Molecule Predicts Whether Biologic Drugs Will Help Individual Rheumatoid Arthritis Patients
Treating Rheumatoid Arthritis: DMARDs vs. Biologics
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Biologic drugs are the newest type of treatment for rheumatoid arthritis (RA), and not only can they make a big difference in the way you feel, but they can also help limit joint damage. But it's important to understand the differences between treating RA with these newer medications and treating it with traditional disease-modifying anti-rheumatic drugs (DMARDs).
RA treatment has made major strides over the past few decades — first with the use of DMARDs and then with the introduction of biologics. Although biologic drugs are technically a type of DMARD, they're usually just called biologics, which helps distinguish them from traditional DMARDs.
“When I started treating rheumatoid arthritis more than 25 years ago, we were limited to relieving pain and swelling with non-steroidal anti-inflammatory drugs (NSAIDs) and steroids," says Stuart Kaplan, MD, chief of rheumatology at South Nassau Communities Hospital in Oceanside, New York. "Today, we can change the course of this disease with newer treatment options."
DMARDs are drugs that can help prevent joint damage and deformity from RA. More than a dozen options exist, and they all work by suppressing the immune system.
“Methotrexate is the gold standard and is often prescribed to someone with rheumatoid arthritis that has active disease," Dr. Kaplan says. “And earlier treatment is best — once joint damage has occurred, it can’t be undone."
Other commonly used DMARDs for RA include hydroxychloroquine and sulfasalazine, which can be prescribed alone or with methotrexate. These drugs tend to be a little weaker, but they have fewer side effects, Kaplan says.
Newer DMARDs: Biologics
Biologics are genetically engineered drugs that block cytokines, the proteins needed to cause an immune response. The first biologic medication for RA was introduced in 1998. Today, many biologics have been approved for treating RA.
“Biologics are a godsend for people who need more than traditional DMARDs, but they come with bigger risks and a higher price," Kaplan says. However, he says, they're quite effective and should be used sooner rather than later if needed.
A study of nearly 1,600 people with RA,published inRheumatologyin March 2019, found that those with severe disease experienced greater improvement in disease activity than those with lower levels of disease, even though they did not hit the targets of remission and low disease activity. However, those with moderate disease activity achieved remission.
Traditional DMARDs and Biologics: A Side-by-Side Look
Key similarities and differences between these RA treatments include:
- Delivery method. Traditional DMARDs are usually taken in pill form, and methotrexate, the most common type, is usually given once a week. Biologics are typically injected under the skin or given by intravenous infusion, a process that takes a few hours in a medical setting. Frequency varies from one biologic to another, and can range from daily to every few months.
- Drug target. Traditional DMARDs target the entire immune system, whereas biologics work by targeting specific steps in the inflammatory process.
- Response time. It can take months before you'll know whether a traditional DMARD is working for you. With biologics, you're likely to experience results within four to six weeks, after just a few treatments. In the meantime, your doctor may also prescribe an NSAID or a steroid medication to help relieve joint pain and swelling.
- Risks. Both traditional DMARDs and biologics can increase your risk for infections, so you need to tell your doctor if you experience a fever, chills, or cold symptoms. Serious infections, such as pneumonia, are the biggest risk of taking a biologic.
- Side effects. Each type of DMARD has its own set of side effects so you should go over these with your doctor if a specific DMARD has been prescribed. For instance, methotrexate can cause liver damage, bone marrow suppression, and miscarriage or birth defects. The most common side effect from biologics is a skin reaction at the site of injection, affecting up to 30 percent of people who take them. There are also other more serious side effects to evaluate before starting biologic treatment, including an increased risk for skin cancer. A study published inClinical Rheumatologyin April 2019 found that people had fewer adverse effects from biologics the longer they were on them.
- Cost. Biologics are much more expensive than traditional DMARDs. Be sure to check with your health insurer if you have any questions about your prescription coverage. If you need help paying for your RA treatment, you may be able to apply for assistance through your specific medication’s manufacturer.
DMARDs and Biologics: A Mix-and-Match Approach
Traditional DMARDs are often used in combination with each other. A traditional DMARD can also be paired with a biologic, but only one biologic is prescribed at a time.
“Today, if methotrexate isn’t working, doctors are more likely to add on a biologic," Kaplan says. "In some cases, methotrexate may be stopped if the biologic is working well. If the first biologic isn’t working, your doctor may try switching you to a different type of biologic."
When to start a traditional DMARD and when to add another or move to a biologic are decisions that you'll make with your doctor. No matter what medication you’re taking, it’s important to discuss potential side effects and risks. You may also need regular blood tests to make sure you're not in danger from certain side effects. In 2015, the American College of Rheumatology updated its treatment guidelines to emphasize that that, when choosing a treatment, doctors should focus just on a patient’s level of disease activity rather than their disease activity and long-term outlook together.
Side by side, both traditional DMARDs and newer biologics are changing the way doctors think about treating RA.
“Years ago, I would’ve said it’s better to have osteoarthritis than rheumatoid arthritis," Kaplan says. "Today, I can say that there are actually better treatment options for RA."
Additional reporting by Beth W.
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