Disease Modifying Anti-Rheumatic Drugs (DMARDs) are used to slow down the progression of rheumatoid arthritis (see 'Information' section). In the past DMARDs drugs were prescribed only after symptoms progressed, but it is now clear that the earlier patients are given them the better..
There are two groups of disease-modifying anti-rheumatic drugs:
1. The first group of the DMARDs drugs includes gold, hydroxychloroquine, methotrexate and sulfasalazine. They are used mainly in the treatment of rheumatoid arthritis but also in some other rheumatic diseases. They reduce pain, swelling and stiffness. They do not work at once but may take several weeks to work. If you do not do well on one of these drugs, or if you develop any side effects, then your doctor may try one of the others (see Arthritus Research UK).
2. Another group of DMARDs are the immunosuppressant drugs. They are called 'immunosuppressant' because they suppress the immune system (the body's own defence system). They include azathioprine, ciclosporin, cyclophosphamide, leflunomide and mycophenolate. Methotrexate, also has effects on the immune system. Because these drugs affect the immune system they may produce side effects, and so need careful monitoring (see Arthritus Research UK).
Various DMARDs are used. Many people had tried more than one type, because of side effects or ineffectiveness. With many of these drugs regular blood and/or urine monitoring is required to check for adverse effects on the liver, immune system etc. When an abnormality was found the doctor discussed what to do (see 'Regular monitoring and other diagnostic tests').
These drugs may take weeks or months to have an effect, which frustrated many people. Several may have to be tried to find the best one. The knowledge that there were different types available was reassuring. About a quarter of the participants understood that DMARDs are intended to control, suppress and stabilise their RA.
Some people felt that these drugs would be effective only for a limited time (usually several years) due to increased tolerance and disease progression. Some people could not tolerate any DMARD and others had avoided them because of their toxicity and potential side effects. Some people who were taking those which suppress the immune system worried about catching infections.
Methotrexate (tablet or intra-muscular injection): Most people took as tablets, with dosages of 5 to 25mg once a week. One woman's partner had been taught how to inject it into her arm, so saving a weekly visit to the GP. Many people found this drug effective and had taken it for up to 13 years. However, in a few people the effectiveness had faded after some years and six found it did not work for them.
Side effects that affected some people included vomiting and nausea, which could last for hours or days after each dose. Some people took it at bedtime to overcome this and one man was helped by taking it after food. Other side effects included headaches, feeling disorientated, hair loss, mouth ulcers, acne, an all over burning rash, raspy voice, stomach problems and loss of balance (overcome with cinnarizine). To counteract some of the side effects many people were given folic acid to take on one or more days that they didn't take the methotrexate.
Two people had breathing problems and stopped the drug whilst these were investigated. One woman had an early menopause, aged 40, and in two people the drug caused nodules near joints. One man who was told not to drink alcohol with methotrexate rejected it. He later found out that alcohol in moderation was acceptable if his liver function was monitored and methotrexate proved effective for him.
One woman, who had RA for 9 years, was treated for breast cancer with chemotherapy and high doses of methotrexate which lessened her RA symptoms then and later. An RA charity worker was concerned that patients did not get enough information about methotrexate.
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Sulfasalazine: Several people found this effective or partially effective, but many had had side effects, especially as the dose was increased. Often small doses are prescribed initially and patients are asked to increase the dose, e.g. 2 tablets daily in the first week, 3 tablets daily the next week, and so on until they reach the target dosage.
As the dose increased people often felt or were sick and consequently lost their appetite, felt generally unwell, had headaches, were dizzy, had indigestion, itchy feet and one woman had flaky skin after several months. One woman's urine and sweat turned yellow. These unwanted effects made people either reduce the dose or stop the drug. One woman found she felt ill if she took it before a night out drinking alcohol so she took it on her return home.
Two people had allergic reactions to sulfasalazine and had rigors which involve shivering, shaking, high body temperature and hallucinations. This required a week's admission to hospital for one woman.
Gold (Myocrysin) is injected; auranofin (Ridaura) is taken as tablets: Gold was most commonly injected at the GP surgery - between one every month up to one per week. Several people had received gold injections over many years and found they had controlled the disease, with fewer flare-ups; although one man described how it took time to find the right dose. For some it worked only for a few months and in others not at all.
Side effects of sickness and diarrhoea resulted in weight loss; other people had a rash, itchy skin, thrush and mouth ulcers so they stopped using it. For some, blood in the urine led to a pause, but after further normal test results treatment could be resumed. Some people found going to the GP or hospital regularly for injections inconvenient, whereas others preferred this method to avoid taking pills.
Penicillamine: Three people found this effective for between 6 months and 10 years before changing to other DMARDs. Three found no benefit and one developed blurred vision and difficulty swallowing which was diagnosed as myasthenia gravis. She did not realise it was a rare side effect and waited a month to report this, which in hindsight, was too long.
Leflunomide: Of two people treated with leflunomide, one found it reasonably effective in controlling her arthritis although she still had flare-ups in winter and had high blood pressure as a side effect. The other woman stopped taking it after developing blurred vision.
Hydroxychloroquine (an anti-malarial drug): Seven people had used this, usually in combination with at least one other DMARD and in two it was not effective. In one man it caused sickness and headaches.
Cyclosporin: Three people had used this, one for 3 years during which his symptoms had improved, although he described the tablets as distasteful and he had some stomach problems. Blood monitoring is required with cyclosporin which one woman found 'a bit of a bind'.
Combinations DMARDs: Two (or three) DMARDs can be prescribed together and most commonly this was methotrexate and another DMARD; one man used sulfasalazine and hydroxychloroquine.
Last reviewed August 2010.
Last updated September 2010.
