Rheumatoid Arthritis - Treatment | Johns Hopkins

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- When a patient is first diagnosed

with rheumatoid arthritis, one of their main questions is

how are we going to treat this?

How am I going to be feeling better?

And there are several ways to treat rheumatoid arthritis.

We try to use medications that we call

disease-modifying drugs and what we mean by that

is that they change the course of the disease.

They prevent erosions in the joints and permanent damage.

And these are key medications to get started early

in rheumatoid arthritis, so our patients

don't have that permanent damage in their joints.

Within this category of medications,

these disease-modifying medications,

there are two main subcategories.

So there are conventional oral disease-modifying medications

and there are biologic disease-modifying medications.

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Often, people will start first with the conventional

oral medications to treat their rheumatoid arthritis

and so some examples of these medications are

Sulfasalazine, Methotrexate and Leflunomide.

And these medications work by modulating

the immune system so that it's not as active

damaging the joints as it normally is

in rheumatoid arthritis.

And these medications have been used for decades

in rheumatoid arthritis.

They are generally well tolerated.

There are some side effects for the particular medications

that need to be considered.

We need to always watch out for side effects

when we're starting any new medication.

When you're on these types of medications,

the main thing to know is that your blood work

will need to be monitored regularly

and this is to make sure that the liver functions

are normal and that the blood counts all stay normal

with these types of medications.

There's not a big increased risk of infection

with these types of medications.

Some do not increase the risk of infection at all,

so that's a plus for this category of medications.

So the fact that these medications are oral

or available by pills you take by mouth,

that's attractive to a lot of patients

as opposed to injections or infusions

like some of the biologic medication.

So we'll often start patients with

a conventional disease-modifying drug

before going to a biologic drug.

And these medications, besides having been around longer,

end up being less expensive and often

there's less trouble with insurance

of getting these medications approved and paid for.

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The other main class of medications

to improve outcomes in rheumatoid arthritis

are biologic disease-modifying drugs.

This class is ever expanding, new drugs are coming out

in the market, but the main categories are

TNF inhibitors, drugs that block an inflammatory protein

called TNF.

Abatacept, which is a drug that helps prevent T cells

from becoming too activated.

Tocilizumab, which is a drug that blocks

a proinflammatory protein that causes inflammation, IL-6.

Rituximab, which works on the B cells.

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The biologic drugs, the first ones approved

were TNF inhibitors and that's about 20 years ago.

So we've been using some of these as long as

two decades for the treatment of rheumatoid arthritis.

The TNF inhibitors are only available in injection

or infusion form.

These medications work by turning down

the immune responses that are too active in RA.

So turning the dial down on your immune system.

So as a result, one of the main things

that we think about is the risk of infection.

Our immune system normally is supposed to protect us

from outside invaders, bacteria, viruses.

And so when we start turning down the immune system

we do somewhat increase the risk of infection.

So before you would start a TNF inhibitor,

your rheumatologist will check you for hepatitis,

viral hepatitis and also for tuberculosis

to make sure that you don't have a chronic infection

that could then come to the surface

as a result of being started on these drugs.

And while you're on these drugs,

if any signs of infection develop like fevers

or productive cough, coughing up stuff to suggest pneumonia,

urinary tract symptoms, skin infections,

anything of that sort, these drugs will potentially

be held while you're treated for those infections

so that you can heal and get back on track.

That's true in general for the biologics

using the TNF inhibitors as an example.

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These drug classes can often be combined,

conventional oral disease-modifying drugs

with biologic drugs.

The oral drugs can be combined together themselves as well.

Sometimes biologic drugs are used on their own.

There are many different treatment options.

So when I have a patient who's diagnosed

with rheumatoid arthritis and they hear

it's a chronic disease that we don't yet cure,

they're often understandably upset by this diagnosis.

But I like to reassure people that in 2017

we have so many great treatment options

for rheumatoid arthritis and we can really manage

the disease well and help people achieve their goals

and stay functional.

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An infusion is a medication that's given directly

into the vein.

So to have an infusion, patient's will go

to an infusion center or a clinic.

They'll have an IV started, so an IV catheter

put into their vein, usually into their arm

and then the medication will be given directly

into the IV.

The good thing about infusion type medications

is that compared to some medications,

which have to be injected by the patient

or a family member at home,

they are going to a healthcare setting

and they don't have to do anything.

They can just sit back and let the nurses there

take care of them and give them the infusion.

The downside of that is that they must then go

and make an appointment and take time out of their day

to have the infusions done versus injection medications,

which can be done at home by the patient

or by family or friends.

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Infusions are often given with premedications

to prevent any bad reactions.

So patients will often receive Tylenol and Benadryl

and sometimes even steroids before they get their infusion

to make sure that everything goes smoothly.

Infusions often are given more frequently up front

and then spaced out.

They are dosed by body weight,

which is nice compared to other types of medications,

which are more one-size fits all dosing.

So infusions are good options

for treating rheumatoid arthritis and other forms

of autoimmune disease that we see in rheumatology

and to find out if that's right for you,

talk to your rheumatologist.

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