Medication
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Biologic Therapies     Other medications and indications for treatment      Disease Modifying Drugs

This page is to provide you with some basic information on medications used for the some of the most common forms of arthritis (e.g., Rheumatoid Arthritis, Ankylosing Spondylitis, Psoriatic Arthritis, Osteoarthritis and Gout). It is not a definitive list and it is only to provide an overview.

The medications you might be prescribed for your arthritis will vary depending upon a number of factors. These include:

• The type of arthritis you have
• The severity of your symptoms
• How active the arthritis is
• Research evidence that demonstrate the value of you having a medication. For instance if the treatment has been shown to reduce or stop the long term damage to your joints
• Your general health and other illness that may need to be considered before your receive treatment.

Once these facts are reviewed and you have been assessed the doctor or nurse/practitioner will discuss the possible treatment options with you. (See Assessment and Monitoring) The final decision about treatment will depend upon you and your healthcare team deciding upon the most appropriate treatment taking all the important facts and your preferences into account. There are sometimes difficult decisions to make in weighing up the risks of treatment and their side effects and the potential benefits you may get as a result of taking the medication. Everyone has their own personal views and individual thoughts about their choices of treatment. Therefore it is important that you have an opportunity to talk about how you feel about the medications.

It is important that whatever treatment you are prescribed that you read the information provided to you and that you have an opportunity to discuss any concerns you have about the treatment. In many hospital units you will see a nurse or practitioner who will talk to you about the treatments and advise you about the risks and benefits of treatments as well as how to manage your medications. Sometimes if your own doctor prescribes treatment he will provide that information or ask you to see the pharmacist or nurse practitioner to discuss the practical issues about your medication.

Some people ask about drug that has recently been launched and you have read about in the newspapers but you haven’t been offered - unfortunately in some cases there are some treatments that are not routinely offered. In some cases it is because the evidence isn’t good enough for some groups of patients, there may be risk that might be too high for some patients to have the treatment or it may be because the drug is not cost effective (as assessed by economic analysis). The cost effectiveness of a drug is usually assessed by authorities who form part of the regulatory framework for the NHS. The treatment choices you will have may vary a bit based upon where you live for example in England and Wales – this is governed by the National Institute of Health and Clinical Excellence (www.nice.org.uk) In Scotland this is the Scottish Intercollegiate Guidelines Network (www.sign.ac.uk)

• how severe the pain is
• how frequent the pain is
• whether there is inflammation in the joint
• how many joints are affected
• whether you have other symptoms such as generally feeling unwell
• how active the arthritis is at the time

• Simple analgesics to help your pain relief (see Managing Pain)

• Non-steroidal anti-inflammatory medications. These are sometimes abbreviated to NSAIDs. There are also a different group of NSAID called a COX II. These drugs are categorised as either traditional NSAIDs and new NSAIDs or COX IIs. Both categories (NSAID and COX IIs) have a number of different drugs in those categories. Your doctor will chose the drug that is most suited to your needs and general health.
                                   •Traditional NSAIDS include, ibuprofen, Diclofenac and naproxen
                                   •COX II type therapies include; Celecoxib

• There has been some debate about the safety of NSAIDs and Cox IIs and whether they increase the risk of heart problems (such as stroke of heart attack) as a result of taking the medication. The research continues although it does appear that all of these treatments have an increased risk of heart problems (some have a high risk profile than others). However COX II therapies are safer for those who are at risk of stomach problems (such as bleeding from the stomach). Your doctor or nurse will discuss you own personal risks and the benefits of receiving on of these treatments with you to help you make the right decision about the best way of relieving your pain.

• It is important that you discuss your general health with your doctor and your pain control is managed bearing in mind your own individual risk factors. If you have a heart problem or specific risks related to heart disease it maybe that you will not be prescribed a COX II or NSAID.

• If you are prescribed a COX II or NSAID it is likely that you will be given the dose that the doctor or nurse hope will relieve your pain but keep your risks to the minimal. So usually this means only a short course of treatments – to be used when you need them but you will be advised to stop them when the flare of your joint pain is over or you will need to go back to see the doctor, nurse or pharmacist to decide about the next step in your treatment. It is important to know how to manage your pain effectively using a step up and step down approach particularly if you have a long term condition (see Managing Pain)

• Steroid tablets may be prescribed. They are very effective in helping the pain although whether patients should receive steroids for long periods of time remains a matter of controversy because of the side effects of long term use. It is important that you ask about how your bones will be protected from the risk of osteoporosis when you are prescribed steroids, particularly if they are prescribed for more than three months. Some people may be more at risk from osteoporosis than others and taking steroids regularly will require an assessment of your risk. You will then need to discuss your views and choices with your doctor or practitioner.

• Other forms of steroid are sometimes used. These include injections or infusions. An injection of one large dose of steroid can be very helpful in relieving the effects of a painful flare and allowing you time to recover and start a new treatment. Another way of having steroids is when they are injected into one or two painful joints.

• Occasional injections appear to have good benefit but do not appear to have the same problems as receiving long term steroid treatments. This may be related to the way the drug is given. If steroids are taken by mouth this means they have to be absorbed by the body before providing benefit.

• Steroid treatments are sometimes given as an infusion particularly if your condition is poorly controlled (a needle is inserted into a vein and some sterile fluid is passed through your veins with the drug, usually for a few hours). You will need to attend your local hospital or day centre as a day case to receive this treatment and often requires a few blood tests and possibly a urine test to ensure you have no infections before you have this treatment.

Disease Modifying Anti-Rheumatic Drugs (a common abbreviation is a DMARD) are specific type of drug that reduces the level of disease activity in the arthritis, although not all forms of arthritis require a DMARD.

Disease Modifying Drugs
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For some types of arthritis the increase in pain is related to an increase in the disease activity. This means to improve control of the disease you may need to start a new treatment or have your treatment altered to improve control of your arthritis. This may mean that you require a specific type of drug that will damp down the immune response that causes the arthritis and inflammation. In recent years it has been common practice to prescribe combination therapy because it has been shown to have additional benefits in controlling the arthritis. This means that you may be prescribed two DMARD drugs to have at the same time.

Research has shown for some types of Arthritis (e.g. Rheumatoid Arthritis, Psoriatic Arthritis and Ankylosing Spondylitis) that early treatment will reduce the potential long term damage to joints. Control of the disease needs to be maintained and that is why you may require additional medications. However many of these DMARDs take a little while before they are effective so it may mean you start treatment and for a few weeks you may feel worse not better. This is because your disease is still active and causing you pain and making you feel tired and washed out. The tablets have not yet started to be effective and yet your disease is still active. A nurse or practitioner should give you some information about the tablets, side effects and what to be aware of before you start treatment. They should also provide you with some information to take home. You should use read the information provided as well as the information included in your medications Sometimes it is useful to read the information again shortly afterwards as many people find they have forgotten some of the information they were given at the time.

An overview of DMARDs

Some DMARDs are given by injection:

ethotrexate given by injection - only once a week. Sometimes people are trained to inject themselves subcutaneously (an injection that is under the first layer of skin but not into deep tissues of the muscle. [RCN pdf subcutaneous methotrexate document page 30]
Gold - given by injection usually once a week at first then once a month.
Cyclophosphamide - this is given to only some types of arthritis and is usually given as an infusion (a needle is inserted into a vein and fluid plus the drug is given to you over a few hours. This usually requires admission to hospital or day centre).

DMARDs in tablet form:

Sulphasalazine.
Leflunomide
Hydroxychloroquine
Penicillamine
Ciclosporin
Azathioprine

For a detailed explanation of these drugs and their side effects you can speak to your nurse or doctor or the rheumatology team. You can also find some useful information on www.arc.org.uk

Biologic Therapies
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These therapies became available since the early 2000s in the UK and are licensed for the treatment of long term conditions such as Rheumatoid Arthritis, Psoriatic Arthritis, Juvenile Idiopathic Arthritis and Ankylosing Spondylitis, and Lupus. Quite often these therapies are given in combination with methotrexate. Many of the available therapies in the UK have been reviewed or are currently being reviewed by the National Institute of Health and Clinical Excellence (NICE). www.nice.org.uk
These treatments can be used to treat a number of conditions related to arthritis and other health conditions that have an auto-immune component such as Crohn’s disease.

These treatments are called Biologic therapies to describe how these new treatments that have been biologically engineered and designed to target specific 'messengers' in the body. These targeted messengers are a normal response to inflammation and raise the alarm for the body to for example fight infection. However, in some of these auto-immune conditions we know that the messengers (called cytokines) continue activating inflammation and do not stop resulting in damage to the tissues.
You may also have seen information about these therapies where they have been more specifically anti-TNF therapies (or anti-Tumour Necrosis Factor alpha). These TNF 'messengers' are called cytokines. There are a number of these cytokines and some have been shown to target inflammation in inflammatory arthritis. The first of the biologic therapies developed were:

• Anti-Tumour Necrosis Factor alpha therapies (adalimumab, etanercept and infliximab)
• Interleukin 1 therapies (anakinra)

As a result of the work on the biologic therapies it has helped researchers understand more about how some disease are driven by the immune system and identify new treatment targets. More recently other therapies have been licensed that target other parts of the immune pathways. These include:

• Rituximab (B cell depletion therapy)
• Abatacept (a therapy that blocks the messenger system between two important communicating cells that are important in activation of the cytokine messengers)

Rituximab
Rituximab works by reducing some but not all of your circulating B cells and cells that are developing into fully fledged B cells (CD 20). B cells are important because they play a powerful role in the immune response. Rituximab is a treatment that has had a great deal of experience in the treatment of a cancer treatment – called non-Hodgkin’s lymphoma and was used to reduce B cells and by chance was shown to benefit people with Rheumatoid Arthritis. More recently research has shown good benefit to other conditions such as Lupus.

Rituximab is a treatment that is given by infusion (needle into a vein with a small bag of fluid which contains the medication). You normally have to go to an infusion unit usually in a hospital to receive your treatment. The treatment is usually two treatments two weeks apart and then you may not require further treatment for quite some time (6 months or more) depending upon how well your disease is controlled. See link to NICE guidance www.nice.org.uk

Abatacept
Abatacept is given as a short infusion. After the first dose you would then have another treatment 2 weeks later – then treatment continues every four weeks. You will need to be given this treatment in an infusion or day case unit. Abatacept works by reducing two signals that are required to active an immune response (blocking CD 80 and CD 86 molecules). NICE guidance in England and Wales has not approved the use of Abatacept, this means that it is not readily available to be prescribed routinely within the NHS.

In addition to these therapies there are a number of other treatments that will in the next few years be licensed. Some of these therapies are targeting different parts of the immune system so it is an exciting time! It also means that there are more options available in the way of treatments for those who have failed to control their arthritis so far.

Benefits of biologic therapies
Research evidence on biologic therapies is very promising with many people gaining a great deal of benefit from the treatments including less pain, better control over the and less damage to joints. However, not everyone gains benefit from these treatments and they are expensive. It is important to have time to talk to a nurse specialist and/or doctor about the treatments. If the treatment is to be prescribed by the NHS there are clear guidelines to decide who should have the treatment. You can see guidelines by the British Society for Rheumatology (www.rheumatology.org.uk) on those who should be eligible for treatment. Your doctor or nurse will be able to give you more advice about these treatments. It will be important to consider your disease and general health before advising you whether biologic therapies might be right for you. You need to make sure you ask about all the important factors that may be important to you about the treatment for example you need to think about whether a treatment by infusion (a needle into your vein allows a bag of fluid to introduce the treatment directly into your body. This involved a couple of hours in a day unit facility in a hospital or special infusion unit) otherwise you may feel that a subcutaneous injection that you can be taught to give to yourself will suit you better. The team looking after you will give you plenty of time to discuss the options with you.

If you are to receive one of these treatments it is important that you understand what is involved in receiving these treatments. Firstly you will need a thorough assessment and screening process to ensure you are eligible and safe to have these treatments. The nurse and doctor will also provide information on your responsibilities whilst receiving treatment.

For a more detailed explanation of biologic therapies and how they work you can access www.nice.org.uk for information on each of the drugs identified above. In addition you can see an article published in the Journal called Musculoskeletal Care (see Publications)

New research - new treatments on their way.

Other Medications and indications for treatment
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The Arthritis Research Campaign website can provide additional information on all the disease areas discussed and treatments available (www.arc.org.uk). In addition it is always important to ensure that you read the information provided with any medication you receive to ensure you understand the risks and benefits of treatment.

Research has shown certain DMARDs to be more helpful in some types of arthritis than others. Some forms of arthritis will require treatments in addition to the drugs used to relieve pain or control the arthritis (such as DMARDs).

This means that some types of arthritis require more specific medication treatment plans. If you are being seen at a hospital rheumatology department ask to have further information on the treatments available. The information provided by the Arthritis Research Campaign (www.arc.org.uk) on the type of arthritis you have will also mention some of the treatments available.

Example of some specific types of arthritis and medications sometime used.

Osteoarthritis
Paracetamol is a very effective treatment but needs to be taken regularly when pain is a problem and a dose that will be effective (as prescribed in the patient information leaflet on dosages to use). For some short and painful times you might be prescribed a non-steroidal anti-inflammatories (NSAID) or COXII inhibitor ( newer type of NSAID might be prescribed). [link see How to Manage Your Pain] . For one or two painful and swollen joints a joint injections may be helpful. Very rarely with severe Osteoarthritis that have a strong inflammatory component disease modifying drugs may be prescribed. Osteoarthritis has increasingly been shown to benefit from a number of non- drug treatments and healthy lifestyle factors such as exercise and weight loss. See the link to NICE guidance on managing Osteoarthritis. www.nice.org.uk

Gout
Gout can be an extremely painful condition. At times of flare up Non-steroidal anti-inflammatories, joint injections and occasionally if repeated attacks are experienced drugs such as Allopurinol maybe prescribed. Research is beginning to explore newer therapies for gout so it is important to seek advice from doctor or nurse if your current treatments are not working. More recently newer therapies have been licensed for gout. For severe attacks that do not respond to anti-inflammatory drugs it may be necessary to have colchicines or steroids. For a helpful booklet on gout produced by the gout society [link to pdf 270kb or go to the www.ukgoutsociety.org or www.arc.org.uk] These booklets contain important and useful information about dietary issues and lifestyle. Practical tips include using ice packs for painful joints and not going for crash diets but to look at important aspects of your diet to reduce for example the protein (purine intake) for example red meats, shellfish and offal.

Paget's disease
Paget’s disease is a disorder of the growth and development of the bone. It can be present without any symptoms but for others the symptoms are of pain in the bones. May require treatment with a bisphosphonate treatment (for example pamidronate) www.paget.org.uk or www.arc.org.uk

Ankylosing Spondylitis
Treatment should include the use of simple pain relief (analgesia such as paracetamol) taken regularly. Many patients also need a non-steroidal anti-inflammatory or COX II. For some people treatment will need to be with the addition of a DMARDs such as Methotrexate or Sulfasalazine are required although often they only provide a small additional benefit. Treatment with a DMARD will depend upon the type of joints involved and number of joints involved. Recently research has demonstrated that biologic therapies (see Biologic Therapies) can be very effective in treating those with moderate to severe Ankylosing Spondylitis. There will be specific criteria that need to be adhered to. Your rheumatology team can provide you with information about this treatment and whether you are eligible for treatment. www.nice.org.uk  www.nass.co.uk  A booklet produced by NASS can be accessed on the NASS website.

Rheumatoid Arthritis & Psoriatic Arthritis
SPatients with RA and PsA will often need simple analgesia (such as paracetamol) or stronger analgesia which is usually paracetamol but includes a small amount of opiod (for example co-codamol) (see Pain Management). Many patients cannot cope with out some back up non-steroidal anti-inflammatories particularly when the pain flares, however these should be taken at the lowest effective dose for the shortest duration possible to relieve pain (step up and step down approach to pain management). Some people may benefit at times from a course of steroids (increasingly many doctors/nurses find the best way to give this is as an intramuscular injection but tablets may also be prescribed). Joint injections can be extremely helpful for one or two troublesome joints. A majority of patients will require a disease modifying drug and a smaller group still will eventually need additional therapies to control their disease (for example biologic therapies). You will need to be assessed carefully to see whether you are eligible for treatment with biologics. There are criteria for receiving treatment with these therapies and the National Institute of Clinical Excellence Guidance Document 36 can be see on www.nice.org.uk to provide additional information. (see Biologic Therapies) www.rheumatoid.org.uk for extensive information for patients with RA. www.papaa.org. For information for those with Psoriatic Arthritis. Or general information about Psoriatic Arthritis and Rheumatoid Arthritis (www.arc.org.uk)

Osteoporosis

Osteoporosis is a condition that makes the bones more fragile and increasing the risk of fractures as a result of low bone mass and poor architecture of the tissues of the bone. There are important aspects to consider maintaining healthy bones and avoiding osteoporosis. These include a healthy balanced diet with a reasonable intake of calcium and Vitamin D as well as ensuring you take regular exercise and maintain a normal body weight. There are specific risk factors that make some people more vulnerable to developing osteoporosis these include, people who have a low body weight (for example those with anorexia, hormonal changes (for example early menopause) and some medications (such as steroids).

Further detailed information can be found on the national osteoporosis society website www.nos.org.uk  or www.arc.org.uk

In recent years the treatment and management of osteoporosis has improved dramatically with a range of therapies available for the prevention and treatment of osteoporosis. A thorough assessment of your condition and individual risk factors will need to be considered before the most appropriate treatment can be recommended. A number of these therapies have been or are currently being reviewed by NICE (www.nice.org.uk)

Systemic Lupus Erythematosus (SLE)
SLE is an auto-immune disease. Inflammation can lead pain in a number of joints, fatigue and skin rashes. The diagnosis of SLE should be made by a consultant rheumatologist and a treatment plan will be made depending upon the severity of the disease and specific problems. Treatments include;

Pain medications to treatment the pain including simple analgesics
Steroids (these can sometimes be at high doses and may also mean additional treatment to protect the bones from osteoporosis).
Cyclophosphamide (given by an intravenous infusion)
Sometime anticoagulant therapies are required e.g. aspirin or warfarin.
Disease modifying drugs therapies may be required for example anti-malarial drugs such as hydroxychloroquine, Mycophenolate Mofetil or Azathioprine.

More recently Rituximab has been used with good results.

Intravenous Immunoglobulins are sometimes prescribed.

Treatments may also be required to deal with specific skin problems and should include information about how to avoid risks of increasing symptoms (such as exposure to the sun) For detailed information on lupus go to: www.lupusuk.org.uk or www.arc.org.uk

Remember that there is more information on specific advice on these different forms of arthritis on the useful links page.

Updated: April 08

Susan Oliver Associates

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© copyright Susan Oliver 2008