It takes a medical degree, a 3 year Internal Medicine residency and Rheumatology fellowship to learn how to best treat Rheumatoid Arthritis. There are many nuances and caveats and even seasoned rheumatologists find themselves asking for help from colleagues. But it doesn’t serve anyone to leave all the decision making to the doctor. Although the topic can get complicated, there are concepts that everyone with RA should be familiar with. Understanding the strategy behind why your doctor prescribes certain medications can ensure that you continue to have productive and effective conversations.
When approaching RA therapy, the treatment options reside in two categories: anti-inflammatory and anti-RA (or diseases modifying, as your doctor will call them). Anti-inflammatory medications, such as ibuprofen, naprosyn, diclofenac and even prednisone, help you feel better here and now. They decrease inflammation in your joints and consequently lower your pain. These medications are not specific for rheumatoid arthritis, as many reach for these medications for headaches, menstrual cramps and muscle soreness.
The second category of medications, anti-RA, or disease modifying medications, change the course of rheumatoid arthritis. They don’t simply bring down inflammation, but they actually modify the immune system, rendering RA less active. Both types of medications are necessary for a successful long term treatment strategy for RA.
Is Prednisone the right treatment for Rheumatoid Arthritis?
We need to talk about prednisone. Prednisone is a type of corticosteroid, oftentimes just called “steroids”. There are many different types of corticosteroids, each with their own unique characteristics. The most commonly prescribed corticosteroid for most autoimmune conditions, but especially RA, is prednisone.
Everyone comes into the clinic afraid of prednisone. And the bad rap isn’t unwarranted. But we can’t ignore that prednisone is a powerful anti-inflammatory medication. During the mid-20th century, prednisone was a miracle drug. It enabled patients to walk and live their lives again and pulled many from the brink of death. Unfortunately, doctors quickly discovered it was not be the miracle they initially believed it to be. There is no doubt it comes with a heavy price tag: diabetes, infections, weight gain and water retention, osteoporosis, elevated blood pressure, heart disease, acne, insomnia, and psychosis. Prednisone is still used in certain circumstances, however, despite these scary side effects. Being thoughtful, intentional and having an exit strategy are key when using these powerful anti-inflammatory tools.
Although this is especially true for prednisone, this applies to all the anti-inflammatory medications. Because many are sold over the counter, many believe they are without risk. But when taken regularly for long periods, medications such as ibuprofen, naprosyn and diclofenac can also lead to many unwanted effects. It is for this reason that taking ONLY anti-inflammatory medications for RA is not an effective or desirable treatment strategy.
Disease modify me!
Thankfully, we also have the DMARDs, Disease Modifying Anti-Rheumatic Drugs. This class of medications prevents the irreversible damage that occurs in the joints and other organs. We can further divide the DMARD category into the synthetic DMARDs (older, pills) and biologic DMARDs (newer, mostly injectables).
Most RA patients, when starting treatment, are given a synthetic DMARD. There are a handful to choose from, including methotrexate, sulfasalazine, leflunomide, hydroxychloroquine and azathioprine. Which one is right for you depends on multiple factors. You and your doctor will discuss these issues, but the most commonly prescribed first DMARD, especially in the US, is methotrexate. Each medication has its own set of possible risks and side effects, but these medications have been used for decades and are very well understood.
They each act on the immune system differently but generally act to re-balance an overactive immune system so that autoimmunity is tapered down and inflammation decreases. That leads to 1) less pain (and less need for those anti-inflammatory medications) and 2) less joint and organ damage. Your doctor is concerned about your pain TODAY but also about your health and vitality for TOMORROW. This is why taking anti-inflammatory medications alone, which do nothing to prevent joint or organ damage, is not an effective strategy. They may help you today, but they do nothing to protect your health in the future.
Approximately 20-30% of people will get good control of their RA with their first DMARD. But that leaves 80-70% of us needing more. What comes next? I’ve always thought of this moment a fork in the road. One direction is towards more synthetic DMARDs (perhaps adding sulfasalazine to methotrexate) and the other direction is towards the biologics. Which road is best for you? Stay tuned for next week’s blog to find out more!
In good health,
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