The number of drugs for the treatment of rheumatoid arthritis has increased significantly in recent
years, and the choices can be quite perplexing. For each drug we need to consider the benefits –
including relief of symptoms and of long term damage. We also need to consider the harms – and
the side effect profile tends to vary from drug to drug. Clearly, any treatment decisions need to be
made carefully with your treating physician.
Conventional Synthetic disease modifying anti-rheumatic drugs. These include methotrexate,
sulfasalazine, leflunomide and hydroxychloroquine.
Methotrexate – This is usually the first drug used. This is taken once a week – usually by mouth but
occasionally by injection – and is often considered the ‘anchor’ drug, because it is widely
recommended as the first medication.
Sulfasalazine – often used second, this is taken twice a day and also requires regular blood tests.
Hydroxychloroquine – the mildest drug in this group. It is taken once a day and is usually well
tolerated. It requires some monitoring of the back of the eye but no regular blood tests.
Leflunomide – this medication is taken once a day and requires regular blood tests. It can affect the
liver, full blood count or blood pressure and has side effects including particularly nausea, loss of
appetite or change in bowel habit.
Biologic disease-modifying antirheumatic drug (bDMARD)
Anti-TNF – There are five drugs within this group (infliximab, etanercept, adalimumab, certolizumab
pegol, golimumab) and there are ‘biosimilars’, which are almost identical but cheaper. They were
the first biologic drug to be developed. They are given by injection, usually just under the skin and
administered by the patient at home to themselves, between once a week and once a month.
Tocilizumab – This is an example of an anti-IL6 antibody. Tocilizumab is used in rheumatoid arthritis,
and is given by injection or infusion.
Rituximab – Rituximab is an antibody against CD-20 targeting some of the white cells in the immune
system. It is used in rheumatoid arthritis and lupus and is given in a pair of infusions a fortnight
apart. Those can be repeated after 6 or 12 months or as required. It is an antibody against.
Jak inhibitors – Tofacitinib and Baricitinib. These are daily tablets which affect the immune system
pathways in the body. There is an increased risk of infection, including shingles, usually minor
changes in liver or kidney function or cholesterol. There can also be an increased risk of blood clots.