Drug Treatments & Arthritis
Arthritis Ireland: Building a better world for people living with arthritis today and a world without arthritis tomorrow
Arthritis affects so many people in countless ways and at all stages of life. The experience of pain, stiffness and fatigue are all too real – as is the disruption it causes to lives.
At Arthritis Ireland, we understand what it’s like to live with this chronic condition. Everything we do is with a view to supporting people living with arthritis. That includes investing in research as well as advocating on your behalf with policymakers and politicians.
This publication is just one aspect of our work. We understand how important it is to be able to access trustworthy information about your health from a reliable source. That is why we work with healthcare professionals and other experts in producing these materials.
There are lots of other supports available to you, including our;
● Award-winning self-management programme, ‘Living Well with Arthritis’.
● Helpline for practical information and emotional support (call 0818 252 846).
● Website and online communication channels.
● Regular information events, podcasts and webinars.
● Volunteer-led local activities around the country.
If arthritis is affecting your life or the life of someone you love, please call or connect with us online (contact details on the back of this booklet).
About this booklet
Most people with arthritis take some kind of medication to help reduce pain and keep their disease under control. This booklet explains the different types of drugs that can be used to treat various forms of arthritis.
Drugs can help ease your symptoms, slow the disease down or, in some cases, even stop it in its tracks. Because drugs are an everyday reality for many people living with arthritis, it’s important that you feel in control of your medication and can discuss what works best for you with your doctor and healthcare team. Part of this is about understanding the types of drugs that might be used to treat your condition and how they work.
This booklet will give you some of the most important information relating to the main drugs that can help benefit people with arthritis. It also lists some of the sideeffects of these drugs, which some people are concerned about but, overall, the benefits tend to outweigh the negatives when it comes to arthritis medications.
Thankfully, significant progress has been made within the area of treating arthritis in recent years so there is a lot to feel positive about. Thanks to these recent advances, innovative medications are now available to help relieve some of the main symptoms. With newer treatment options now available, most people with arthritis can lead normal, productive lives, without major limitations.
Throughout this booklet, we will refer to various arthritis forms using their acronyms – rheumatoid arthritis (RA), psoriatic arthritis (PsA), osteoarthritis (OA), axial spondyloarthritis (axSpA) and juvenile idiopathic arthritis (JIA).
Drugs used to treat arthritis
Just like there are many forms of arthritis, including RA, PsA, axSpA and many more, there are also many different types of drugs used to treat the disease, depending on the form that you have and other factors, such as any pre-existing conditions.
Some medications can help to halt the progression of the disease, or to help keep it under control so that flare-ups become less common. There is a group of medications that can even help to put the condition into either partial or complete remission. So, in essence, drugs to treat arthritis can be categorised into two main groups;
● Drugs which control the symptoms of the condition: These are used to treat most types of arthritis. They alleviate specific symptoms such as pain, swelling and stiffness. They include painkillers and nonsteroidal anti-inflammatory drugs (NSAIDs).
● Drugs which affect the condition itself: These drugs affect the progression of the disease through, for instance, suppressing the immune system (the body’s own defence system) and also preserve joint function. These drugs include disease modifying anti-rheumatic drugs (DMARDs), corticosteroids (steroids) and biologics. These drugs can also control symptoms.
For more information on drug treatments, please visit www.arthritisireland.ie
The goals of arthritis drugs
The main goals of most drug treatments are;
● to relieve symptoms (such as pain or fatigue);
● to stop or reduce inflammation;
● to prevent further joint damage;
● to improve the individual’s ability to function and overall wellbeing;
● to reduce longer-term complications associated with having the condition.
Your healthcare team may choose from a variety of drug options, depending on your overall health and the type and severity of your disease. You may need to try several different treatments, or a combination of treatments before it is determined what works best for you. This will be done in consultation with your healthcare team and, therefore, it is crucial that you communicate with them regarding your symptoms and experiences.
Some people find it useful to keep a journal to chart the progression of their arthritis and the effects, positive or negative, of any medications used to treat it. (Please see the central pages in this booklet for a helpful ‘medications log’).
“After a lot of trial and error, I have finally found a drug combination that suits me and my body.”
Drugs which control the symptoms of the condition
Pain control treatments
The first-line option for pain is the use of painkillers or non-steroidal anti-inflammatory drugs (NSAIDs). Both are types of drugs called analgesics. Usually, you will find that your symptoms improve within hours of taking these drugs, but the effect will only last for a few hours, so you need to use the medicines regularly.
Most of these painkillers are in tablet form, however several NSAIDs are also available as suppositories, which you insert into the rectum, and gels or creams, which you apply directly to the affected area if the pain is localised. Some of these (e.g. ibuprofen) are available over the counter while others (e.g. ketoprofen) are only available on prescription. NSAID gels may be a good option if NSAID tablets tend to upset your stomach. Some of the drug is still absorbed into the bloodstream so be careful not to use too much gel, particularly if you are also taking NSAID tablets, as this may increase the chance of side-effects.
What’s the difference?
The difference between traditional painkillers and NSAIDs is that painkillers target pain by interrupting pain signals before they get to the brain, whilst NSAIDs tend to help manage pain by reducing inflammation in the body (they do this by blocking hormone-like substances called prostaglandins). NSAIDs are a class of medications typically used on a more long-term basis to treat inflammatory types of arthritis.
Drugs which affect the condition itself
Steroids
Some doctors may also recommend steroids, also known as ‘corticosteroids’ if you experience swelling in your joints. They act like the natural hormone, cortisol, in your body and they work quickly so they can be effective for short-term relief in helping to reduce inflammation and ease symptoms such as swelling, pain and stiffness. Although quick and often very effective, steroids are normally given as part of a wider medication programme.
Steroids can be given in tablet form (such as prednisolone), or by injection either into a muscle or directly into a joint (such as methylprednisolone). Some steroids can be applied as a gel or cream for topical application (such as hydrocortisone). There are also steroid eye drops that can be used for uveitis, a condition that causes inflammation in the eye.
Steroids usually have a more rapid effect than DMARDs. You may notice an improvement in your symptoms within a few days of starting steroids. However, they are not suitable for use as regular painkillers due to their side-effects. For this reason, they tend to be only used on a short-term basis, for example, when an individual is experiencing a flare-up of their condition.
If you are given steroids, your healthcare team will make sure that you’re on the lowest possible dose to keep your condition under control. You may also be given a drug called a proton pump inhibitor (PPI) or another medicine to protect your stomach while taking steroids. There are some instances where steroids will not be given, due to an individual having a pre-existing condition. These include;
• Diabetes, high blood pressure, epilepsy or a mental health condition.
• Systemic sclerosis – a rare disease that involves the hardening and tightening of the skin. It may also cause problems in the blood vessels, internal organs and digestive tract.
• Any infection that affects your skin, such as rosacea, acne or skin ulcers since these can be made worse by using steroids.
An overview of drugs
Disease modifying treatments (DMARDs)
These include traditional DMARDs and biologic DMARDs. Both are used to slow down or stop the inflammation that causes pain, swelling and stiffness in the joints. DMARDs are important also because they actually help to prevent damage to the joint. These drugs can be taken on their own, or alongside NSAIDs, and sometimes you might need to use more than one DMARD.
DMARDs cannot ‘fix’ joint damage that has already occurred. However, the real advantage of DMARDS is that doctors know that prescribing a DMARD early on slows or even stops progression of joint damage. DMARDS change the way that the condition progresses, and, when effective, will prevent your arthritis from getting worse.
Remember, DMARDS do not work instantly. They usually begin to work in about 6-12 weeks, and some may take longer - up to 3-4 months.
Phosphodiesterase 4 inhibitors
If DMARDs do not appear to be working, or where an individual cannot take DMARDs for some reason, a type of medication called phosphodiesterase 4 inhibitors may be used. This medication works by reducing the activity of an enzyme in the body which is involved in the process of inflammation.
Biologic DMARDs
Biologic therapies are a special type of DMARD that have changed the approach from merely controlling pain and inflammation to the actual prevention of joint destruction. These drugs work particularly well for those with RA and other forms of inflammatory arthritis. They are often prescribed for people with moderate to severe RA who have not improved using traditional DMARDs. Biologics are either used alone or with other RA medications.
Biologics can be self-administered, by injection, or given into the vein (IV) in a hospital or clinic setting. These drugs work very well for people with inflammatory forms of arthritis – this group see a significant impact on their level of pain, stiffness and inflammation and those people are usually able to reduce or even eliminate the use of NSAIDs.
The biologic drug group also includes a category of medicines called ‘biosimilars’. These drugs are followon versions, which are independently developed after the patent protecting the original product has expired (this also means they tend to be cheaper to buy).
Biosimilar medicines are intended to have the same mechanism of action as the original biological medicines and are designed to treat the same diseases.
Like with other drugs, there are many different types of biologics and biosimilars and whilst one may work for some people, it may not for others (or may stop working so well after a period of time) which is why it’s crucial to stay in touch with your healthcare team in order to monitor your progress.
These are four main types of biologics currently available;
1. Anti-TNFs are also known as ‘TNF inhibitors’ or ‘TNF blockers’. These drugs include; adalimumab, certolizumab pegol, etanercept, golimumab and infliximab. They work against inflammation in a very targeted and specific way. They essentially block a central protein (or ‘cytokine’) called TNF (tumour necrosis factor), which relates to inflammation, and they halt disease activity, slowing the progress of joint damage and other symptoms.
2. Interleukin (IL) inhibitors block different types of molecules, called interleukins, that cause inflammation in the body. IL inhibitors play a role in activating parts of the immune system. They include anakinra, ustekinumab, secukinumab, ixekizumab and tocilizumab. These drugs essentially work by reducing or slowing inflammation and limit tissue damage caused by an overactive immune system.
3. B-cell inhibitors are used to treat RA when other treatments have not worked as well. An example is rituximab.
4. T-cell deactivators work by interfering with the activity of T-cells, reducing unnecessary inflammation. These drugs are used to treat RA, JIA and PsA when other treatments have not worked as well. An example is abatacept.
As with all medications, if you develop any new symptoms soon after starting new medications, you should stop taking them and consult your healthcare team as soon as possible.
JAK Inhibitors
There are newer, synthetic types of DMARDs that, unlike conventional DMARDs, don’t slow down your disease by suppressing the entire immune system. Instead, these targeted drugs (also known as ‘small molecule agents’) specifically target certain parts of the immune system. They work by limiting the action of Janus Kinase enzymes involved in the initiation of the inflammation process. These medications may not be the first treatment option for you and you may be initially prescribed a biologic therapy. Examples include tofacitinib, upadacitinib and baracitinib.
Information and advice about medication is constantly changing, with new drugs becoming available frequently. To ensure you have the latest information call the Arthritis Ireland helpline (0818 252 846) for more up-to-date information.
Arthritis drugs in more detail
Painkillers
There are three main types of types of painkillers used:
1. Simple non-opioid painkillers: These are the most common types of painkillers and are usually available over the counter. Paracetemol (Panadol®), aspirin (Disprin®) and ibuprofen (Nurofen®) are all examples.
2. Opioid analgesics: Opioid analgesics are strong painkillers used for more severe pain. They are generally prescription-only medicines that must be prescribed by a doctor. Codeine and tramadol are examples. Examples of even stronger opioid painkillers include oxycodone and morphine. Opioids carry more side-effects than other painkillers and there is a risk of dependency or addiction.
3. Compound painkillers: These are a combination of drugs used in one tablet (Solpadeine® is an example, which combines paracetamol and codeine). The most commonly used drugs in compound analgesics are paracetamol, aspirin, ibuprofen and tramadol. Steroid injections may also be given to those living with OA when the joints are particularly painful, and relief is needed.
NSAIDs
These are used for short-term relief from the pain, swelling and stiffness associated with arthritis. You should find relief within one hour of taking NSAIDs, although it can take several days to feel the full benefit. There are around 20 different NSAIDs that are currently prescribed, including;
• Ibuprofen (Brufen®, Nurofen® and others)
• Diclofenac (Voltarol®, Diclomax®, Difene®)
• Naproxen (Naprosyn® and others)
• Celecoxib (Celebrex®)
• Etoricoxib (Arcoxia®)
Steroids
“My doctor was really helpful when I was trying to decide on a course of treatment.”
Steroid treatment can be a quick and effective way to address inflammation, although improvement is typically temporary. Steroids suppress the normal activity of the immune system, so they are normally given as part of a wider rehabilitation programme and are not relied on for long-term treatment. Steroid medicines are sometimes included in compound medicines used to treat a variety of conditions.
Steroids can be administered in injection form, or as tablets, by eye drops or applied to the skin as a cream or gel and may be used to treat RA, lupus, gout, uveitis or PsA. You may need an ultrasound prior to treatment to find out where the inflammation is, so that the injection can be administered to the precise area for maximum benefit. Your doctor will test your blood and urine from time to time because steroids can mask diabetes symptoms.
Some of the types of steroids used include;
• Prednisolone (Deltacortril®, Prednesol®), betamethasone, dexamethasone - given by tablet. Prednisolone is available as a plain tablet or in a special form called ‘enteric coated’ so that it dissolves more slowly, passing beyond the stomach before releasing its contents. This can help reduce nausea and stomach irritation.
• Methylprednisolone (Depo-Medrone®, SoluMedrone®), triamcinolone (Adcortyl®), hydrocortisone (Solu-Cortef®) - given by injection.
• Hydrocortisone (Cortopin® and others), mometasone (Elocon®), betamethasone (Betnovate® and others), clobetasol (Dermovate®) - administered in a cream/gel applied directly to the skin.
• Prednisolone (Pred-Forte® Eye Drops), betamethasone (Betnesol® Eye/Ear/Nose Drops), dexamethasone (Maxidex® and others), fluorometholone (FML Liquifilm®) - administered as eye drops.
DMARDs
Azathioprine (Imuran®) – is an effective treatment for several different types of rheumatic disease, including RA and lupus. One of the actions of azathioprine is to affect how your immune system works, so it is always prescribed with care. If you are on steroid treatment, your doctor may also prescribe azathioprine as it sometimes means the dose of steroids can be reduced. Azathioprine is taken as a tablet, once or twice daily. Before it is agreed that you are to start azathioprine, your doctor will order a blood test for an enzyme called TPMT – if you have low levels of this enzyme it may mean that you need a lower dose as the side-effects may be stronger (as TPMT helps to break down the drug in your body). Because it is a slow-acting drug, you may not notice any effects for eight weeks or longer.
“Working
as an active partner with my healthcare team means I’m involved in the decision-making around my medications.”
Ciclosporin (Neoral®, Sandimmun®) – is used for people with RA, PsA and lupus to reduce pain, swelling and stiffness. It is usually taken in capsule form, twice a day, although it is also available as a liquid. It is important to avoid grapefruit juice when taking ciclosporin as this can increase the amount of the drug in your body. People normally start on a low dose and increase it as necessary. It may take up to four months before you feel any benefit.
Hydroxychloroquine (Plaquenil®) – this drug regulates the immune system, which can be overactive in certain conditions. People with lupus, JIA or RA are most likely
to benefit from this drug. Hydroxychloroquine requires yearly eye tests as there are rare situations where the retina of the eye can be affected. Hydroxychloroquine is taken in tablet form once or twice a day, preferably with food. This drug is slow acting, so it can take three to six months for its full benefit to be felt, although some effects may be noticeable within four to six weeks.
“Since starting methotrexate, I’m more aware of my alcohol consumption as my medical team has advised it can interfere with the effectiveness of my treatment.”
Leflunomide (Arava®) – is a disease-modifying antirheumatic drug (DMARD) that comes in tablet form. It is used to treat RA and PsA. Like other drugs in this group, it acts to suppress the natural response of the immune system to attack its own tissues, causing pain and other symptoms in people with RA. It comes in tablet form and is taken daily. As with other DMARDs, leflunomide does not work immediately and it may be up to six weeks before you feel any effect and as long as six months before you feel the full benefit. You must have regular blood and blood pressure tests if you are taking leflunomide as this drug can sometimes cause hypertension (high blood pressure).
Methotrexate (Maxtrex®, Metoject®, Nordimet®)
Perhaps the most well known of the DMARDs, methotrexate can be given to treat many types of arthritis including RA, PsA, JIA, lupus and other autoimmune conditions. It can be more effective and have fewer side-effects than some other DMARDs and is usually prescribed early in the disease. Similar to some other drug treatments, because one of its actions is to reduce the activity of the immune system, it can leave you prone to infection. Patients on this drug can also report nausea, diarrhoea and mouth ulcers. You should tell your doctor immediately if you develop a sore throat,
fever, bruising or bleeding or any other new symptoms, or if you come into contact with someone who has chickenpox or shingles during treatment. Methotrexate is normally administered once a week. It is available as both a tablet and as an injection. It is slow-acting, taking up to 12 weeks to become fully effective. You will need regular blood tests every two to four weeks as methotrexate can, very occasionally, damage the bone marrow or the liver.
“The
arthritis
drugs I take allow me to do more activities with my children, so I think it’s worth taking them.”
Sulfasalazine (Salazopyrin®) – is now widely used to treat RA, PsA, arthritis linked with inflammatory bowel disease and, sometimes, JIA. This drug reduces the inflammation in joints and decreases pain, swelling and stiffness. It may be used in addition to steroids to help control your disease. The drug has a special ‘enteric’ coating which means it dissolves more slowly, passing beyond the stomach before releasing its contents. This can help reduce nausea and stomach irritation. The tablets should be swallowed whole so that the coating is not broken. They must not be chewed or crushed. You will need to have monthly blood tests for the first three months of taking the drug, followed by tests every three months.
Phosphodiesterase 4 inhibitors
Apremilast (Otezla®) – used to treat PsA and psoriasis, this DMARD targets an enzyme known as phosphodiesterase 4 (PDE4) which is involved in the inflammatory response within the body. This drug can reduce swollen and tender joints, as well as helping to improve skin symptoms including scalp and nail psoriasis. This drug is also effective in the treatment of Behçets disease (a rare, autoimmune disorder that involves inflammation of the blood vessels). You are unlikely to be prescribed this drug if you have had a history of
depression, if you’re underweight or if you have lactose intolerance. This is taken in tablet form and typically takes about four months to take full effect.
Pregnancy and medications
It is crucial to inform your healthcare provider if you are pregnant or planning to conceive as this will affect the decisions around the choice of drug treatment available to you. Shared decision making with your healthcare team is essential to ensure that the medications that you are on during pregnancy are suitable and safe. In fact, drug therapy should be reviewed prior to conception, during pregnancy and again during breastfeeding. But drug therapy is still essential – in fact, the evidence suggests that the outcome for mother and baby is much better when the mother’s disease is prevented from flaring by treating the condition adequately during the pregnancy. The aim is to continue medications for optimum disease control, achieving the lowest dose needed during pregnancy and switching to ‘pregnancy-friendly’ medications.
Biologics
Anti-TNFs
Adalimumab (Humira®, Amgevita™, Imraldi™, Hulio™, Yuflyma®, Hukyndra® and Idacio®) – is an anti-TNF drug used to treat RA, axSpA, JIA and PsA. You are likely to only be prescribed adalimumab if you have already tried methotrexate or another DMARD which did not work. There are certain conditions under which your doctor will not prescribe adalimumab. For instance, they may decide against this drug if you have had tuberculosis in the past. Adalimumab is used once every two weeks by injection under your skin. If adalimumab works for you, you should start feeling better in around 2 to 12 weeks.
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Subcutaneous injections
The word ‘subcutaneous’ means ‘under the skin’. You, your partner or another family member can learn how to administer these arthritis injections at home. Your healthcare team can demonstrate this to you/your family member prior to starting treatment.
Certolizumab pegol (Cimzia®) – another anti-TNF drug that can help block the action of chemicals in your body that cause pain and swelling in your joints. This drug will be prescribed for RA, axSpA or PsA. Before starting, you’ll have a chest X-ray and blood tests to check if you’ve ever been exposed to tuberculosis (TB). Your doctor won’t prescribe certolizumab pegol if you’ve had repeated or serious infections, multiple sclerosis (MS), cancer, or a serious heart or lung condition. It is administered as a subcutaneous injection. If this drug is suitable for you, you should notice an improvement in your symptoms within around 6-12 weeks.
Etanercept (Enbrel®, Benepali®, Erelzi®) – like adalimumab and infliximab, etanercept is an anti-TNF drug used to treat RA, PsA, axSpA and JIA. As with adalimumab, there are certain conditions under which your doctor will not prescribe etanercept. If etanercept is suitable for you, it will need to be injected under your skin once or twice a week. You will have a chest X-ray and blood tests before starting treatment and regular blood tests while you are taking the drug. If you respond to the treatment, you will probably feel better in around 2 to 12 weeks.
Remember that any new drug treatment will take some time to start working and, therefore, try not to become discouraged if you do not see immediate results.
Golimumab (Simponi®) – used to treat RA, PsA, axSpA and JIA, golimumab is a biologic often used in combination with methotrexate. As with many of the other drugs, not everyone will be suited to taking this drug and, therefore, blood tests and a chest X-ray will be done prior to starting treatment. Given by injection, typically once a month, this drug can take about 8-12 weeks to feel its full effects.
Infliximab (Remsima®SC, Remicade®, Inflectra®) – is an anti-TNF drug available to treat RA, PsA and axSpA. Infliximab is usually only prescribed for people who meet specific criteria and is given over several sessions, usually in hospital using an intravenous drip into a vein. You will have a chest X-ray and blood tests before starting treatment and regular blood tests while you are taking the drug. If infliximab works for you, you should begin to feel the benefits in around 2 to 12 weeks.
IL Inhibitors
Anakinra (Kineret R®) – this interleukin-1 receptor antagonist (IL-1Ra) is used to treat RA and other autoinflammatory disorders, adult-onset Still’s disease (a rare type of inflammatory arthritis) and, in rare cases, gout. Before starting this drug, which is given by injection, you must inform your healthcare team about whether you have an infection, or a history of recurring infections or kidney problems. This drug can take between three and six months to feel the full benefits.
“I never thought I’d learn to inject myself, but the benefits of my medications make it worth it and I’m more used to it now.”
Ustekinumab (Stelara®) – this biologic drug blocks two proteins IL-12 and IL-23 which helps reduce the inflammation that is associated with PsA and psoriasis. Your doctor may not prescribe this drug if you have recurrent infections, if you’ve had phototherapy for
psoriasis/injections for allergies or cancer. Blood tests and other tests will be done prior to starting treatment in order to ensure that you are suitable. This drug is given as a subcutaneous injection at a four week interval for the second injection, and then every 12 weeks from then on.
Skin safe
Anti-TNF drugs have been associated with some types of skin cancer, although the exact link between the two is still unclear. Therefore, it is advisable to be extra safe around skin protection in the sun; make sure to wear sunscreen with a factor of 30 or higher, take cover in shade and wear a hat while outdoors in sunny climates. Also regularly check your skin for any new spots or changes to moles while on this treatment.
Secukinumab (Cosentyx®) – used to treat PsA, axSpA and psoriasis if it’s severe and other treatments haven’t worked, this drug blocks the effects of the protein IL-17A which can cause pain, inflammation and damage to the joints. Having recurring infections or inflammatory bowel disease (such as Crohn’s disease or ulcerative colitis) will prohibit you from having this drug. Your healthcare team will also check that you have no TB bacteria in your body before beginning this treatment. Like some others, this is a long-term treatment and can take anything from three weeks to up to a year to take effect.
Ixekizumab (Taltz®) – used to treat PsA and axSpA, this biologic therapy is similar in that it blocks IL-17A and thereby helps to reduce inflammation, pain and joint damage. Given as a subcutaneous injection, your healthcare team will rule out certain conditions (such as the ones listed above) before starting treatment, in addition to ruling out hepatitis and HIV infection. It can take around four to five months to experience the full benefits of this drug.
Tocilizumab (RoActemra®) – is a biologic most often used for RA and JIA. It is also now licensed for use for giant cell arteritis (GCA), a condition that causes pain and swelling in the blood vessels. It is administered by monthly infusion (which takes about an hour once a month) or by subcutaneous injection weekly. This drug may be used on its own or in combination with methotrexate. It works by blocking one of the most common chemical influencers in the rheumatoid system called IL-6. This drug can take three to six months to work. Your healthcare team are unlikely to give you this drug if you get recurrent infections, have had cancer or liver disease, a history of diverticulitis, heart problems or have a low number of white blood cells or platelets. Screening for hepatitis B and C, along with a chest X-ray will also be required prior to beginning treatment, and screening for raised cholesterol will be done regularly as this drug can affect cholesterol levels.
B-cell Inhibitors
Rituximab (MabThera®, Truxima®, Rituxan®) – is a type of biologic drug that has recently become available for people with RA, lupus and other auto-immune diseases. It works by selectively targeting B-cells, which are known to play a role in the progression of RA. You will only be prescribed rituximab if you have already tried treatment with other medications, including anti-TNFs. Rituximab is used in conjunction with methotrexate. This drug is given in a single treatment course of two infusions (ie. through a drip into a vein) two weeks apart. Each dose, which is usually given in a hospital, typically lasts for 6-12 months.
T-cell deactivators
Abatacept (Orencia®) – this drug works by interfering with the T-cell response, which affects the mechanism of RA, JIA and PsA. You will only be prescribed abatacept if you have already tried treatment with other medications, including anti-TNFs. It can be given by
intravenous infusion in hospital (taking between one and two hours) or by subcutaneous injection. This drug will be used with caution if you tend to have recurring infections. You receive your second dose two weeks after your first, and then you receive a dose every four weeks.
JAK Inhibitors
JAK inhibitors are available in tablet form (taken daily). They need to be used with caution in patients over the age of 65. They include the following;
Tofacitinib (Xeljanz®) – used to treat RA and PsA, this JAK inhibitor works on the causes of inflammation within the body to help reduce pain and swelling, as well as slowing down joint damage. People typically notice an improvement within the first 12 weeks of taking this drug. It is taken usually as a dose of two tablets a day – one in the morning and one in the evening. Similar to other drugs, there are certain conditions which will prohibit you using this drug, including the presence of shingles, disease of the lungs, liver or kidneys, heart problems or cancer. Discuss these with your healthcare team when deciding on which treatment will suit you and your condition best.
Always inform your healthcare provider about the medicines you currently take before starting a new treatment for your arthritis condition.
Upadacitinib (Rinvoq®) – used in the treatment of RA, PsA and axSpA, upadacitinib works to limit the action of janus kinase enzymes which are involved in the inflammatory process in rheumatological conditions. If upadacitinib works for you, your symptoms should start to improve within 2–8 weeks after you start taking it, but you may not notice the full benefit for 3–6 months. Upadacitinib is usually prescribed alongside methotrexate, however, upadacitinib should not be used
alongside other immunosuppressive or biologic drugs or other JAK inhibitors. Your doctor may decide not to prescribe upadacitinib if you’ve had or have shingles, disease of the lungs, liver or kidneys, heart problems (including high blood pressure, high cholesterol, or blood clots), stomach ulcers or cancer.
It takes time
Many drug treatments are long-term so, if they don’t seem to be working at first, it’s important to keep using them, unless you are experiencing severe side-effects. When your symptoms being to improve, it’s also important to continue your treatment in order to help keep your condition under control. Always consult your healthcare team if you want to discuss any changes to your medication.
Baricitinib (Olumiant®) – used to treat RA, this drug works by blocking the action of janus kinase enzymes, which are involved in the inflammation that causes RA. Most people will notice an improvement in pain, stiffness and swelling within the first 12 weeks of treatment. This drug is a long-term treatment so you should still keep taking it, even when your symptoms improve, to help keep your condition under control. You will not be recommended this drug if you have recurrent infections, shingles, a disease of the lungs, liver or kidneys, heart problems, high blood pressure, high cholesterol, a very low white or red blood cell count or if you have cancer.
Managing the nausea associated with medication
For some people, the nausea associated with their arthritis medications can be significant in the early days of their treatment. For some others, this unfortunately continues for some time, but this is certainly not the case for everybody.
Some medications need to be taken with food, whilst others need to be taken on an empty stomach – if you are unsure, ask your pharmacist and healthcare team. Some things that can help;
1. Discuss your symptoms with with your pharmacist and healthcare team – they could review the timing or dosage of your medications and suggest alternatives to help with the nausea. You can use the medications log at the centre of this booklet to help you to keep track of the details surrounding your medications.
2. If you have been prescribed anti-nausea medications as part of your treatment make sure to take them as soon as you begin to feel nauseous.
3. For people taking methotrexate and who are feeling nauseous, you could ask your healthcare team if you can switch to a subcutaneous injection instead of oral methotrexate, or you could switch to taking your medication prior to going to bed.
4. Drink plenty of water throughout the day, or sip on lemon and ginger, hot water or herbal teas to help reduce nausea.
5. Eat five smaller meals a day, rather than three large meals as overeating can increase nausea.
6. Slow down your eating and avoid lying down after any of your meals – sitting upright can aid digestion.
7. Avoid things that are known to irritate the stomach, such as alcohol, smoking or excessive caffeine.
8. Do not stop taking your medications if they are making you nauseous before consulting with your healthcare team as stopping medications too early can make your arthritis more difficult to treat or may cause unwanted side-effects.
Red flags: The following are red-flags that may indicate other causes of nausea so seek medical attention from your GP if you are experiencing any of the following;
• Vomiting blood or bile.
• Unexplained weight loss.
• Severe abdominal pain.
• High temperature, neck stiffness, a rash or reluctance to look at light.
• Increasing weakness or loss of consciousness.
• Continuous or worsening vomiting after 48 hours.
Making decisions about arthritis drugs
It is important to remember that any drug can have sideeffects. You should discuss these with your healthcare team. However, in most cases, the benefits you might receive from taking a drug will outweigh any potential side effects. Your symptoms (and your life) may be made easier to manage with the right drugs or combination of drugs.
Not only that, but it must be remembered that certain arthritis drugs can prevent the progression of serious joint damage, and others can halt the disease entirely, meaning the condition can be put into remission. This is why it’s important to be as open as possible and to listen to your healthcare team, who are trained in prescribing these medications.
In some cases, the side-effects can simply be too difficult to tolerate. Communicate this with your healthcare team, write down the side-effects that you find most challenging and discuss alternative options that may be possible.
Often with arthritis treatment, it can be a case of trial and error. This can take time and requires patience and also the hope and belief that you will reach a point where your condition is well managed. This can be optimised when combined with self-management techniques such as getting daily physical activity, eating well, learning relaxation techniques and practising good sleep hygiene. Be mindful of your sources
Steroids can sometimes affect diabetes, high blood pressure, epilepsy and some mental health issues. If you have any of these preexisting conditions, it is crucial that you let your healthcare team know.
Although the internet is a great tool for equipping ourselves with more knowledge, it’s very important that we don’t believe everything that we read, particularly since there is a considerable amount of so-called ‘facts’ out there which are simply incorrect, and not based on science. Some websites can be alarmist and, as most of us know, we can sometimes self-diagnose conditions that we may not even have. Try to consult only reputable websites – please see the back of this booklet for more information.
Questions to ask when considering medications
It is crucial that you engage with your healthcare providers and ask relevant questions so that you can be involved in the decisions around your treatment and the medications chosen. Asking questions about your treatment or medicine is important to help you understand your options.
Here, we offer some suggestions to help you navigate that decision-making process and to hopefully help reassure you as best as possible that you and your healthcare provider are selecting the optimal treatment for your specific condition and your needs.
1. What is the goal of this medication?
2. How do I take this medication (any particular instructions involved in its administration)?
3. How should I store this medication (does it need to be refrigerated?)
4. What are the likely or expected benefits of taking this medicine?
5. Why this medication instead of another?
6. What is likely to happen if I don’t take this medication?
7. Does this new prescription mean I should stop taking other medicines?
8. How long is it likely to be before I start to notice an improvement in my symptoms?
9. Should I stop taking the medication when I start to feel much better?
10. What is the advice around alcohol while on this medication?
11. Which tests do I need done prior to, or while on this medicine and how often?
12. Are there foods, drinks, other medicines, or activities to avoid while I’m taking this medicine?
13. What are the most common side-effects of this particular medication?
14. When should I alert my healthcare team about a problem or side effect I am experiencing?
15. How can I best manage those side-effects, should they occur?
Drug Substitutions
Drug shortages can happen from time to time due to manufacturing delays, unexpected increases in demand and the unavailability of key ingredients. The Health Products Regulatory Authority (HPRA) keeps a list of those shortages. In partnership with your doctor, your pharmacist will always try their utmost to substitute/source an alternative brand or product type to ensure that you are not missing a dose of your medication.
Patient Information Leaflets (PIL)
PIL stands for Patient Information Leaflet – this is the leaflet that is included in the pack with every medicine. A PIL is written by the pharmaceutical company and is a patient-friendly version of the summary of product characteristics. All PILs are checked and approved by the European medicines licensing agencies.
Valuable information contained in the PIL includes;
• the name of your medicine and what is it used for (section one),
• a list of situations where a medicine should not be taken or used in (section two),
• how to take or use your medicines (section three),
• a list of possible side-effects (section four),
• how to store your medicine (section five) and - further information, including other ingredients included in the medicine’s formulation (section six).
It is important to recognise that the risk of joint damage and permanent disability with some forms of arthritis is much greater than the risk of side-effects from DMARDs to control the disease.
All medicines can cause side-effects, although not everybody gets them. It’s important to balance the risks and benefits involved in using this possible medication, but also to remember to read the information in a balanced way.
For instance, if 1 in 10 people tend to experience a certain side-effect, then that means that 9 in 10 people typically will not experience that side-effect. It is important to keep this in mind when reading sideeffects; some people will experience the specific sideeffect mentioned, but also many will not, and you could be one of those many.
At the same time, it is no harm to be aware of possible side-effects and to monitor how you are feeling so that you are not enduring difficult side-effects that are negatively impacting your life on a longer term basis.
Reducing infection risk
While on a traditional DMARD or newer biologic DMARD, the risk of infection increases. It is crucial that you report any new symptoms, such as a sore throat, flu-like symptoms or a high temperature to your healthcare team if they develop. Other tips to help keep infection at bay include;
• Washing hands regularly and thoroughly.
• Carrying a small bottle of antibacterial hand gel with you wherever you go.
• Keeping your oral hygiene good by regular brushing of your teeth and gums.
• Keeping surfaces in your house clean and hygienic.
• Ensuring you store and prepare food according to high food hygiene standards.
• Stopping smoking if you currently smoke.
Your immune system
Your rheumatologist has prescribed a specific drug therapy because they believe that the benefits outweigh the risks. The good news is that many of the newer biologic drugs are safe and effective. However, as with traditional DMARDs, these newer classes of drugs carry comparable risks as they similarly weaken the body’s ability to fight germs, making you more vulnerable to infections while taking them.They can increase the risk of infection, including colds, diarrhoea and urinary tract infections. In addition, because these drugs essentially restrict the immune system, people using them may need to take extra precautions before receiving vaccines that contain live viruses.
Due to the fact that these medications can cause or worsen inflammatory bowel disease, such as ulcerative colitis or Crohn’s disease, you will need to declare these conditions to your doctor. If you currently have, or have had, tuberculosis or hepatitis, inform your doctor and healthcare team before deciding to take these medications.
Managing side-effects
In addition to nausea, there are a range of other possible side-effects that you may or may not experience from your medications. The good news is that, in many cases, there are things you can do to help manage those side-effects.
NSAIDs: Since NSAIDs can cause digestive problems (stomach upset, indigestion or damage to the lining of the stomach), another type of drug, called a proton pump inhibitor (PPI), is often prescribed to help protect the stomach. In addition to this, you can help prevent these effects by keeping alcohol to a minimum and not smoking, as well as trying to take your tablets with, or just after, your meals.
Vaccinations
The HSE recommends that all people taking immunosuppressants and steroid tablets should have yearly flu vaccinations, and pneumonia vaccinations every five years. However, some other vaccinations can be dangerous and should be avoided. For instance, ‘live vaccines’ such as polio and rubella need to be avoided whilst on a biologic. This is particularly relevant to anyone planning a trip to certain parts of South America or Africa where a yellow fever vaccination certificate can be required. It is important to discuss immunisation with your healthcare team before starting any new medication.
Opioids: Since opioids are intended for only shortterm use, decreasing the amount of administered opioid to minimise adverse effects while preserving the benefits is important. When it comes to constipation, a high-fibre diet, increased fluid intake, and increased physical activity play an important role. Pharmacologic management includes daily stool softeners in addition to regular use of stimulant laxatives.
Steroids: Steroids can cause you to put on weight or have an increased appetite, so it’s important to keep an eye on your diet while taking them. Making sensible food choices and including some physical activity in your daily routine should help you to maintain a healthy weight. Steroids can also weaken bones, which can lead to a condition known as osteoporosis. This condition makes it more likely that you’ll fracture your bones, sometimes after very minor falls or bumps. Your doctor may advise you to take drugs called bisphosphonates, or calcium and vitamin D supplements, along with the steroids to help prevent this. Regular exercise, such as walking, can also help to reduce the risk of getting osteoporosis. You should also make sure you get enough calcium in your diet, and avoid smoking and drinking too much alcohol.
Traditional DMARDs and biologics: The key thing with DMARDs biologics is to inform your healthcare team about any pre-existing condition you may currently have, or any history of recurring infections that you had in the past. The other important factor is to be patient with these drugs. It may take time for you to notice the benefits – in some cases this can mean several weeks or even months. In terms of managing your weakened immune system, basic hygiene practices will serve you well, such as regularly washing your hands, carrying hand sanitiser with you (and possibly a face mask when you think it’s necessary) and brushing your teeth and gums twice a day.
Further information
This is only an outline of some of the drugs taken by people living with arthritis. Your healthcare team will be able to discuss in much more detail with you which drugs may be best suited to you. Arthritis affects everyone differently so you will need to work with your doctor to develop your own tailored treatment package.
Information and advice about drugs is constantly changing. To ensure that you are up-to-date, you may find the following websites/helplines useful.
• Arthritis Ireland – arthritisireland.ie or call our helpline on 0818 252 846
• The Health Products Regulatory Authority (HPRA) –hpra.ie
• The European Medicines Agency (EMA) –ema.europa.eu
• Irish Pharmaceutical Healthcare Association –www.medicines.ie
• Patient Information (which meets the NHS England’s information standards) – patient.info/medicine
In terms of general health information, reputable sources of information to consult include;
• Mayo Clinic – mayoclinic.com
• The HSE – hse.ie
• Safefood – safefood.ie
• Centers for Disease Control and Prevention – cdc.gov
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This information booklet has been funded by Amgen Limited. The views and opinions expressed herein represent those of Arthritis Ireland and not Amgen Limited. Amgen had no editorial input into the content of the publication.
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Published August 2024