Treatment
Disease Modifying Anti-Rheumatic Drugs (DMARDs)
Inflammatory arthritis is a painful and debilitating auto-immune disease that causes swelling and damage to cartilage and bone around the joints. It is a chronic condition with no cure, but medications can control the inflammation, helping to prevent long-term damage and disability.
DMARDs reduce the inflammation in your joints to help prevent pain, swelling and prevent long-term damage. Not all medications work for everyone and there are certain restrictions on how we use the treatments.
There are guidelines by the Scottish Intercollegiate Guidelines Network (SIGN) and the British Society for Rheumatology (BSR) that determine how medications are used for Inflammatory Arthritis. There are also local pharmacy guidelines as to how we use these medications.
There are 3 types of DMARDs:
Conventional Synthetic DMARDs (csDMARDs):
Methotrexate
Sulfasalazine
Hydroxychloroquine
Leflunomide
These treatments are used initially for Inflammatory Arthritis and normally take up to 3 months to have full effect. They come in tablet form, but methotrexate is also available as an injection. You may be given a Steroid injection into the muscle in your buttock or Steroid tablets to take until these drugs take effect.
Your chest X-ray is normally taken before your start these medications. Your blood tests will be checked before and frequently when you begin some of these medications and if no problems the frequency of blood tests will be reduced.
Biologic DMARDs (bDMARDs):
Anti TNF:
Adalimumab
Certolizumab
Etanercept
Golimumab
Infliximab
IL 6 Inhibitors:
Sarilumab
Tocilizumab
IL17 Inhibitors:
Ixekizumab
Secukinumab
IL12 and 23 Inhibitor:
Ustekinumab
IL23 Inhibitor:
Guselkumab
T-Cell co-stimulator Inhibitor:
Abatacept
B-cell depletor:
Rituximab
bDMARDS block the activity of key chemicals, cells or proteins involved in inflammation that cause joint swelling and other symptoms. They are powerful and specific therapies that target very particular parts of the immune system. They are divided into groups which relate to the protein or white blood cell they block in the immune system.
These treatments are used if you cannot tolerate or have side effects to the csDMARDs or if these medications are not enough to control your inflammatory arthritis. They can take from 2 to 16 weeks to have full effect. Some treatments are given by an injection into the layer of fat between the skin and muscle. This is called a subcutaneous injection and is usually given into the thigh or abdomen. You will be taught how to inject. Injections are delivered to your home address by a Home Delivery Company. Your nurse will inform you of the name of the company.
Others are given as an injection into the vein through a drip. This is called an intravenous infusion and is given in the rheumatology day unit at Ashgrove House, or the Macmillan unit in the Balfour Hospital if you live in Orkney. Currently there are no facilities at Dr. Grays hospital in Elgin to administer the infusions. You will be monitored throughout your infusion and you should inform the nurses straight away if you feel unwell.
Your Disease Activity Score (DAS28, tender and swollen joint count or BATH Indices) may be calculated and needs to be in the moderate or severe disease activity category level before you can start these medications.
The DAS28 score | NRAS | Disease Activity Score
Before staring these medications specific blood tests have to be taken to rule out tuberculosis (TB), Hepatitis B and C, HIV and to check if you have antibodies for the chickenpox/shingles virus.
If you are found to have TB, Hepatitis or HIV, further blood tests may be required. You may also have to be monitored more closely or take extra medication along with your bDMARDs.
If you have not had chickenpox or shingles and are found to have no antibodies, you will have to have the chickenpox vaccination before you start your treatment. This will be carried out at one of the vaccinations centres.
You may also be asked to have the pneumonia vaccination before starting bDMARDs and this will be carried out at one of the vaccinations centres.
Your chest X-ray is normally updated before your start these medications.
Biosimilars:
A biosimilar medicine is a biological medication manufactured to be similar to an existing originator biological medication whose patent has expired. It has no meaningful differences from the original in terms of quality, safety or efficacy.
Targeted Synthetic DMARDs (tsDMARDs)
JAK Inhibitors:
Baricitinib
Filgotinib
Tofacitinib
Upadacitinib
These are newer treatments for inflammatory arthritis. These treatments are used if you cannot tolerate or have side effects to the csDMARDs or if these medications are not enough to control your inflammatory arthritis. They can be quicker acting than the csDMARDs and the bDMARDs. They come in tablet form.
The same pre-treatment tests that are needed for the bDMARDs will be carried out before you start these medications.
Useful Links
National Rheumatoid Arthritis society
National Axial Spondyloarthropathy Society
Published: 30/05/2022 16:05