Various conditions cause chronic or long-term inflammation of the joints. The rheumatologist then uses DMARDs to slow the progression of joint damage. DMARDs stand for ‘disease-modifying antirheumatic drugs’. The Dutch term for this is ‘drugs that influence the course of the disease against rheumatism’. These conditions do not cure the joint disease, but the (combination of) medications does ensure a remission. In addition, thanks to the drugs it is possible to protect the joints from further damage. Every drug has side effects. DMARDs mainly affect the stomach, liver, blood and eyes. Close monitoring by the rheumatologist is therefore necessary to detect these side effects in a timely manner and to adjust the medication if necessary.

• Indication: Inflammatory joint disorders
• Effect of medicine against chronic joint inflammation
• Using medicine for the first time
• Commonly prescribed disease-modifying antirheumatic drugs

• Azathioprine
• Biological medicines (biologicals)
• Cyclosporine
• Hydroxychloroquine
• Leflunomide
• Methotrexate
• Minocycline
• Tofacitinib

• Side effects of DMARDs

• Blood problems
• Liver problems
• Stomach complaints

Indication: Inflammatory joint disorders

The rheumatologist uses DMARDs for chronic inflammatory conditions that damage the joints. Examples of this are:

• psoriatic arthritis (psoriatic arthritis: inflammation of the skin and joints)
• juvenile idiopathic arthritis (inflammatory condition with joint pain)
• rheumatoid arthritis (inflammation of joints and organs)
• ankylosing spondylitis (ankylosing spondylitis: persistent joint inflammation)
• systemic lupus erythematosus (autoimmune disorder)

Effect of medicine against chronic joint inflammation

DMARDs act on the immune system to slow the progression of inflammatory joint disease. This increases the quality of life for most patients. Some patients even achieve remission of their symptoms. The flare-ups are less painful or stressful and the patient also usually experiences longer symptom-free periods. By regularly taking a DMARD, the patient is less likely to suffer from long-term joint damage. Without DMARDs, inflammation slowly destroys the joint tissue, resulting in a deformed and unusable joint. The patient should continue to take the medication, even during a remission or symptom-free period, to keep the symptoms at bay. The symptoms often return when the patient stops taking the medication.Before starting the drug, a blood test is required / Source: Frolicsomepl, Pixabay

Using medicine for the first time

Various DMARDs are available on the market for the treatment of inflammatory joint diseases, but rheumatologists use some drugs more often than others. Combinations of medications are also sometimes necessary to achieve a desired effect. The rheumatologist often has to test various (combinations of) medications and doses before a desired result is achieved for the patient. This is different for every patient. The rheumatologist also looks at the existing joint and organ damage and any other underlying problems. The rheumatologist normally also conducts a blood test before starting the medication. He also orders X-rays. These tests are necessary to better monitor the disease and any side effects of medicines over time.

Commonly prescribed disease-modifying antirheumatic drugs

Azathioprine

Rheumatologists use Azathioprine (Imuran) for many different inflammatory conditions, including rheumatoid arthritis. The most common side effects are nausea and vomiting, sometimes with stomach pain and diarrhea. Long-term use of azathioprine is associated with an increased risk of developing cancer.

Biological medicines (biologicals)

Abatacept (Orencia), adalimumab (Humira), anakinra (Kineret), certolizumab (Cimzia), etanercept (Enbrel), etanercept-szzs (Ereizi), golimumab (Simponi, Simponi Aria) and infliximab (Remicade). The rheumatologist injects these medications under the skin or administers them directly through a vein (intravenously). They neutralize one of the signals from the immune system (TNF), which causes inflammation and joint damage. Rituximab (Rituxan) and tocilizumab (Actemra) are also biologic medications, but they are not TNF inhibitors. Rituxan attacks B cells and actemra affects IL-6 (interleukin = type of protein that plays a role in inflammation). However, the rheumatologist uses these medications in combination with methotrexate, which also reduces the complaints. These medications have fewer side effects than other DMARDs. However, the patient does have an increased risk of developing a serious infection. These medicines very rarely also have a negative effect on liver or blood counts.

Cyclosporine

The powerful drug Cyclosporine (Neoral) slows the progression of joint damage. However, this drug sometimes damages the kidneys and has other side effects. The rheumatologist therefore prescribes the medicine for patients with serious joint infections that do not respond to other (combinations of) medicines.

Hydroxychloroquine

The rheumatologist prescribes Hydroxychloroquine (Plaquenil) and Sulfasalazine (Azulfidine, Salazopyrine) for patients with mild inflammation of the joints. They are not as powerful as other DMARDs, but tend to cause fewer side effects. In rare cases, eye problems arise from the use of Plaquenil. Typically, the drug, which is available in tablet form, is only fully effective after three to six months of use. With long-term use of high doses, the patient must undergo an annual eye examination to assess the health of the eyes.Some DMARDs are not recommended for women who wish to become pregnant / Source: PublicDomainPictures, Pixabay

Leflunomide

Leflunomide (Arava) works in much the same way as methotrexate. When combined with this drug, the results may be even more effective. The patient experiences approximately similar side effects as with methotrexate. Sometimes Arava causes diarrhea. Arava is potentially harmful to a fetus and therefore this medication is not indicated for women who wish to become pregnant.

Methotrexate

Methotrexate (MTX) is the most commonly used DMARD. The drug works as well or better than any other single drug. This relatively cheap medicine has a number of side effects, such as a skin rash and stomach complaints. In addition, the drug is potentially toxic (poisonous) to the liver or bone marrow. In addition, a baby is sometimes born with congenital defects because the mother has taken this medicine. In rare cases, the medicine causes shortness of breath. Regular blood tests are necessary when using methotrexate. Taking folic acid reduces some side effects of the drug. The drug is safe for long-term use and children can also use Methotrexate.

Minocycline

The rheumatologist only sporadically prescribes the antibiotic Minocycline (Minocin) to stop the inflammation. Usually the patient must take the drug for several months before the symptoms diminish. It takes about one year before the maximum effects are achieved. With long-term use, skin discoloration occurs due to the use of Minocycline.

Tofacitinib

Tofacitinib (Xeljanz) (JAK inhibitor) is often used by rheumatologists when patients no longer respond to the use of methotrexate. The patient takes the medicine via a pill twice a day. The medicine inhibits immune responses and therefore increases the risk of serious infections, cancer and lymphoma.

Side effects of DMARDs

DMARDs work throughout the body to combat joint inflammation. They often cause side effects. The rheumatologist therefore often gradually increases the dose and also starts a medication before introducing another DMARD. The rheumatologist wants to treat chronic joint inflammation and minimize the side effects.

Blood problems

DMARDs work on the immune system and therefore increase the risk of infection. White blood cells, which normally fight infection, are also lower due to the use of DMARDs (neutropenia). Due to the low number of red blood cells (anemia), the patient is tired more often. Regular blood tests are necessary to check blood counts.

Liver problems

Patients occasionally experience liver problems. This also requires regular blood tests to detect signs of liver damage in time. The patient is advised to drink alcohol in a limited manner.

Stomach complaints

DMARDs sometimes cause nausea, sometimes with vomiting or diarrhea. Other medicines treat or improve these symptoms. If the symptoms are too uncomfortable, the rheumatologist will use another medication.

read more

• Joint Health: Tips for Maintaining Healthy Joints
• Swollen joints: Causes of joint swelling
• Joint pain: Causes of painful joints (arthralgia)
• Joint stiffness: Causes of stiff joints
• Ankylosing spondylitis: Persistent joint inflammation