In most cases, treatment for rheumatoid arthritis (RA) begins with medication. Common drugs for RA can be divided into two categories: drugs that treat RA symptoms, and drugs that slow the progression of RA. Your treatment plan may start with one or both types, depending on how severe your RA is. In some cases, surgery may be needed to fuse or repair damaged bone or joints. Here's more information about the risks and benefits of the most common RA medications.
NSAIDs and COX-2 Inhibitors
Nonsteroidal Anti-inflammatory Drugs (NSAIDs) are very effective at relieving the symptoms of RA -- joint pain, swelling, and inflammation -- but they don't slow RA's progression.
Traditional NSAIDs, such as aspirin, ibuprofen, and naproxen, work by blocking two enzymes in the body -- COX-1 and COX-2 -- which contribute to inflammation and pain. But COX-1 also helps protect the lining of your stomach and other tissues, so blocking it can cause side effects such as ulcers and gastrointestinal bleeding.
Another type of NSAID, called a COX-2 inhibitor, was designed to be easier on the stomach by blocking only the COX-2 enzyme. But these newer NSAIDs aren't problem-free. Two COX-2 inhibitors (rofecoxib and valdecoxib) were taken off the market due to increased risk of stroke and heart attack. Only one COX-2 inhibitor (celecoxib) is available in the U.S. Short-term use of NSAIDs -- for 1 to 2 weeks -- is generally considered safe, but when taken long-term, side effects may include:
- Ulcers and gastrointestinal bleeding
- High blood pressure
- Fluid retention
- Impaired kidney function
- Increased risk of heart attack and stroke
If you need to take NSAIDs for longer periods of time, your doctor may also prescribe treatments, such as misoprostol, a proton pump inhibitor, or an H2 inhibitor to help prevent gastrointestinal ulcers and bleeding.
Corticosteroids
Corticosteroids (aka, steroids) provide quick relief from pain and inflammation. They may be used at high doses in combination with disease-modifying antirheumatic drugs (DMARDs) to quickly reduce inflammation at the start of treatment. But as DMARDs begin to take effect, steroids are usually tapered down to very low doses and may be discontinued entirely.
Direct corticosteroid injections can relieve acute joint pain flare-ups, but for safety reasons, injections are generally limited to no more than a few per year. Short-term side effects of corticosteroids include weight gain, acne, and irritability. Long-term side effects include high blood pressure, cataracts, glaucoma, diabetes, psychological problems, and osteoporosis.
Chemical and Biologic DMARDs
Disease-modifying antirheumatic drugs (DMARDs) are a broad category of drugs that can be divided into two classes: chemical DMARDs, and the newer biologic DMARDs, also called biologics or biologic response modifiers (BRMs). All DMARDs aim to readjust the overactive immune response that characterizes RA. The main difference between the two classes is that chemical DMARDs affect your larger immune system, while biologics target specific immune cells.
DMARDs are considered the gold standard for treating RA, and may be used alone or combined with NSAIDs, corticosteroids, or other DMARDs. RA treatment often begins with a chemical DMARD called methotrexate. If methotrexate alone is not enough, a common second-step is to combine methotrexate with a biologic DMARD called a TNF-blocker. Other types of biologics may be used if TNF-blockers don't do the job.
Early, aggressive treatment with DMARDs can prevent damage to joints, bones, and other parts of your body, and may slow or even halt RA's progress. But these powerful drugs work by weakening your immune system and may cause serious side effects, including nausea, skin rashes, hair loss, and increased risk of infection.
Unlike NSAIDs and steroids, which offer quick relief, DMARDs may take up to 6 months to relieve pain and inflammation. To reduce pain and inflammation quickly, your doctor may combine DMARD treatment with pain relievers or steroids for the first few months.
