What You Should Know About Taking DMARDs for Rheumatic Disease

What are DMARDs?

DMARD stands for “disease-modifying antirheumatic drug.” This is a term that encompasses a few different types of medications.

What are the types of DMARDs?

• Traditional DMARDs include drugs that have been used for several decades. They have broad effects on the immune system.
• Biologic DMARDs are more targeted and act on specific components of the immune system.
• Targeted small-molecule DMARDs known as JAK inhibitors are newer drugs that also block more precise pathways inside immune cells.

What are some examples of different types of DMARDs?

Traditional DMARDs include methotrexate, sulfasalazine, hydroxychloroquine, leflunomide and azathioprine. These drugs are taken orally (by mouth), although methotrexate is also available as an injection. This older class of DMARDs is still commonly used but they may not be enough on their own to adequately control symptoms and limit the damage caused by disease. They are often used in conjunction with other therapies. Hydroxychloroquine and sulfasalazine are generally not immunosuppressive, while the other DMARDs mentioned here are. These medications can be used in combination.

Biologic DMARDs are often prescribed when traditional DMARDs are not effective or not tolerated by the patient (for example, if they have adverse side effects or allergic reactions). Common ones include adalimumab, etanercept, certolizumab, infliximab and golimumab, which all affect a molecule called tumor necrosis factor. Biologic DMARDs that affect other components of the immune system include anakinra, tocilizumab, sarilumab, abatacept and rituximab.

JAK inhibitors, targeted small-molecule DMARDs, include tofacitinib, baricitinib, and upadacitinib. Janus kinases (JAK) are proteins involved in inflammation. As their name implies, JAK inhibitor medications impede the inflammatory process caused by these proteins.

What diseases do DMARDs treat?

Many of these drugs were developed to treat rheumatoid arthritis, but they are now used to treat a variety of inflammatory disorders. These include:

How are DMARDs given?

It depends on which one you are taking. Most of the traditional DMARDs, as well as the newer targeted small-molecule DMARDs, are taken orally in pill form, although methotrexate can also be injected. 

Biologic DMARDs on the other hand, are often subcutaneous injections that individuals can give themselves at home, either weekly or every other week. Some biologic DMARDs are given by IV in an infusion suite. 

How do DMARDs work?

They all work in slightly different ways, depending on their specific mechanism of action. But what they have in common is that they act on some part of the immune system, lowering inflammation and preventing immune cells from attacking healthy tissues.

Another thing these medicines have in common is that they all typically make individuals with rheumatic disease feel better. They reduce pain, swelling and problems with mobility, and improve a person’s quality of life.

Importantly, because they control inflammation, they actually prevent long-term damage, including damage to the joints. Decades ago, before we had these medications, people with rheumatoid arthritis developed severe deformities, especially in their hands. Now we are able to prevent that from happening.

What are the other benefits of DMARDs?

One major benefit is preserving a patient’s mobility. And we know that if someone is able to move around normally, their mood will be better. They will also sleep better.

The other thing that’s important to mention is that being in a state of high inflammation all the time increases the risks of heart disease and cancer. By treating a patient’s inflammation, we reduce the risk that these other kinds of problems will develop.

Do DMARDs suppress the immune system?

Yes. One thing that most DMARDs have in common is that they bring down inflammation by lowering the immune response. This makes people more susceptible to infections. People who are taking them need to be mindful of this and stay up to date with their immunizations. Other measures to reduce infections include handwashing, being sure to get sufficient sleep, and staying active.

Do DMARDs cause weight gain?

No. DMARDs can have a number of different side effects, but weight gain is generally not one of them.

What are some other side effects of DMARDs?

Some DMARDs like methotrexate and leflunomide should not be taken during pregnancy. When these and other medications are used in women of child-bearing potential, we are careful to counsel regarding birth control measures. It is important to discuss pregnancy plans with your rheumatologist and be aware of medication safety in pregnancy. 

Many of these medications can also have an effect on the liver. Your doctor will monitor liver tests with blood work and will counsel you on whether or not your medication can interact with alcohol. For example, methotrexate can be toxic to the liver, and it is best to avoid drinking alcohol if you are treated with methotrexate. 

Like many medications, all of these drugs have a pretty long list of potential side effects. When you start a new medication, these lists can be overwhelming. Open communication is very important to me. What I want my patients to know is that I will help them manage whatever they are experiencing. 

The good news is that we have so many medications now, and the number of choices has multiplied. I help my patients find the best medication to bring their disease under control and reduce their pain and other symptoms.

Is there anyone who can’t take DMARDs?

For people with some complex medical conditions, including chronic infections and cancer, it may be harder to find a drug that works for them. But for almost everyone we are usually able to find something that controls their rheumatic disease and is compatible with their other medications and conditions. We frequently work in combination with a patient’s other doctors to find the best treatment.

What is the difference between DMARDs and corticosteroids?

DMARDs can be used in combination with corticosteroids like prednisone. It may take up to three months for a DMARD to have its full effect, but steroid drugs work quickly. If someone has a lot of pain, we may give them both so they can start feeling better right away.

But the long-term side effects of steroids are significant. So once the DMARD starts to kick in, we wean patients off the steroid.

Can you take NSAIDs when taking DMARDs?

Yes. Nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin, ibuprofen and naproxen are generally safe when used in combination with DMARDs. It’s also OK to take acetaminophen (Tylenol) while taking DMARDs to help relieve more immediate pain.

What is the success rate of DMARDs?

This really depends on the type of disease someone has and how severe it is. But for more common conditions like rheumatoid arthritis, most patients are able to get to very low disease activity with these medications. 

Sometimes it's not always the first medicine that helps them. But when you consider all the drug options we have, we really do very well for most of our patients.

Posted: 12/13/2024

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