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- When a patient is first diagnosed
with rheumatoid arthritis, one of their main questions is
how are we going to treat this?
How am I going to be feeling better?
And there are several ways to treat rheumatoid arthritis.
We try to use medications that we call
disease-modifying drugs and what we mean by that
is that they change the course of the disease.
They prevent erosions in the joints and permanent damage.
And these are key medications to get started early
in rheumatoid arthritis, so our patients
don't have that permanent damage in their joints.
Within this category of medications,
these disease-modifying medications,
there are two main subcategories.
So there are conventional oral disease-modifying medications
and there are biologic disease-modifying medications.
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Often, people will start first with the conventional
oral medications to treat their rheumatoid arthritis
and so some examples of these medications are
Sulfasalazine, Methotrexate and Leflunomide.
And these medications work by modulating
the immune system so that it's not as active
damaging the joints as it normally is
in rheumatoid arthritis.
And these medications have been used for decades
in rheumatoid arthritis.
They are generally well tolerated.
There are some side effects for the particular medications
that need to be considered.
We need to always watch out for side effects
when we're starting any new medication.
When you're on these types of medications,
the main thing to know is that your blood work
will need to be monitored regularly
and this is to make sure that the liver functions
are normal and that the blood counts all stay normal
with these types of medications.
There's not a big increased risk of infection
with these types of medications.
Some do not increase the risk of infection at all,
so that's a plus for this category of medications.
So the fact that these medications are oral
or available by pills you take by mouth,
that's attractive to a lot of patients
as opposed to injections or infusions
like some of the biologic medication.
So we'll often start patients with
a conventional disease-modifying drug
before going to a biologic drug.
And these medications, besides having been around longer,
end up being less expensive and often
there's less trouble with insurance
of getting these medications approved and paid for.
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The other main class of medications
to improve outcomes in rheumatoid arthritis
are biologic disease-modifying drugs.
This class is ever expanding, new drugs are coming out
in the market, but the main categories are
TNF inhibitors, drugs that block an inflammatory protein
called TNF.
Abatacept, which is a drug that helps prevent T cells
from becoming too activated.
Tocilizumab, which is a drug that blocks
a proinflammatory protein that causes inflammation, IL-6.
Rituximab, which works on the B cells.
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The biologic drugs, the first ones approved
were TNF inhibitors and that's about 20 years ago.
So we've been using some of these as long as
two decades for the treatment of rheumatoid arthritis.
The TNF inhibitors are only available in injection
or infusion form.
These medications work by turning down
the immune responses that are too active in RA.
So turning the dial down on your immune system.
So as a result, one of the main things
that we think about is the risk of infection.
Our immune system normally is supposed to protect us
from outside invaders, bacteria, viruses.
And so when we start turning down the immune system
we do somewhat increase the risk of infection.
So before you would start a TNF inhibitor,
your rheumatologist will check you for hepatitis,
viral hepatitis and also for tuberculosis
to make sure that you don't have a chronic infection
that could then come to the surface
as a result of being started on these drugs.
And while you're on these drugs,
if any signs of infection develop like fevers
or productive cough, coughing up stuff to suggest pneumonia,
urinary tract symptoms, skin infections,
anything of that sort, these drugs will potentially
be held while you're treated for those infections
so that you can heal and get back on track.
That's true in general for the biologics
using the TNF inhibitors as an example.
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These drug classes can often be combined,
conventional oral disease-modifying drugs
with biologic drugs.
The oral drugs can be combined together themselves as well.
Sometimes biologic drugs are used on their own.
There are many different treatment options.
So when I have a patient who's diagnosed
with rheumatoid arthritis and they hear
it's a chronic disease that we don't yet cure,
they're often understandably upset by this diagnosis.
But I like to reassure people that in 2017
we have so many great treatment options
for rheumatoid arthritis and we can really manage
the disease well and help people achieve their goals
and stay functional.
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An infusion is a medication that's given directly
into the vein.
So to have an infusion, patient's will go
to an infusion center or a clinic.
They'll have an IV started, so an IV catheter
put into their vein, usually into their arm
and then the medication will be given directly
into the IV.
The good thing about infusion type medications
is that compared to some medications,
which have to be injected by the patient
or a family member at home,
they are going to a healthcare setting
and they don't have to do anything.
They can just sit back and let the nurses there
take care of them and give them the infusion.
The downside of that is that they must then go
and make an appointment and take time out of their day
to have the infusions done versus injection medications,
which can be done at home by the patient
or by family or friends.
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Infusions are often given with premedications
to prevent any bad reactions.
So patients will often receive Tylenol and Benadryl
and sometimes even steroids before they get their infusion
to make sure that everything goes smoothly.
Infusions often are given more frequently up front
and then spaced out.
They are dosed by body weight,
which is nice compared to other types of medications,
which are more one-size fits all dosing.
So infusions are good options
for treating rheumatoid arthritis and other forms
of autoimmune disease that we see in rheumatology
and to find out if that's right for you,
talk to your rheumatologist.
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