Rheumatoid Arthritis Treatment. Dr. Humeira Badsha Dubai UAE
Biological Response Modifiers (BRM):
In the last decade we have seen the introduction of new medications for RA which sometimes have produced dramatic results. These act on blocking the chemicals, called cytokines that are involved in inflammation. The goal of treatment in 2000 is REMISSION and these BRMs give patients the best chance to be disease free.
TNF inhibitors act by decreasing a chemical called tumor necrosis factor (TNF).
50 mg once weekly
(under the skin)
40 mg every 2 weeks
(under the skin)
3-5mg/ kg. body weight
These medication work by blocking the production of joint inflammation. They usually work better when used in combination with standard medications such as methotrexate or sulfasalazine. They are highly effective but not everyone needs them. They are usually reserved for those who are unable to take or have inadequate response to the standard treatments for rheumatoid arthritis. They have been shown to prevent joint damage and give excellent outcomes in rheumatoid arthritis.
The commonest side effects are injection site reactions or irritation. Rarely latent tuberculosis can get reactivated. Patients are always screened prior to treatment with a skin test for TB and a chest x-ray. Immune system gets suppressed and hence there is a higher chance of infections. Most of these infections are classified as ‘non-serious’. Patients taking these medicines should not have live vaccines. It is sometimes recommended that these are stopped 2-4 weeks before major surgery.
Very rare side effects include heart failure, lupus or neurological diseases. Some of the other disadvantages are that these medications are expensive and insurance companies do not pay for them. They need to be kept refrigerated. With Remicade there can be infusion reactions occurring during or after the drug administration. Patients can feel dizzy, short of breath. These reactions subside usually by slowing the rate of infusion.
Mabthera (Rituximab or Rituxan) is a new class of BRM which inhibits CD20 B cells (a kind of white cell). It was initially used for the treatment of lymphoma but has now emerged as a powerful new tool for rheumatoid arthritis treatmet. It is given as 2 injections of 1000 mg of intravenous infusions (separated by 2 weeks). This treatment is repeated 6 -12 months later. Infusion reactions such as low blood pressure, itching, difficulty breathing can occur but the chances are usually greater with the first infusion. Mabthera also carries the risk of infections.
Abatacept (Orencia) works by blocking the T cells which in turn activate B cells to produce TNF. Abatacept is used in patients who have not responded to methotrexate or anti-TNF medications. Side effects include cough, dizziness, infections and infusion reactions. The initial dose is 500 – 1000 mg intravenously, 2nd dose 2 weeks later and
4 weekly thereafter.
Actemra blocks a substance called IL6 and is a new treatment for RA> It is a monthly Intravenous infusion