Dr. Joshua F. Baker is a faculty member appointed within rheumatology and epidemiology at the University of Pennsylvania and funded by a career development award through Veterans Affairs Clinical Science Research & Development to do clinical research in rheumatoid arthritis. Through this support, he is focusing on modifiable risk factors with the goal of improving clinical care of chronic rheumatic diseases, particularly rheumatoid arthritis. Specifically, he aims to conduct observational and interventional studies with a focus on disease activity measures; obesity; muscle, bone, and joint health; cardiovascular disease; and other long-term outcomes.
There are several studies to suggest that it is safe for most to try more traditional disease-modifying drugs such as methotrexate, sulfasalazine, and hydroxychloroquine before going on to biologic drugs. Many people with rheumatoid arthritis will not need a biologic drug. However, many people do not reach disease remission on these medications. If you do not reach disease remission, your rheumatologist is likely to try a biologic drug. In addition, if you have other medical problems that make the traditional medicines less safe, your rheumatologist may prefer a biologic drug earlier in your treatment.
Most biologic drugs have very few side effects since they are proteins targeted at a specific rheumatoid arthritis pathway. Some patients will experience injection site reactions that are not dangerous, but can be bothersome. There is likely to be a small risk of infection for patients taking biologics, but this rarely precludes the use of these therapies for most patients.
Currently rheumatologists do not typically prescribe two biologic drugs. This strategy has not been studied, but there is concern that it could increase the risk of infection. The use of two biologics would also vastly increase the cost of treatment and is unlikely to be covered by insurance.
Most patients initiating biologic drugs will begin to show signs of improvement within the first 2 to 3 months. Patients may continue to improve after this time, but usually we can tell pretty early whether there is going to be a meaningful improvement. My practice is to wait 3 months before giving up on any therapy.
Generally speaking, this combination is well-studied and considered very safe. However, when combining drugs for rheumatoid arthritis, you should consider the increased risks of infection when combining two therapies. The current recommendations suggest that you should also not receive live vaccines while taking multiple drugs for rheumatoid arthritis given this potential risk.
Since rheumatoid arthritis symptoms are closely tied to other medical conditions, it is important to treat each patient as an individual. Many people will benefit from weight loss, exercise, and mindfulness exercises. While no specific dietary recommendations for the disease itself have been suggested, rheumatologists would generally agree that healthy fruits, vegetables, grains, and healthy fats are a good approach.
The debate about whether biologic drugs cause cancer has gone on for more than a decade. There is no definitive evidence that they increase the risk of cancer despite very large and well-done studies. The studies that do suggest that there might be an increased risk all find that this risk is small. Since we also suspect that active rheumatoid arthritis can also lead to an increased risk of cancer, taking medication that reduces your disease activity may actually lower your risk. Skin cancers may be more likely with certain biologics, and this should be considered if there is a family or personal history.
There are many biologic drugs available now. There is limited evidence to suggest that we can tell which drug will work for which patient. There are also few head-to-head studies to suggest that one therapy is better than another. Therefore, a discussion with your doctor and a team decision-making approach is appropriate.
While rheumatoid arthritis rarely goes into remission without some treatment, we are fortunate to have many effective drugs that can be taken for many years without known complications. There is recent interest in understanding who can come off of biologics and when this should be done. Most rheumatologists would want you to stay in remission for a few years before trying to wean any of your therapies. However, many can successfully taper the doses of their therapies, and a minority of patients may be able to discontinue.
It is important to make sure that your current symptoms are due to rheumatoid arthritis disease activity before trying new therapies.It’s important to tell your doctor how you are feeling, what your limitations are, and how your life has been affected by your current symptoms so that you can discuss the best path forward. Your doctor should look at your joints, assess for inflammation, and determine if there are other conditions that might be contributing to your symptoms.
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