Arthritis: Disease-Modifying Medications

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Arthritis: Disease-Modifying Medications
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There are a variety of arthritis medications that work by altering the immune system. These drugs halt the underlying processes that cause certain forms of inflammatory arthritis including rheumatoid arthritis (RA), ankylosing spondylitis, and psoriatic arthritis. These are called disease-modifying antirheumatic drugs, or DMARDs.

These drugs not only treat arthritis symptoms, but they also can slow down progressive joint destruction. Some of these medications are traditionally used to treat other conditions such as cancer or inflammatory bowel disease, or to reduce the risk of rejection of a transplanted organ. However, when chemotherapy medications (such as methotrexate or Cytoxan) are used to treat rheumatoid arthritis, the doses are significantly lower and the risks of side effects tend to be considerably less than when prescribed in higher doses for cancer treatment.

Traditional DMARDs can be grouped in different categories and include:

Anti-malaria medications, particularly Plaquenil
Arava
Organ antirejection drugs, such as cyclosporine
Miscellaneous drugs, such as Azulfidine and gold
Chemotherapy drugs, such as methotrexate, Imuran, and Cytoxan
Anti-malaria Drugs (Plaquenil)
Plaquenil (hydroxychloroquine) is a drug used to treat malaria. It was discovered that it worked for arthritis when people taking the drug for malaria reported improvements in their arthritis. The drug affects the immune system, although doctors do not know precisely how it works to improve rheumatoid conditions.

Usually Plaquenil is used when other RA treatments fail. It can be given along with steroid treatment to reduce the amount of steroid needed. It is also given to treat the facial rash of lupus.

Plaquenil is given by mouth daily. Side effects include low white blood cell counts, blood or protein in the urine, nausea, and skin rashes. High doses can rarely cause injury to the back of the eye (retina); therefore, patients on this drug should see an eye doctor every six to 12 months.

Arava
Arava (leflunomide) helps calm the inflammation associated with RA. Arava interferes with genes in developing cells, like those of the immune system.

Arava is a tablet that is taken in a dose of 10 or 20 milligrams once a day. Arava can be taken on an empty stomach or with meals. Possible side effects include rash, hair loss, irritation of the liver, nausea, diarrhea, and abdominal pain. When taking Arava, it is necessary to have regular blood tests for liver function and blood count testing. Arava is not recommended for people who have liver disease, pregnant or nursing women, or people with immune systems weakened by an immune deficiency or disorder.

Since Arava can cause serious birth defects, both men and women should use a reliable method of birth control while being treated with this medication. If a woman taking Arava wishes to become pregnant, she must stop the Arava, take a medication called cholestyramine for 11 days to get all the Arava out of the body, and then have a blood test to prove that the drug is gone. Less is known about the effects of Arava on men planning to father children. To be safe, men should consider cholestyramine treatment before attempting to conceive.

Cyclosporine
Cyclosporine is a tablet that's best known as a drug to prevent rejection of transplanted organs. It works by stopping an overactive immune system from attack. Therefore, it's effective in stopping joint inflammation and destruction caused by RA.

The side effects include high blood pressure, headache, kidney problems, nausea, diarrhea, and heartburn. Regular blood count testing is mandatory.

Azulfidine
Azulfadine (sulfasalazine) is used for treatment of rheumatoid arthritis, arthritis associated with ankylosing spondylitis, and arthritis associated with inflammatory bowel diseases such as ulcerative colitis and Crohn's disease. It may be used alone or in combination with other medications. Persons allergic to sulfa drugs should not take Azulfadine.

Gold
Gold has been used as a medical treatment for centuries and was a mainstay of RA treatment from the 1920s to the mid 1980s. Currently it is a rarely used treatment for RA as newer medications are more effective.

Gold works by decreasing inflammation in the joints, although doctors don't know how it does this. Gold is given orally or by injection into the muscle. The injection is more effective than the oral version.

Possible side effects include skin rash, anemia, low white blood cell count, or liver and kidney problems.

Methotrexate
The most commonly used DMARD is methotrexate. Since the early 1980s, methotrexate has gained prominence as an effective treatment for RA. It also has advantages in having dose flexibility, as higher doses may be used for worse disease, and it is easy to monitor for side effects by testing for liver function and blood counts.

Side effects of methotrexate include rash, mouth sores, hair loss, fatigue, liver inflammation, and bone marrow toxicity. The risk of side effects can be reduced by taking daily folic acid.

Imuran
Imuran (azathioprine) is a chemotherapy drug that can be effective for RA, particularly for complications such as vasculitis. It is an oral tablet. Side effects include nausea, vomiting, rash, mouth sores, liver and blood count abnormalities, and increased risk of infection. Regular blood test monitoring is mandatory.

Cytoxan
Cytoxan (cyclophosphamide) is a powerful immune suppression medication. Cytoxan is used only for serious complications of RA, such as vasculitis or inflamed lungs. Cytoxan can cause hair loss, oral sores, fatigue, bone marrow suppression, and increased risk of infection. Regular blood test monitoring is mandatory.

Reviewed by the doctors at The Cleveland Clinic Department of Rheumatic and Immunologic Diseases.

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