What are disease-modifying antirheumatic drugs?
Disease-modifying antirheumatic drugs are a group of drugs commonly used in people with autoimmune diseases such as rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, and systemic lupus erythematosus.
They work by reducing pain and inflammation and preventing damage to joints or other organs.
The goal of these drugs is to suppress the body’s overactive immune system. Their effects appear within weeks or months and they are not designed to provide immediate relief from symptoms.
Other medications, such as analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs, e.g., ibuprofen or naproxen) and, sometimes, cortisone, are administered to provide faster relief from ongoing symptoms.
A common side effect of anti-rheumatic drugs is that they may increase the risk of infections, such as upper or lower respiratory tract infections, so it is very important to get the appropriate vaccinations as needed.
How is the appropriate DMARD selected for each case?
The choice of medication depends on various factors, such as the severity of the disease, the balance between possible side effects and expected benefits, other medical conditions, and the patient’s personal preference.
Before starting treatment, the patient and doctor should discuss the benefits and risks of each type of treatment, including possible side effects, dosage regimen, frequency of monitoring, and expected results.
Sometimes a person needs to try different medications or combinations to find the one that works best and has the fewest side effects.
Disease-modifying antirheumatic drugs are divided into three categories:
– Classic/conventional immunomodulators
– Biological agents
– Targeted synthetic immunomodulatory drugs
What are classic/conventional immunomodulators?
The most common conventional DMARDs are hydroxychloroquine, methotrexate, leflunomide, and azathioprine. There are other drugs that are used less frequently, such as cyclosporine, sulfasalazine, mycophenolate, and cyclophosphamide.
Hydroxychloroquine
It is used early in the course of rheumatoid arthritis and often in combination with other DMARDs. It is also very commonly used to treat systemic lupus erythematosus.
It is usually taken in pill form once or twice a day and may take two to three months or longer to improve symptoms.
It is usually a very well-tolerated drug. Side effects are uncommon. Rarely, skin rash, skin hyperpigmentation, indigestion, diarrhea, or headache may occur.
Extremely rarely, and after many years of taking the medication, a problem may occur in a part of the eye called the retina. It is important to have an eye examination once a year, as preventive screening allows for the early detection of this toxicity and discontinuation of the drug before vision problems occur.
Methotrexate
Methotrexate is used to treat several autoimmune diseases such as rheumatoid arthritis, psoriatic arthritis, systemic lupus erythematosus, and others.
When it starts working, it reduces pain, swelling, and stiffness in the joints.
It is taken weekly (on the same day each week) as a pill or subcutaneous injection (using a thin, small needle). It may take more than six weeks of treatment to see an improvement in symptoms. Methotrexate can be combined with other conventional DMARDs or with a biological agent or other targeted synthetic DMARD if methotrexate alone does not adequately control the disease.
It is generally a well-tolerated drug and any side effects that occur usually subside when the dose is reduced or the drug is discontinued.
Side effects include stomach problems, feeling tired, mouth ulcers, and hair loss. Proper monitoring is crucial for identifying possible side effects of the drug. One month after starting treatment, blood tests are performed to check blood cell production by the bone marrow and liver and kidney function. Liver problems may occur, but they are usually reversible when the drug is discontinued.
People using methotrexate should also limit their alcohol consumption due to the increased risk of liver damage with this combination.
Οι γυναίκες δεν πρέπει να μείνουν έγκυες ή να θηλάζουν ενώ λαμβάνουν μεθοτρεξάτη.
Women should not become pregnant or breastfeed while taking methotrexate.
Proper monitoring is important in people taking methotrexate. Blood tests every 3-4 months are recommended.
Anyone taking methotrexate should take folic acid (at least 5 mg weekly) to reduce the risk of certain side effects, such as stomach upset, mouth sores, low blood cell counts, and abnormal liver function.
Leflunomide
Leflunomide is used to treat inflammatory arthritis such as rheumatoid arthritis and psoriatic arthritis.
Once it starts working, it reduces pain, swelling, and stiffness in the joints.
It is taken orally once a day. It can also be used in combination with a biological agent.
Possible side effects include rash, hair loss, abnormal liver function tests, nausea, diarrhea, weight loss, and abdominal pain. High blood pressure may occur in up to 10 percent of people.
Regular blood tests are required one month after starting treatment and every 3-4 months during treatment for monitoring.
Women should not become pregnant while taking leflunomide or while it is still detectable in the body.
Azathioprine
It is mainly used in cases of systemic lupus erythematosus and other connective tissue diseases, but not in rheumatoid arthritis, psoriatic arthritis, or ankylosing spondylitis. It is taken orally once or twice a day.
The most common side effects of azathioprine include nausea, vomiting, decreased appetite, abnormal liver function, and low white blood cell count. Regular blood tests are recommended during treatment with azathioprine.
More information about these and other medications can be found on the website of the Cretan Rheumatism Association (https://www.srcrete.gr/enimerotiko-yliko/) or on the information pages of other associations (links to other associations can be found in the useful links tab).
