Disease Modifying Anti-Rheumatic Drugs (DMARDs)

 

What are disease modifying drugs?

 

Disease modifying anti-rheumatic drugs (or DMARDs for short) are drugs that are used to treat a number of forms of arthritis, modifying not only the symptoms but the otherwise long-term effects of untreated arthritis – like permanent damage in the joints.  Unlike pain killers and anti-inflammatory drugs (NSAIDs; see BSR Patient Information on NSAIDs), which simply treat pain and stiffness, DMARDs treat the underlying causes of arthritis. DMARDs are important in treating some, but not all,  forms of arthritis (e.g. rheumatoid or psoriatic arthritis but [generally] not osteoarthritis). There are a number of different DMARDs:

  • Hydroxychloroquine
  • Sulfasalazine
  • Methotrexate
  • Leflunomide
  • Azathioprine
  • Myocphenolate mofetil
  • Ciclosporin

There are also a newer group of drugs known as “biological therapies” and they are dealt with in separate BSR Patient Information.

 

Which is the best DMARD for me?

 

 

Your rheumatologist will usually make an assessment of the risks and benefits of the different drug treatments and discuss with you the reasons for using a certain drug or combination of drugs.

There are many factors involved in the decision including:

  • The type of arthritis you have and how severe it is;
  • Your age – some drugs become less safe with age;
  • Plans for or current pregnancy or breast feeding – some drugs can affect fertility or have an effect on a  developing baby;
  • Your lifestyle – particularly your usual alcohol intake;
  • Any other medical conditions that you suffer from and other drugs that you take – for example some drugs can increase blood pressure and may not be the best choice for somebody who already has blood pressure problems.

Methotrexate is the most commonly chosen DMARD in early rheumatoid arthritis and psoriatic arthritis. It is sometimes given in combination with other drugs as well.  

 

Can I be sure that the DMARD chosen for me will work?

 

Unfortunately, there is currently no way to predict whether one drug will work better than another for a particular person.  It is also not possible to predict who will develop side effects with any particular drug. 

This means that it can take time to find the right drug for you.  Your specialist will suggest what he or she thinks will be the best drug for you. Not all drugs work for everybody and all drugs can cause side effects in some people.  Contact your doctor or your Specialist Rheumatology Practitioner telephone advice/helpline (if you have access to one) if you think you are having side effects to your DMARD.

 

How quickly will my DMARD work?

 

DMARDs take time to work and it can take several weeks or even months for them  to ease the pain, swelling and stiffness. The aim of treatment is to achieve the lowest level of activity of your arthritis as possible.  If this target cannot be achieved your rheumatologist will discuss changing your treatment.  This may involve either adding another drug to your treatment or changing it.  However, this would not normally happen until you have had at least 4 months of treatment.

 

What can be done for my arthritis while I wait for the DMARD to work?

 

Your specialist will often recommend using non-steroidal anti-inflammatory drugs (NSAIDs; see Patient Information on ‘NSAIDs’) as well as your DMARD. NSAIDs can help to manage your joint pain, stiffness and swelling quickly whilst waiting for your DMARD to start working.

Glucocorticoids (‘Steroids’; see Patient Information on ‘Glucocorticoids’) may also be used in the early stages of arthritis treatment to ease symptoms quickly. Glucocorticoids are either given as tablets (Prednisolone) taken on a daily basis for the first few weeks, or given as injections into particularly swollen joints or as a long lasting injection into the muscle of your bottom/thigh (methylprednisolone).  Whether you need glucocorticoid and how it might best be given will depend on the severity of your arthritis and the joints that are affected. You can discuss this with your Rheumatologist.

Glucocorticoids will often make you feel better very quickly. This does not mean that you do not need your DMARD as well.  The effects of glucocorticoids wear off after a few weeks, and (for example) Prednisolone tablets are no longer used as long term treatment in most cases or arthritis because of the side effects that they can cause add up, if used over a long period of time.

When will I be able to stop DMARD treatment?

  

Most people who have an arthritis that requires DMARD therapy will take some treatment long term, often for the rest of their lives.  Once your arthritis has stayed well controlled for a period of months, slowly reducing the treatment may be possible.  In most people the aim is to find the lowest level of therapy that will keep the arthritis under control, rather than aiming to stop the drug completely.

The decision to try to reduce DMARD treatment will be affected by how well your Rheumatologist feels that your arthritis is controlled, whether there is new joint damage developing as seen on X-Rays and your own views on taking medication.  If you are unhappy taking your medication, or want to look to reduce it, talk to your rheumatologist or rheumatology specialist nurse first.

 

Is infection a side-effect of DMARD treatment?

 

Yes, for some. Typically Hydroxychloroquine and sulfasalazine are not associated with a significant infection risk but methotrexate, Leflunomide and Ciclosporin are. Glucocorticoids (e.g. Prednisolone) are as well (see: BSR Patient Information on Glucocorticoids).

If you get an infection while taking a DMARD then please consult your GP as the advice on what to do will often be provided to them in a Shared Care document produced by them and your Rheumatology team. Alternatively, discuss what to do with your Rheumatology Practitioner directly or via the Helpline Telephone contact number. For methotrexate for example it is OK if you have an infection, to promptly stop the methotrexate for 2-3 weeks if necessary.

 

Do I need the winter vaccinations?

 

It’s advisable for patients taking most DMARDs including methotrexate to have the winter flu vaccination each year and to be brought up to date with the Pneumovax vaccination each year. Please discuss this with your GP surgery staff. Your Rheumatology practitioner can advise further.

 

What other side effects should I look out for with DMARD treatment?

 

 

The side effects vary to some extent from drug to drug.  You should be given an information sheet about each drug you take explaining what side effects to look out for.

Common side effects which can happen with any drug include:

  • Feeling sick (nausea)
  • Being sick (vomiting)
  • Tummy ache

These side effects are not serious. They will usually settle down very quickly when stopping the drug or reducing the dose. Some of the drugs can cause more serious problems with your liver or with the white cells in your blood.  White cells are important in fighting infection.

Signs that you might have more serious side effects from your drugs include:

  • Yellowing of your skin or eyes (jaundice)
  • Dark urine
  • Mouth ulcers

Are any precautions taken to look for serious side effects?
All DMARDs (except for hydroxychloroquine) require blood test monitoring. Detailed information about monitoring for each DMARD is made available to your GP in the form of a card or booklet.  Most rheumatology departments have their own cards and include advice on whom to contact if blood test abnormalities are found. Generally:

You will have blood taken (and possibly a chest X-ray) before starting treatment, then have blood tests  between every 2 to 4 weeks (depending on which DMARD you are receiving) for the first 6 months;

With some drugs you will also be asked to provide a urine sample for checking or have a blood pressure check at the same time as you have your blood tests done;

Usually these blood tests can be done at your health centre. Your rheumatology department will provide guidance to your doctor or health centre nurse about what tests to do and what to do if they are abnormal;

After the first 6 months of treatment it may be possible for the monitoring tests to be done less often.

 

Useful Links

 

Search the name of your DMARD at  www.medicines.org.uk and read the PILS document or go to  www.arthritisresearchuk.org and search the name of your DMARD under ‘Arthritis Information’.


To conclude, if you are in any doubt speak with your Rheumatology team.