corticosteroids can cause easy bruising, bone thinning, cataracts, weight gain, a round face and diabetes. Doctors often prescribe a corticosteroid to relieve acute symptoms, with the goal of gradually tapering off the medication.

TNF blockers may cause headache, fever, chills, nausea and myalgia that happen most often after the first dose and then decrease with subsequent doses. Serious, and sometimes fatal, infections have also been reported with these drugs. Be sure to discuss the risks with your doctor.

Anakinra can cause injection-site reactions, decreased white blood cell counts, headache and serious infections, including upper respiratory infections. The rate of respiratory infections may be slightly higher in people who have asthma or chronic obstructive pulmonary disease.

Always Ask Your Pharmacist

If you experience problems with rheumatoid arthritis treatment, your pharmacist is a reliable source of information about rheumatoid arthritis management and can help you monitor your condition, maximize the benefits of your medications, limit side effects and identify drug-drug or drug-disease interactions. Your pharmacist will work closely with your doctor to create a safe and appropriate care plan.

Optimal control of rheumatoid arthritis requires the coordinated care of your health care team. Doctors, nurses and other caregivers must work closely with pharmacists and others to ensure therapy is safe and effective. Incomplete management of rheumatoid arthritis or another medical condition may lead to complications or limit the success of treatment.