Rheumatoid Arthritis

Disease modifying anti-rheumatic drugs (DMARDs) for rheumatoid arthritis

Disease Modifying Anti-Rheumatic Drugs (DMARDs) are used to slow down the progression of rheumatoid arthritis. In the past DMARDs drugs were prescribed only after symptoms progressed, but it is now clear that the earlier patients are given them the better.

Conventional DMARDs include methotrexate, sulphasalazine, hydroxychloroquine and leflunomide. They are used mainly in the treatment of rheumatoid arthritis but also in some other rheumatic diseases. They reduce pain, swelling and stiffness. They do not work at once but may take several weeks to work. If you do not do well on one of these drugs, or if you develop any side effects, then your doctor may try one of the others.

Many people will have to had try more than one DMARD, either because of side effects or ineffectiveness. With many of these drugs regular blood monitoring is required to check for adverse effects on the liver, immune system etc. When an abnormality was found the doctor discussed what to do (see 'Regular monitoring and other diagnostic tests'). Hydroxychloroquine doesn’t need blood monitoring, but does need an annual optician review as it can affect the back of the eye (retina) although this is rare.

These drugs may take weeks or months to have an effect, which frustrated many people. Several may have to be tried to find the best one. The knowledge that there were different types available was reassuring. Though many of those we interviewed did not understood that DMARDs are intended to control, suppress and stabilise their RA.

Some people felt that these drugs would be effective only for a limited time (usually several years) due to increased tolerance and disease progression. Some people could not tolerate any DMARD and others had avoided them because of their toxicity and potential side effects. Some people who were taking those which suppress the immune system worried about catching infections.

Methotrexate (tablet or intra-muscular injection): Most people we talked to took this as tablets. One woman's partner had been taught how to inject it into her arm, so saving a weekly visit to the GP. Many people found this drug effective and had taken it for up to 13 years. However, in a few people the effectiveness had faded after some years and some found it did not work for them at all.

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Side effects that affected some people included nausea, which could last for hours or days after each dose. Some people took it at bedtime to overcome this and one man was helped by taking it after food. Other side effects included headaches, feeling disorientated, hair loss, mouth ulcers, acne, an all over burning rash, raspy voice, stomach problems and loss of balance (overcome with cinnarizine). Often splitting the dose over two consecutive days can help too.

A couple of people had breathing problems and stopped the drug whilst these were investigated. One woman had an early menopause, aged 40, and in two people the drug caused nodules near joints. One man who was told not to drink alcohol with methotrexate rejected it. He later found out that alcohol in moderation was acceptable if his liver function was monitored and methotrexate proved effective for him.

One woman, who had RA for 9 years, was treated for breast cancer with chemotherapy and high doses of methotrexate which lessened her RA symptoms then and later. An RA charity worker was concerned that patients did not get enough information about methotrexate.

Sulfasalazine: Several people found this effective or partially effective, but many had had side effects, especially as the dose was increased. Often small doses are prescribed initially and patients are asked to increase the dose, e.g. 2 tablets daily in the first week, 3 tablets daily the next week, and so on until they reach the target dosage of 1g twice a day (4 tablets in total).

As the dose increased people often felt or were sick and consequently lost their appetite, felt generally unwell, had headaches, were dizzy, had indigestion, itchy feet and one woman had flaky skin after several months. One woman's urine and sweat turned yellow. These unwanted effects made people either reduce the dose or stop the drug. One woman found she felt ill if she took it before a night out drinking alcohol so she took it on her return home.

A couple of people had allergic reactions to sulfasalazine and had rigors which involve shivering, shaking, high body temperature and hallucinations. This required a week's admission to hospital for one woman.

Leflunomide: Of the people we interviewed treated with leflunomide, one found it reasonably effective in controlling her arthritis although she still had flare-ups in winter and had high blood pressure as a side effect. The other woman stopped taking it after developing blurred vision.

Hydroxychloroquine (an anti-malarial drug): of those that used this it was usually given in combination with at least one other DMARD not everyone found it effective and in one man it caused sickness and headaches.

Combinations DMARDs: Two (or three) DMARDs are often prescribed together and most commonly this was methotrexate and another DMARD; one man used sulfasalazine and hydroxychloroquine.

Other medications used in the past include Gold, cyclosporin and penicillamine but these very rarely prescribed now.

Last reviewed August 2016.

Last updated August 2016.

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