Disease modifying anti-rheumatic drugs (DMARDs) are among the most effective treatments for rheumatoid arthritis (RA). They help relieve pain and inflammation and prevent permanent joint damage.
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 has no cure at the moment, but medications can help relieve symptoms. These medications include:
- anti-inflammatory drugs
Some of the most effective treatments are disease modifying anti-rheumatic drugs (DMARDs), a category that includes tumor necrosis factor (TNF)-alpha inhibitors.
Rheumatologists often prescribe DMARDs right after diagnosing you with RA. Much of the permanent joint damage from RA happens in the first 2 years, according to the Johns Hopkins Arthritis Center. DMARDs can make a big impact early on in the course of the disease.
These medications work by weakening your immune system. This action reduces RA’s attack on your joints, which lessens its damage overall.
The DMARD methotrexate (Otrexup, Rasuvo, RediTrex, Trexall) is the most commonly prescribed RA medication.
Other DMARDs that the Food and Drug Administration (FDA) has approved to treat RA include:
- azathioprine (Azasan, Imuran)
- baricitinib (Olumiant), which is only available as a brand-name drug
- cyclosporine (Gengraf, Neoral, Sandimmune)
- hydroxychloroquine (Plaquenil)
- leflunomide (Arava)
- sulfasalazine (Azulfidine, Azulfidine EN-tabs)
- tofacitinib (Xeljanz, Xeljanz XR), which is only available as a brand-name drug
- upadacitinib (Rinvoq), which is only available as a brand-name drug
Biologics are anti-inflammatory drugs that are made from living organisms. Some newer biologics also function as DMARDs and have been approved by the FDA to treat RA.
Biologics work by targeting specific immune system pathways and are administered by injection or infusion.
Biologics for RA include:
- abatacept (Orencia)
- anakinra (Kineret)
- rituximab (Rituxan)
- tocilizumab (Actemra)
- all TNF-alpha inhibitors
They’re only available as brand-name drugs.
TNF-alpha is a substance that occurs naturally in the 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.
Several factors contribute to RA’s damage to the joints, but 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.
The FDA has approved six TNF-alpha inhibitors for RA:
- adalimumab (Humira)
- certolizumab pegol (Cimzia)
- etanercept (Enbrel)
- 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 lower TNF-alpha levels in your body to help decrease RA symptoms.
TNF-alpha inhibitors begin to work more quickly than other DMARDs. They may start to take effect after just 2 weeks.
Biosimilars aren’t exact copies of biologics but are engineered to produce the same results.
Biosimilars for RA include:
- adalimumab-adaz (Hyrimoz)
- adalimumab-adbm (Cyltezo)
- adalimumab-afzb (Abrilada)
- adalimumab-atto (Amjevita)
- adalimumab-aqvh (Yusimry)
- adalimumab-bwwd (Hadlima)
- adalimumab-fkjp (Hulio)
- etanercept-szzs (Erelzi)
- etanercept-ykro (Eticovo)
- infliximab-abda (Renflexis)
- infliximab-axxq (Avsola)
- infliximab-dyyb (Inflectra)
- infliximab-qbtx (Ixifi)
- rituximab-abbs (Truxima)
- rituximab-arrx (Riabni)
These biosimilars are also categorized as TNF-alpha inhibitors or biologic DMARDs.
While all of these biosimilars have been approved by the FDA, some of them aren’t currently available for purchase. This is largely because the patents for the brand-name 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 relief from pain.
For this reason, rheumatologists often prescribe fast-acting pain relievers such as corticosteroids or nonsteroidal anti-inflammatory drugs (NSAIDs) at the same time. These drugs can help lower pain while you wait for the DMARD to take effect.
Examples of corticosteroids or NSAIDs that may be used with DMARDs are listed below.
- methylprednisolone (Depo-Medrol, Medrol, Solu-Medrol)
- prednisone (Prednisone Intensol, Rayos)
Over-the-counter NSAIDs include:
- ibuprofen (Advil, Motrin)
- naproxen sodium (Aleve)
Prescription NSAIDs include:
- celecoxib (Celebrex)
- 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 showering or bathing regularly. Also, stay away from people who are sick.
Most people with RA respond well to TNF-alpha inhibitors and other DMARDs. For some people, these options may not work at all.
If they don’t work for you, tell a 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 a rheumatologist on how you’re feeling and how well you think your medication is working.
Together, you and a doctor or healthcare professional can find an RA treatment plan that’ll work for you.
Can my diet affect my rheumatoid arthritis?A Healthline reader
An anti-inflammatory diet that is high in antioxidants and rich in omega-3 fatty acids may help control inflammation as well as lower the risk of cardiovascular disease that can be associated with unmanaged RA.
The Mediterranean diet is a sustainable and healthy way to eat for people with RA and inflammatory diseases in general.
Foods that are high in antioxidants include fruits and vegetables. Foods rich in omega-3s include oily fish such as wild salmon, mackerel, sardines, and black cod, as well as tree nuts such as walnuts and almonds. Flaxseeds and chia seeds are also good ways to add omega-3s to your diet. Both seeds can be easily sprinkled onto your foods and are also good sources of protein and fiber.
Reducing simple sugars and foods made with white flour can also lower inflammation. Fat cells in the body carry inflammation.
Many RA medications are targeted toward lowering this inflammation. Therefore, lowering excessive fat and working toward a lean body mass would be ideal.
Other diets that are being studied but aren’t conclusive are plant-based diets, vegan diets, and certain elimination diets.Margaret R. Li, MD, FACRAnswers represent the opinions of our medical experts. All content is strictly informational and should not be considered medical advice.