Drugs to treat Rheumatoid Arthritis

Biologic DMARDs

Immunosuppressive that target specific components of the inflammatory process; usually combined with methotrexate. Seven drugs are used from this class for RA; 5 of the drugs interfere with tumor necrosis factor (TNF). One agent promotes destruction of B lymphocytes and one inhibits activation of T lymphocytes these drugs pose a risk for serious infection and maybe cancer bc they suppress immune function

Biologic DMARDs: T cell activation inhibitors

Abatacept (Orencia); prevents T cells from forming; T cells play a role in the autoimmune attack on joints; this type of med is used when RA does not respond to other drug therapy adverse effects: mostly headache, upper respiratory infection, nasopharyngitis and nausea, serious infections (pneumonia, cellulitis, bronchitis, diverticulitis, pyelonephritis) don't give with TNF antagonists or live vaccines

classes of antiarthritic drugs

NSAIDs (provide quick pain relief only) Glucocorticoids (provide quick pain relief and slow disease progression but long term therapy can cause serious toxicity) Disease modifying antirheumatic drugs (DMARDs) (reduce joint destruction and slow progression but can be more destructive than NSAIDs; DMARDs can be biologic or non biologic Treatment with DMARD is early (within 3 months of RA diagnosis) and the aim is to delay joint degeneration. DMARD takes weeks or months to take effect, so NSAIDs are given until the DMARDs take effect after which the NSAIDs are withdrawn Glucocorticoids are given to reserve short term management of symptom flare ups and also to control symptoms until DMARDs start working

RA and treatment

RA is an autoimmune disease causing inflammation of the joints (swelling, pain, stiffness); treatment is directed at relieving pain, maintain ROM and joint fxning, maintain systemic involvement, delay disease progression nondrug measures: physical therapy (massage, warm baths, heat application, enhance mobility and reduce inflammation); exercise, surgery, rest

Biologic DMARDs: B lymphocyte depleting agents

Rituximab (Rituxan); this drug mimics an antibody that binds to the antigens on B cells which then signal to our immune system to attack causing B cell lysis; it is used in combo with methotrexate (IV) for treatment of moderate to severe RA in adults. Adverse effects: infusion reaction (severe hypersensitivity 30-120 minutes after infusion begins (hypotension, bronchospasms, angioedema, pulmonary infiltrates, MI and cardiogenic shock follow) deaths have occurred within 24 hours; premedicate with antihistamine and Tylenol to prevent this rxn; with a mild rxn, initially lower the IV rate and see if symptoms subside or persist. These medications pose a huge risk for infections

Non biologic DMARDs: Sulfasalazine

Sulfasalazine; used for decades to treat IBD and now used for RA. It has antiinflammatory and immunomodulatory actions; slows the deterioration in one month of treatment adverse effects: GI disturbances (N/V, diarrhea, anorexia, abd pain;use of an enteric coated formulation and dividing doses minimize these effects); dermatologic effects (pruritis, rash, uticaria); hepatitis and bone marrow suppressions are rare but monitor periodically for early detections don't take if you're allergic to sulfa drugs

Non biologic DMARDs: methotrexate

nonbiologic DMARDs: methotrexate; fast acting, therapeutic effects seen in 3-6 weeks; efficacy, low cost and relatively safe major toxicities are hepatic fibrosis, bone marrow suppression, GI ulceration, pneumonitis; periodic liver and kidney fxn tests are mandatory as well as a CBC and platelet count. Recent studies have shown that pts taking methotrexate have an increased risk of death from cardiovascular disease, infection and certain cancers (melanoma, lung cancer, and non-Hodgkin's lymphoma) contraindications: pregnancy due to increased risks of congenital abnormalities and fetal death. Administered once a week PO or injection; should be taken with folic acid to reduce GI disturbances and hepatic toxicity

Biologic DMARDs: TNF Antagonist

these drugs neutralize TNF, an important immune mediator in joint injury in RA; TNF helps fight off infection; when the body neutralizes TNF with etanercept, the risk of infection increases; this risk for infection is further increased in patients with HIV, diabetes, use of other immunosuppressive drugs such as glucocorticoids and methotrexate; can be used to treat Crohn's. 1st TNF antagonist available: Etanercept (Enbrel); it's highly effective in the reduction of RA symptoms and disease progression; may also promote serious infections and other adverse effects Adverse effects: Mild (injection site reactions such as erythema, itching, swelling and pain); severe (increases risk for severe infection such as invasive fungal infections); TB is of special concern; live virus vaccines should be avoided with this drug; severe allergic reactions, heart failure, cancer, hematologic disorders, liver injury, CNS demyelinating disorder and other adverse effects; drug interactions are with other immunosuppressants and live virus vaccines

Glucocorticoids

used for pain and inflammation and they also help delay progression of RA. Usually administered PO and can lead to toxicity and adrenal suppression, gastric ulcers, and osteoporosis (prednisone)