The 5 Main Classes of Rheumatoid Arthritis Drugs

Rheumatoid arthritis (RA) is a complex disease. Perhaps not surprisingly, treatment can be complex as well. The five main classes of drugs used for RA—DMARDs, corticosteroids, biologics, NSAIDs, and analgesics—each play a different role. Some of these arthritis medications only relieve pain, some stop inflammation, and others address the disease process to prevent a flare-up of symptoms and halt disease progression.

Aspirin tablets spilling from a bottle.
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RA treatment typically involves one or more of these medications to target different aspects of the disease. Your doctor will consider your medical history, current symptoms, and your disease progression in determining the right type of arthritis treatment for you.

DMARDs

Disease-modifying anti-rheumatic drugs (DMARDs) are slow-acting medications that work behind the scenes to hamper the progression of rheumatoid arthritis and reduce the risk of permanent joint damage.

DMARDs are the first-line treatment recommended for rheumatoid arthritis.

The most commonly prescribed DMARD is methotrexate (sold under the brand names Rheumatrex and Trexall). Other DMARDs include: 

Small-molecule DMARDs including JAK inhibitors are among the newer options in this drug class. Xeljanz (tofacitinib) is one of these. It works by inhibiting the JAK pathway inside cells which plays a significant role in inflammation associated with rheumatoid arthritis.

DMARDs are taken on a long-term basis and can take weeks or even months to become fully effective. When taking DMARDs, your doctor will order periodic blood tests to monitor your liver enzymes.

Side effects of DMARDs include upset stomach, nausea, diarrhea, hair loss, mouth sores, rash or serious skin reactions, and problems with the liver, kidneys, or lungs.

Corticosteroids

Corticosteroids, also called glucocorticoids, are synthetic drugs that mimic the effects of cortisol—a hormone naturally produced by the adrenal gland that affects several functions in the body, including the immune system. Cortisol has the ability to quickly control inflammation by decreasing levels of prostaglandins as well as inflammatory cytokines.

Doctors often prescribe corticosteroids for fast, temporary relief of RA symptoms while waiting for DMARDs to take effect at the start of treatment or during a painful flare-up. 

Corticosteroids can be taken orally (tablet, capsule or syrup form); applied topically (cream, ointment); or injected into the joint (intra-articular), a muscle, or a vein (intravenously).

Corticosteroids commonly prescribed to treat rheumatoid arthritis include:

Despite their benefits, corticosteroids have the potential for undesirable side effects such as, infection, bone mineral density loss, increased appetite, weight gain, fluid retention, and high blood pressure—especially if they're taken for a long period of time or at a high dose.

If your doctor puts you on a corticosteroid, it's important to take it exactly as prescribed.

Biologics

Biologics, so named because they are produced from living organisms, are a newer class of DMARD. Genetically engineered from a living organism, biologics target specific inflammatory cells, cellular interactions, and cytokines that cause RA-related tissue damage. In doing so, biologics help reduce arthritis symptoms and slow disease progression.

Biologics are prescribed as an add-on therapy after treatment with methotrexate or other DMARDs have failed to relieve symptoms and influence disease progression.

Four main types of biologics are used to target different autoimmune reactions: 

TNFIs are the most commonly prescribed class of biologics. Recommended as a second-line treatment when methotrexate and other DMARDs fail to halt disease activity, they target an inflammation-causing substance called tumor necrosis factor (TNF).

In people with RA and other rheumatic conditions, high TNF levels contribute to inflammation and disease progression.TFNIs work by blocking TNF, therefore preventing inflammation in the joints.

Most biologics are self-injectable, but some are given intravenously in a hospital or outpatient center. 

Biologics cost more to produce and are more expensive than older DMARDs. Most health insurance companies require pre-approval paperwork from your doctor detailing medical necessity prior to covering biologics.

Biologic therapies suppress the immune system and can make you more vulnerable to infections such as a cold, upper respiratory tract infection, sinus infection, sore throat, bronchitis, or urinary tract infection.

Other side effects include headache, nausea, and injection-site reactions.

NSAIDs

Nonsteroidal anti-inflammatory drugs, commonly referred to as NSAIDs, are a large group of drugs primarily prescribed to reduce inflammation, pain, and fever, NSAIDs are commonly used to treat RA symptoms, as well as those related to a host of other conditions.

NSAIDs work by preventing an enzyme called cyclooxygenase (COX) from making prostaglandins, which are hormone-like chemicals involved in inflammation. COX-1 and COX-2 are the two types of these enzymes.

Traditional NSAIDs—such as aspirinnaproxen, and ibuprofen—block both COX-1 and COX-2 enzymes. Newer NSAIDs, such as Celebrex (celecoxib), block only COX-2; these drugs were developed because COX-1 is known to have a beneficial effect of protecting the stomach lining.

The newer NSAIDs and higher doses of older NSAIDs require a prescription, but many older medications are available over the counter (OTC) in reduced strength—for example, Advil (ibuprofen) and Aleve (naproxen).

NSAIDs can be helpful for relieving pain and inflammation during a flare-up, but do have side effects if taken on a long-term basis. If you find yourself needing to take NSAIDs every day, talk to your doctor to determine if changes to your medication regimen are necessary.

Analgesics

Prior to the development of more targeted therapies, analgesics were the primary treatment for arthritis pain. This class of drugs includes non-narcotic pain relievers like Tylenol (acetaminophen) and opioid painkillers such as hydrocodone.

Analgesics work to relieve arthritis by changing the way the body senses pain. They can be effective for short-term pain relief during a flare-up but are not commonly recommended any longer due to the availability of more effective treatments.

Sold over the counter, acetaminophen is the most common analgesic. It is found as a standalone medication or in combination drugs like those formulated for colds, migraines, and period pain.

In large doses, acetaminophen can cause liver failure. Use caution to not mix products containing acetaminophen and do not exceed 4,000 milligrams (mg) per day.

Opioid analgesics such as oxycodone, codeine, and morphine are highly effective at reducing pain, but cause disorientation and can be fatal if taken in large doses.

Opioids are highly addictive and can quickly lead to physical dependence if taken regularly. They should be used sparingly, as directed, and only after other medications fail to bring relief.

Ultram (tramadol), a time-released opioid, is sometimes prescribed for moderate to severe RA pain as it is thought to have a lower risk of abuse than other narcotics. However, addiction is still a risk with this drug.

VicodinLortab, and Norco are brand-name formulations of hydrocodone and acetaminophen. They should not be taken with Tylenol or a combination cold medicine.

Side effects of opioids include nausea, constipation, and trouble focusing or thinking clearly.

A Word From Verywell

Treating RA is important for maintaining your quality of life, slowing disease progression, and minimizing disability. Be sure to follow your doctor's instructions and be vocal about whether or not your symptoms are improving. It is not uncommon for one's RA treatment regimen to change over time.

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