Rheumatoid arthritis (RA) is a chronic autoimmune disorder. It causes your immune system to attack the healthy tissues in your joints, resulting in pain, swelling, and stiffness.

Unlike osteoarthritis, which results from normal wear and tear as you age, RA can affect anyone at any age. No one knows exactly what causes it.

RA currently has no cure, but medications can help relieve symptoms. These medications include:

  • anti-inflammatory drugs
  • corticosteroids
  • drugs that suppress the immune system, or immunosuppressants

Some of the most effective drug treatments are disease modifying anti-rheumatic drugs (DMARDs), which include TNF-alpha inhibitors.

Rheumatologists often prescribe DMARDs right after a diagnosis of RA. Much of the permanent joint damage from RA happens in the first 2 years, so these drugs can make a big impact early on in the course of the disease.

DMARDs work by weakening your immune system. This action reduces RA’s attack on your joints, which lessens the damage overall.

The DMARD methotrexate (Otrexup, Rasuvo) is the most commonly prescribed RA drug.

Other DMARDs that the Food and Drug Administration (FDA) has approved to treat RA include:

  • azathioprine (Azasan, Imuran)
  • baricitinib (Olumiant)
  • cyclosporine (Neoral, Sandimmune)
  • hydroxychloroquine (Plaquenil)
  • leflunomide (Arava)
  • sulfasalazine (Azulfidine)
  • tofacitinib (Xeljanz)

Biologic DMARDs

Biologics are anti-inflammatory medications that are made from living organisms. Some newer biologic medications also function as DMARDs and have been FDA-approved to treat RA.

They work by targeting specific immune system pathways and are administered by injection or infusion:

  • abatacept (Orencia)
  • anakinra (Kineret)
  • rituximab (Rituxan)
  • tocilizumab (Actemra)
  • TNF-alpha inhibitors

Off-label DMARDs

These DMARDs aren’t FDA-approved for RA, but they may be used off-label to treat the condition:

  • cyclophosphamide (Cytoxan)
  • minocycline (Minocin)
  • mycophenolate mofetil (CellCept)
OFF-LABEL DRUG USE

Off-label drug use means a drug that’s approved by the FDA for one purpose is used for a different purpose that hasn’t yet been approved.

However, a doctor can still use the drug for that purpose. This is because the FDA regulates the testing and approval of drugs, but that doesn’t include how doctors use drugs to treat their patients.

So your doctor can prescribe a drug however they think is best for your care.

Tumor necrosis factor alpha, or TNF alpha, is a substance that occurs naturally in your body. When you have RA, the immune system cells that attack the joints create higher levels of TNF alpha. These high levels cause pain and swelling.

While several other factors contribute to RA’s damage in the joints, TNF alpha is a major player in the process.

Because TNF alpha is such a big problem in RA, TNF-alpha inhibitors are one of the most important types of DMARDs on the market right now.

Six TNF-alpha inhibitors have been FDA-approved for RA:

  • adalimumab (Humira)
  • etanercept (Enbrel)
  • certolizumab pegol (Cimzia)
  • golimumab (Simponi), an injectable drug that’s given monthly
  • golimumab (Simponi Aria), an infusion drug that’s eventually given every 8 weeks
  • infliximab (Remicade)

TNF-alpha inhibitors are also called TNF-alpha blockers because they block the activity of TNF alpha. They reduce TNF alpha levels in your body to help decrease RA symptoms.

They also begin to work more quickly than other DMARDs. They may start to take effect within 2 weeks to a month.

Biosimilars

Biosimilars, which aren’t exact copies of biologics but are engineered to produce the same results, include:

  • adalimumab-adaz (Hyrimoz)
  • adalimumab-adbm (Cyltezo)
  • adalimumab-afzb (Abrilada)
  • adalimumab-atto (Amjevita)
  • adalimumab-bwwd (Hadlima)
  • adalimumab-fkjp (Hulio)
  • etanercept-szzs (Erelzi)
  • etanercept-ykro (Eticovo)
  • infliximab-abda (Renflexis)
  • infliximab-axxq (Avsola)
  • infliximab-dyyb (Inflectra)

These biosimilars are also categorized as TNF-alpha inhibitors or biologic DMARDs.

While all of these biosimilars have been FDA-approved, some of them aren’t currently available for purchase. This is largely because the patents for the biologics haven’t expired yet.

The main downside to using DMARDs is that they’re slow to act. It can take several months to feel any pain relief from a DMARD.

For this reason, rheumatologists often prescribe fast-acting pain relievers such as corticosteroids or nonsteroidal anti-inflammatory drugs (NSAIDs) to take at the same time. These drugs can help reduce pain while you wait for the DMARD to take effect.

Examples of corticosteroids or NSAIDs that may be used with DMARDs are listed below.

Corticosteroids include:

  • prednisone (Prednisone Intensol, Rayos)
  • methylprednisolone (Depo-Medrol)
  • triamcinolone hexacetonide (Aristospan)

Over-the-counter NSAIDs include:

  • aspirin
  • ibuprofen (Advil, Motrin)
  • naproxen sodium (Aleve, Naprosyn)

Prescription NSAIDs include:

  • celecoxib (Celebrex)
  • nabumetone
  • piroxicam (Feldene)

DMARDs suppress your entire immune system. This means they put you at a greater risk for infections.

The most common infections found in people with RA are:

To help prevent infections, practice good hygiene, such as washing your hands often and bathing daily or every other day. You should also stay away from people who are sick.

Most people with RA respond well to TNF-alpha inhibitors and other DMARDs, but for some people, these options may not work at all.

If they don’t work for you, tell your rheumatologist. They’ll likely prescribe a different TNF-alpha inhibitor as a next step, or they may suggest a different kind of DMARD altogether.

Be sure to update your rheumatologist on how you’re feeling and how well you think your medication is working.

Together, you and your doctor can find an RA treatment plan that’ll work for you.