By Alan Martin, MD
During my career as a rheumatologist, there has been no more significant breakthrough in the treatment of rheumatoid arthritis (RA) than the introduction of biologic agents when Enbrel came on the market in 1998.
The traditional therapies are still used initially for treatment. These are labeled disease-modifying anti rheumatic drugs (DMARD). The most commonly used DMARD medications are methotrexate, hydroxychloroquine, sulfasalazine and leflunamide. These medications may be used alone or in combinations, as long as there are no contraindications. Some RA patients do achieve a significant improvement and can be maintained on these medications alone. Many patients, unfortunately, do not achieve an acceptable improvement, and their disease activity continues.
The biologic agents have revolutionized the treatment of RA in their ability to slow down disease progression, and in some cases, induce remission of disease. These drugs were engineered to specifically inhibit proteins secreted by cells that regulate the immune response and promote inflammation. There are multiple categories of biologics that each block specific aspects of the immune system. Some examples are Enbrel, Humira, Simponi Aria, Remicade, Actemra, Rituxan, Orencia and Xeljanz. Sixty to seventy percent of patients have a measurable improvement, and fifteen to twenty percent may have remission or close to remission of their RA.
Every patient’s disease process and response to medication is unique, and one biologic may help one patient more than another. Therefore, in some patients, multiple trials of different biologic medications may be used in succession. Treatment decisions are based on the balance of improving the disease process weighed against the risks of drug toxicity. Evaluating which medication is right for each patient, the physician takes into account lab studies, x-rays and the patient’s medical history. Conditions in a patient’s previous or current medical history that may affect the decision of using biologics are infectious exposures, current infection risk, nerve disorders, history of heart failure, other chronic diseases and pregnancy.
To assess the effectiveness of these medications, a rheumatologist uses multiple parameters, including number of joints involved, x-ray progression and functional status. Functional status is assessing the patient’s ability to perform daily activities such as walking, dressing and grooming and performing household or work duties. Unfortunately, not all RA patients are candidates for biologic medications. Fortunately, though, most patients will be able to benefit from the use of biologics and see improvement in their activity and pain level.
We have come a long way since simple analgesics such as aspirin were used to treat RA. Those simple analgesics did not address the disease process and provided minimal pain relief. Now we have biologics that can slow down the disease progression and at times put the disease in remission, which leads to a higher quality and more enjoyable life.