Getting Aggressive Against Rheumatoid Arthritis

The right mix of medications is crucial

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Fifteen years ago, doctors treated rheumatoid arthritis conservatively. We might start with anti-inflammatories and work our way up to disease-modifying drugs such as methotrexate.

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The problem? This approach simply didn’t do enough. Symptoms would linger, and the damage this autoimmune disorder does to joints would continue to add up.

Things have changed. Taking our cue from the way oncologists treat cancer, we have become more aggressive in how we treat arthritis. In some cases, we can stop — and even reverse — the damage using a combination of medications.

Disease-modifying agents

Disease-modifying agents have been in use for years, but they have become our baseline of treatment rather than a later option. The most common disease-modifying agent is methotrexate (Rheumatrex®, Trexall®), which slows down the inflammation process that leads to joint damage.

“Think of the inflammation of rheumatoid arthritis as a stream. Our goal in treatment is to stop the flow of that stream before it becomes a waterfall.”

Scott Burg, DO

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Department of Rheumatologic and Immunologic Disease

Biologics

Think of the inflammation of rheumatoid arthritis as a stream. Our goal in treatment is to stop the flow of that stream before it becomes a waterfall.

A newer class of drugs known as biologics help us do this. Biologics target specific points in the inflammation stream. These medications include well-known TNF inhibitors (Enbrel®, Humira®, Remicade® and Simponi®), which counteract a natural compound in our bodies that leads to inflammation. In addition, B-cell (Rituxan®) and T-cell inhibitors (Orencia®) give us other options based on a patient’s needs and reactions to treatment.

Corticosteroids

Drugs such as prednisone and methylprednisolone are still a part of many treatment plans. However, these drugs merely treat symptoms rather than targeting the disease process. That’s why we increasingly turn to newer, better options.

Finding the right mix

If you are diagnosed with rheumatoid arthritis, don’t be surprised — or alarmed — if a doctor prescribes multiple drugs at once. The best treatment outcomes come from finding an appropriate mix of medications. A doctor may start you with methotrexate and a TNF inhibitor, for example. Over time, based on how well you respond, the doctor may try different biologics at different doses until the mix is just right.

The ultimate goal is to have you taking the lowest dose possible of the smallest number of medications. We typically try to taper people off of corticosteroids — which have the most harmful side effects — first. Then, as physical exams, X-rays and MRIs show improvement and even disease reversal, we bring doses of other medications down gradually.

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The cost of treatment

Unfortunately, not all of these medications are covered by all insurance plans. And many of these drugs, particularly the biologics, are expensive.

If your doctor prescribes these medications but you run into issues with insurance or affordability, ask about discounts. Recognizing the expense involved, some drug companies have developed discount plans to help patients get the treatment they need.

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Scott Burg, DO

Scott Burg, DO, is a staff rheumatologist who specializes in osteoarthritis, rheumatoid arthritis, gout, osteoporosis and golf injuries.
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