Disease-Modifying Antirheumatic Drugs (DMARDs) are medications used to treat rheumatoid arthritis (RA). DMARDs reduce pain and inflammation, slowing the damage done to tissues and the progression of the disease.
DMARDs include a combination of older, well-established medications and newer biologic DMARDs that are more effective at targeting disease symptoms and causes.
These medications are used in treating RA as part of a holistic plan under your specialist’s supervision. You will be closely monitored for side effects and reassessed regularly to ensure your DMARDs treatment plan remains effective.
What are DMARDs?
Disease-modifying antirheumatic drugs (DMARDs) are a group of medications that decrease inflammation and pain in the body and are especially effective for treating inflammatory diseases such as rheumatoid arthritis.
They are often labelled as immunosuppressants because they work to suppress, slow or change how your immune system responds to disease.
DMARDs help to:
- Decrease pain and inflammation
- Preserve joint function
- Reduce or prevent joint damage and bone erosion
- Slow the speed and spread of disease
DMARDs are most commonly used to treat RA but can also help treat other inflammatory conditions such as:
- Ankylosing spondylitis
- Crohn’s disease
- Inflammatory bowel disease
- Inflammatory myositis
- Juvenile idiopathic arthritis
- Multiple sclerosis
- Psoriatic arthritis
- Rheumatoid vasculitis
- Sjögren’s syndrome
- Some cancers
- Systemic lupus erythematosus
- Systemic sclerosis
- Uveitis
How do DMARDs work?
These medications have several different effects on the body. They all work to dampen down your body’s natural immune response. So if you have an autoimmune disease such as RA, it sends your immune system into overdrive.
Instead of your immune system attacking any foreign infections in your system, it will instead attack your body’s healthy tissues by mistake, causing pain, inflammation and degradation of joints and connective tissues.
DMARDs work to:
- Reduce your immune system’s response to attacking its healthy tissues
- Target a specific pathway of your body’s immune system response
- Work on individual immune system proteins
What are the types of DMARDs?
Once you have been diagnosed with RA, you will usually be offered treatment using a combination of traditional DMARDs and biologics as part of your ongoing disease management programme.
The DMARDs you may be prescribed include:
- Hydroxychloroquine
- Leflunomide
- Methotrexate
- Sulfasalazine
You may be given methotrexate as your first treatment option, paired with another DMARD and pain relief using corticosteroids. These may be combined with other biological treatments.
Your specialist will monitor you carefully for reactions as there are a few common side effects of methotrexate, which include:
- A sore mouth
- Diarrhoea
- Feeling sick
- Hair loss
- Headaches
- Loss of appetite
You will also undergo regular screening as methotrexate can affect your blood cells and liver function, but most people tolerate methotrexate well.
What are biologics?
Biologics are DMARDs that are made using molecular biology. Biologics are made using proteins that target specific molecules, pathways and cells in the body that cause damage to tissues and inflammation. Biologics are proving more effective than traditional DMARDs in treating inflammatory conditions such as RA.
How long does it take for DMARDs to work?
DMARDs need some time to build up in your system before you notice any positive effects. It is essential to keep taking your medications even if you believe they are not working in the beginning.
You won’t get immediate pain and inflammation relief when you first take DMARDs, so your specialist may give you alternative pain relief until your DMARDs can take over the job and start working effectively to reduce pain and swelling. It may be a month or more before you feel noticeable results from taking DMARDs, so you shouldn’t get despondent when you see slow results.
It may be necessary for your specialist to try two or three different types of DMARDs before you find the most suitable combination for your needs. Once you find the most effective combination, you will usually have to take your medication for the long term.
How are DMARDs taken?
Traditional DMARDs are usually taken orally in tablet form by mouth. Biologic DMARDs are given by injection or infusion via an IV directly into a vein.
How do you decide which DMARDs are the best for me?
Your RA specialist will need to thoroughly examine you and perform several diagnostic tests before deciding on the best DMARDs to treat your condition.
Some factors that are considered include:
- Allergies or food sensitivities you have
- How active and severe your disease is
- Other medical or health conditions you currently have or have been treated for
- Other medications you are presently taking
- The expected benefits of the DMARD
- The side effects of DMARD(s)
If you are a woman and planning to become pregnant, some DMARDs will be unsuitable for use. You should also notify your RA specialist if you take food supplements, herbal extracts, or over-the-counter painkillers.
How are DMARDs prescribed?
Your RA specialist will prescribe DMARDs as part of your treatment plan and the most appropriate combination of DMARDs and other medications according to your screening tests and lab results.
You may be prescribed DMARDs as:
- A single traditional DMARD
- A single traditional DMARD combined with a low-dose corticosteroid, such as prednisone or cortisone, or other drugs
- Two or more traditional DMARDs that work in combination
- A traditional DMARD in combination with a biologic DMARD
Your prescription medication may only contain a single traditional DMARD if you suffer from mild to moderate RA. You will be monitored closely throughout your treatment plan. Suppose your symptoms don’t improve after a couple of months. In that case, your RA specialist may increase your dose, move you to a different DMARD or add a complementary DMARD, including a biologic DMARD, to help relieve your symptoms.
It may take some time working with your RA specialist to discover the right combination of DMARDs or medications to treat your condition that works most effectively with the fewest side effects.
What are the possible side effects of DMARDs?
Side effects can vary depending on the type of DMARD you are prescribed. One patient may feel some mild side effects, but the next will experience none. This is why your RA specialist will work closely with you to monitor your reactions to any prescribed DMARD and a better alternative found if you experience any substantial side effects to your treatment.
Commonly reported side effects of traditional DMARDs include:
- Abdominal pain
- Diarrhoea
- Increased risk of infections
- Liver problems
- Loss of appetite
- Low white cell count
- Nausea
- Rash or other allergic reaction
Common side effects of biologic DMARDs include:
- Increase in cholesterol levels, low blood cell counts and increased liver enzymes
- Increased risk of blood clotting (Janus kinase inhibitors)
- Increased risk of common and severe bacterial, fungal and viral infections
- Reactivation of tuberculosis, herpes zoster, hepatitis B and C
Side effects can be very specific to an individual DMARD, so you may not experience any of the side effects listed above or just one or two according to the DMARD you are prescribed.
It is essential to keep your RA specialist up to date with any side effects you notice when taking DMARDs. It may be possible to get the same health benefits from another DMARD without the accompanying side effects.
Some patients can experience more potent side effects from taking DMARDs to the extent that the side effects are troublesome enough to interfere with their quality of life. This is why you need to keep your RA specialist informed of your reactions to your medications so changes can be made as soon as possible.
Who cannot take DMARDs?
Like other prescription medications, some health conditions prevent you from safely taking DMARDs as part of your RA treatment plan. These include if:
- You have a low level of stem cells in your bone marrow
- You have a low white blood cell count
- You have an active infection
- You have certain blood cancers, kidney, liver or heart conditions
- You have immunodeficiency disorders. These are disorders that keep your body from fighting infections and diseases
Your RA specialist will check your medical history and the results of your screening tests and rule out DMARDs if they are not considered an appropriate treatment option for you.
What results can I expect from taking DMARDs?
The effect that your DMARD and medication combination will have on your symptoms and disease progression will vary according to how severe your RA is and any other health issues you may have or are being treated for.
DMARDs are a revolutionary move forward in treating RA and other autoimmune health conditions. It has to be clarified that DMARDs don’t cure RA or prevent it from developing, but you are more likely to achieve better outcomes and improved quality of life when using them than more traditional treatment options.
There are several common side effects of taking some DMARDs, but most people seem to tolerate them well. However, you should inform your RA specialist ASAP if you experience sudden and severe side effects, including fever, skin rash, nausea or vomiting, and symptoms of infection (sore throat, chills, fever). You should also contact your RA specialist if you become pregnant while taking DMARDs.
Article by Dr. Naveen Bhadauria
