Role of Advanced Therapies in Arthritis
Rheumatologists are treating inflammatory arthritis with targeted DMARDs and biologics.
New super-specific medicines and new uses of existing drugs are changing the way rheumatoid arthritis (RA), psoriatic arthritis (PsA) and other inflammatory diseases are treated. In the not-too-distant past, arthritis often meant joint deformity and disability, and even early death.
Earlier diagnosis and advanced medicines have changed the landscape of arthritis treatment. As a result, people with arthritis are now living longer and healthier lives than ever before.
“In the 1980s and 1990s, the goal was to control disease activity as much as we could, but now our goal is to treat these diseases aggressively early on to prevent progression, downstream consequences including heart risks and the need for surgery,” says Linda A. Russell, MD, an assistant attending physician at the Hospital for Special Surgery in New York City.
Doctors call this strategy “treat to target” and it’s helping people who have inflammatory diseases live better.
There is no cure for RA, PsA or ankylosing spondylitis (AS). But by pairing the right medicines with the right person and not being afraid to make changes, remission – no signs of active disease — is possible for many.
Starting with Traditional DMARDs
Traditional disease modifying anti-rheumatic drugs (DMARDs) are usually the first medicines used for inflammatory diseases like RA, Dr. Russell says.
As their name suggests, these drugs slow the disease down. They may be used together, with other types of DMARDs, with nonsteroidal anti-inflammatory drugs (NSAIDs) or with corticosteroids. Using two or three traditional DMARDs together (called combination therapy) was once common in RA treatment. Research shows these combinations can still hold their own against some of the newer drugs.
“The traditional DMARDs are so much cheaper than some of the newer medications, and have been around so much longer, that we try a DMARD first. But we don’t wait too long to move on,” Dr. Russell says. If, after a three-month trial, symptoms aren’t improving, another DMARD or a biologic may be added to the mix, she says.
Moving to Advanced Therapies
Biologics work on specific parts of the immune system, making them more precise than traditional DMARDs. These powerful medicines are given as a shot or in a doctor’s office through an IV (intravenous infusion). “Most often, patients take these drugs with methotrexate, as the mix of medicines is more helpful than either alone,” says Dr. Russell.
Usually the first biologic your doctor will prescribe is one that blocks tumor necrosis factor-α (TNF-α). If the first anti-TNF drug you try doesn’t work or does work at first but stops working, you may try another anti-TNF. If you have a serious side effect or you don’t get relief from the second anti-TNF, there are several other biologics your doctor can prescribe.
The newest kids on the block are called “targeted DMARDs” and these are usually tried when biologics fail, says David Pisetsky, MD, PhD, a professor of medicine and immunology and chief of rheumatology at Duke University Medical Center in Durham, North Carolina.
Unlike the traditional DMARDs, targeted DMARDs are super-specific. They target different players in the inflammation process than biologics. Unlike biologics, they come in pill form.
“Biologics have been around longer than targeted DMARDs so they are typically used first, but in the future, targeted DMARDs may be started sooner,” Dr. Pisetsky says.
Cost, preferences about oral versus injectable medicines, and medical history all factor into the decision about which drugs to try and when to try them. “Different patients respond to different drugs,” says Melissa Bussey, MD, an assistant professor in the division of allergy, immunology and rheumatology of Loyola University Chicago Stritch School of Medicine. “The good news here is that we have many options to try.”