NSAIDs and other anti-inflammatory drugs
Rheumatoid arthritis (RA) is an inflammatory condition that often strikes in middle age. It may not be diagnosed immediately. At first it may resemble common arthritis. Some people treat their symptoms with over-the-counter pain relievers like aspirin, ibuprofen, or naproxen. These drugs are called nonsteroidal anti-inflammatory drugs, or NSAIDs. They may offer some relief, but they cannot halt the disease.
NSAIDs may cause stomach upset in some patients. In rare cases, they may cause serious bleeding in the stomach or intestines. They may also interact with certain prescription drugs. Celecoxib (Celebrex) is a prescription NSAID that provides similar anti-inflammatory relief. However, it is less likely to cause stomach problems. Even after diagnosis and treatment, some doctors may recommend continued use of anti-inflammatory drugs.
RA is best treated early, before joints become too damaged by inflammation. Modern disease-modifying anti-rheumatic drugs (DMARDs) have made it possible to live a normal, or near-normal, life with RA. Most doctors prescribe methotrexate first. Methotrexate has been used for decades. It works by blocking certain proteins involved in inflammation.
Possible side effects of methotrexate include nausea, vomiting, and abnormal liver function. Some patients develop mouth sores, rash, or diarrhea. Tell your doctor if you develop shortness of breath or chronic cough. Additionally, some patients may experience hair loss. Women should not take methotrexate during pregnancy. You may be asked to take the B-vitamin folate to reduce some side effects.
Leflunomide (Arava) is an older DMARD that helps reduce pain and swelling due to RA. It may be given in addition to methotrexate, if methotrexate alone is inadequate to control the progression of RA.
Leflunomide can damage the liver, so it’s important to have your liver function monitored with routine blood tests. Because of its possible effects on the liver, you cannot drink alcohol while taking this drug. Leflunomide can also cause birth defects, even after you’ve stopped taking the drug. It should not be taken by women who are pregnant or who might become pregnant. Diarrhea is the most common side effect.
Hydroxychloroquine and sulfasalazine
Hydroxychloroquine (Plaquenil) is an older DMARD sometimes still used for mild RA. It may work by interrupting signaling among cells. It’s one of the best-tolerated DMARDs. Side effects are usually mild and may include nausea and diarrhea. Taking the drug with food may help. Changes to the skin are less common. These may include rashes or the appearance of dark spots. In extremely rare cases the drug may affect vision. Report any vision problems to your doctor immediately.
Sulfasalazine is an old drug still occasionally used to treat RA. It combines an aspirin-like pain reliever with an antibiotic sulfa drug. Side effects are usually mild. Nausea and abdominal discomfort are the most common complaints. The drug increases sun sensitivity. Take precautions to avoid sunburn.
Biologics: Anti-TNF drugs
Biologics have greatly improved the treatment of RA. They work by interrupting certain components of the immune system. One group of biologic drugs works by blocking the inflammatory protein known as tumor necrosis factor (TNF). Because these drugs suppress the immune system, infection is among the most serious side effects of these drugs.
Anti-TNF biologics are given by injection. Irritation at the site of injection is a common side effect. It’s important to be tested for latent tuberculosis and hepatitis B virus infection before starting treatment because anti-TNF drugs impair the immune system. If present, these infections can flare up after treatment begins. The risk of lymphoma and skin cancer may rise with long-term use of these drugs.
Some RA drugs were originally used to prevent rejection after organ transplant. These drugs are called immunosuppressants. Some are still used occasionally to treat RA. Cyclosporine is an example. Azathioprine is another. Cyclosporine may cause high blood pressure, kidney problems, or trigger gout. Azathioprine may cause nausea, vomiting, and less often, liver damage. Like other medications that affect immune system function, these drugs make infections more likely.
Cyclophosphamide (Cytoxan) is a potent immunosuppressant reserved for severe RA. It is usually only given if other drugs have failed. Side effects can be serious and may include low blood counts that increase risk of infection. It can also make it harder for men or women to have a baby. Bladder irritation is another risk.
Older drugs: Gold preparations and minocycline
Various substances have been used to control RA joint inflammation. Gold is one of oldest of these. Although seldom used now, it can be surprisingly effective. It is usually given by injection, but a pill form also exists. Gold preparations can cause unpleasant side effects. Skin rashes, mouth sores, and changes in the sense of taste are the most common side effects. Gold can also affect blood counts.
Although RA is not caused by an infection, an older antibiotic, minocycline, may help treat mild RA. It works like some other DMARDs to suppress inflammation. Dizziness, skin rash, and nausea are common side effects. Minocycline use may encourage vaginal yeast infection in women.
Biologics: JAK inhibitors
Tofacitinib (Xeljanz) is the first drug in a new class of biologic treatments for RA. It is a Janus kinase (JAK) inhibitor. Unlike other DMARDs, it is available as a pill. This eliminates potential side effects related to injections.
Like other DMARDs, tofacitinib may cause increased risk of infections. People with active infections, or carriers of hepatitis B or C virus, should not take tofacitinib. After starting the drug, you should report any symptoms of infection. These symptoms may include fever, muscle aches, chills, cough, or weight loss, among other symptoms.
You should also be aware of the lung infection called histoplasmosis. This infection is common to the central and eastern United States, as well as parts of Central and South America, Africa, Asia, and Australia. You can get the infection by breathing in fungal spores from the air. Tell your doctor if you live in, or expect to visit, any of these areas.
Tofacitinib tends to increase blood lipid levels, but the ratio of “bad” LDL-cholesterol to “good” HDL-cholesterol levels usually remains the same.