Patient education: Disease-modifying antirheumatic drugs (DMARDs) (Beyond the Basics)
- Peter H Schur, MD
Peter H Schur, MD
- Editor-in-Chief — Rheumatology
- Section Editor — Basic Science
- Professor of Medicine
- Harvard Medical School
- Section Editor
- Daniel E Furst, MD
Daniel E Furst, MD
- Section Editor — Treatment Issues in Rheumatology
- Clinical professor, University of Washington, Seattle
- Clinical professor, University of Florence, Florence, Italy
- Professor of Rheumatology, University of California in Los Angeles (Emeritus)
- Director of Research, Pacific Arthritis Associates
DISEASE-MODIFYING ANTIRHEUMATIC DRUG OVERVIEW
Disease-modifying antirheumatic drugs (DMARDs) are a group of medications commonly used in patients with rheumatoid arthritis. Some of these drugs are also used in treating other conditions such as ankylosing spondylitis, psoriatic arthritis, and systemic lupus erythematosus. They work to decrease pain and inflammation, to reduce or prevent joint damage, and to preserve the structure and function of the joints. (See "Patient education: Rheumatoid arthritis symptoms and diagnosis (Beyond the Basics)" and "Patient education: Rheumatoid arthritis treatment (Beyond the Basics)" and "Patient education: Complementary and alternative therapies for rheumatoid arthritis (Beyond the Basics)".)
WHAT ARE DISEASE-MODIFYING ANTIRHEUMATIC DRUGS?
DMARDs work to suppress the body's overactive immune and/or inflammatory systems. They take effect over weeks or months and are not designed to provide immediate relief of symptoms.
Other medicines, such as pain relievers, nonsteroidal antiinflammatory drugs (eg, ibuprofen or naproxen), and, sometimes, prednisone, are given to provide faster relief of ongoing symptoms. DMARDs are often used in combination with these medications to reduce the total amount of medication needed and to prevent damage to joints.
DISEASE-MODIFYING ANTIRHEUMATIC DRUGS
The choice of DMARD depends on a number of factors, including the stage and severity of the joint condition, the balance between possible side effects and expected benefits, and patient preference. Before treatment begins, the patient and clinician should discuss the benefits and risks of each type of therapy, including possible side effects and toxicities, dosing schedule, monitoring frequency, and expected results. Certain screening tests, including blood tests for past exposure to certain infections, may be needed before starting some of these medications.
In some cases, one DMARD is used. In others, more than one medication may be recommended. Sometimes a patient must try different medicines or combinations to find one that works best and that has the fewest side effects. A patient who does not respond completely to a single DMARD may be given a combination of DMARDs, such as methotrexate plus another medication.
The most common DMARDs are methotrexate, sulfasalazine, hydroxychloroquine, and leflunomide. Less frequently used medications include gold salts, azathioprine, and cyclosporine.
Methotrexate — Methotrexate was originally used as a chemotherapy treatment for cancer. When used in much lower doses for rheumatoid arthritis and other rheumatic diseases, methotrexate works to reduce inflammation and to decrease joint damage. It is usually taken once per week as a pill, liquid, or injection. Methotrexate may be combined with other DMARDs or with a biologic agent if methotrexate alone does not adequately control a patient's disease. (See 'Biologic agents' below.)
Common side effects include upset stomach and a sore mouth. Methotrexate can interfere with the bone marrow's production of blood cells. Low blood cell counts can cause fever, infections, swollen lymph nodes, and easy bruisability and bleeding. Liver or lung damage can occur, even with low doses, and therefore requires monitoring. People using methotrexate are strongly discouraged from drinking alcoholic beverages because of the increased risk of liver damage with this combination. Patients should not become pregnant while taking methotrexate.
Monitoring reduces the risk of long-term damage from methotrexate. Testing is performed prior to starting treatment to determine if there has been exposure to certain infections. A chest x-ray is also recommended before beginning treatment, and regular blood testing is recommended. While taking methotrexate, all patients should take folic acid 1 mg daily or folinic acid 5 mg weekly to reduce the risk of certain side effects, such as upset stomach, sore mouth, low blood cell counts, and abnormal liver function.
Sulfasalazine — Sulfasalazine is used in the treatment of rheumatoid arthritis and of arthritis associated with ankylosing spondylitis and inflammatory bowel disease (ulcerative colitis and Crohn’s disease). It is not clear how sulfasalazine works. It may be combined with other DMARDs if a person does not respond adequately to one medication. It is taken as a pill two to four times per day, and it is usually started at a low dose and is increased slowly to minimize side effects.
Side effects of sulfasalazine include changes in blood counts, nausea or vomiting, sensitivity to sunlight, skin rash, and headaches. People who are allergic to sulfonamide medications, such as sulfamethoxazole-trimethoprim (sample brand names: Bactrim, Septra), may have a cross-reaction to sulfasalazine and should therefore not take it. Periodic blood tests are recommended to monitor the blood count on a regular basis.
Sulfasalazine is a yellow-orange color; patients who take it may notice that their urine, tears, and sweat develop an orange tinge, which can stain clothing and contact lenses. Patients should drink plenty of fluids while taking sulfasalazine and should avoid taking it on an empty stomach or with antacids.
Hydroxychloroquine — Hydroxychloroquine, originally developed as a treatment for malaria, was later found to improve symptoms of arthritis. It can be used early in the course of rheumatoid arthritis and is often used in combination with other DMARDs. It is also very frequently used for treatment of systemic lupus erythematosus. It can be combined with steroid medications to reduce the amount of steroid needed. It is usually taken in pill form once or twice per day.
Taking a high dose of hydroxychloroquine for prolonged periods of time may increase the risk of damage to the retina of the eye, although high doses are not usually required for treatment of rheumatoid conditions or lupus. An eye examination by an ophthalmologist is recommended before starting treatment and periodically thereafter. It is common to have an eye check-up done once each year.
Leflunomide — Leflunomide inhibits production of inflammatory cells to reduce inflammation. It is often used alone but may be used in combination with methotrexate for people who have not responded adequately to methotrexate alone or together with a biologic agent. It is taken by mouth once daily.
Side effects include rash, temporary hair loss, liver damage, nausea, diarrhea, weight loss, and abdominal pain. Testing for prior exposure to hepatitis and regular blood testing while on therapy are needed to monitor for liver damage and other toxicities. Patients should not become pregnant while taking leflunomide or while it is still detectable in the body.
Azathioprine — Azathioprine has been used in the treatment of cancer, rheumatoid arthritis, lupus, and a variety of other inflammatory illnesses since the 1950s. It has also been used in organ transplantation to prevent rejection of the transplanted organ. Azathioprine is generally reserved for patients who have not responded to other treatments.
The most common side effects of azathioprine include nausea, vomiting, decreased appetite, liver function abnormalities, low white blood cell counts, and infection. It is usually taken by mouth once to four times daily. Blood testing is recommended during treatment with azathioprine.
Cyclosporine — Cyclosporine was originally developed to prevent rejection after organ transplantation. It works in patients with rheumatoid arthritis to inhibit T lymphocytes, a cell that contributes to the inflammation associated with rheumatoid arthritis. There is concern about the long-term safety of cyclosporine and its association with kidney disease and high blood pressure, so it is generally reserved for patients who have not responded to other treatments. It is usually taken by mouth in pill or liquid form twice per day; an injectable form is also available. It is occasionally used to treat kidney disease due to lupus.
Side effects include high blood pressure, swelling, kidney damage, increased hair growth, nausea, diarrhea, and heartburn. Patients should have blood pressure and kidney function monitoring on a regular basis.
Another class of medications used in persons with rheumatoid arthritis and related inflammatory rheumatic conditions is biologic agents, sometimes called biologic DMARDs (in contrast to the conventional or traditional nonbiologic DMARDs discussed in this topic review), including etanercept, adalimumab, infliximab, certolizumab pegol, and golimumab, which are all part of a class of drugs called tumor necrosis factor (TNF) inhibitors, and a variety of other agents with different targets, including anakinra, abatacept, rituximab, and tocilizumab. Another group of DMARDs, called kinase inhibitors, includes tofacitinib. A biologic DMARD or a kinase inhibitor is often combined with methotrexate or other DMARDs to improve efficacy. (See "Patient education: Rheumatoid arthritis treatment (Beyond the Basics)", section on 'Biologic DMARDs'.)
WHERE TO GET MORE INFORMATION
Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Rheumatoid arthritis (The Basics)
Patient education: Juvenile idiopathic arthritis (The Basics)
Patient education: Ankylosing spondylitis (The Basics)
Patient education: Vasculitis (The Basics)
Patient education: Disease modifying antirheumatic drugs (DMARDs) (The Basics)
Patient education: Behçet's syndrome (The Basics)
Patient education: Psoriatic arthritis in children (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Rheumatoid arthritis symptoms and diagnosis (Beyond the Basics)
Patient education: Rheumatoid arthritis treatment (Beyond the Basics)
Patient education: Complementary and alternative therapies for rheumatoid arthritis (Beyond the Basics)
Patient education: Rheumatoid arthritis and pregnancy (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
General principles of management of rheumatoid arthritis in adults
Overview of immunosuppressive and conventional (non-biologic) disease-modifying drugs in the rheumatic diseases
Randomized clinical trials of combinations of nonbiologic DMARDs in rheumatoid arthritis
Alternatives to methotrexate for the initial treatment of rheumatoid arthritis in adults
Initial treatment of rheumatoid arthritis in adults
Treatment of rheumatoid arthritis in adults resistant to initial nonbiologic DMARD therapy
The following organizations also provide reliable health information.
●National Library of Medicine
●The Arthritis Foundation
●National Institute of Arthritis and Musculoskeletal and Skin Diseases
●American College of Rheumatology
●American Academy of Family Physicians
- Felson DT, Smolen JS, Wells G, et al. American College of Rheumatology/European League Against Rheumatism provisional definition of remission in rheumatoid arthritis for clinical trials. Arthritis Rheum 2011; 63:573.
- Steiman AJ, Pope JE, Thiessen-Philbrook H, et al. Non-biologic disease-modifying antirheumatic drugs (DMARDs) improve pain in inflammatory arthritis (IA): a systematic literature review of randomized controlled trials. Rheumatol Int 2013; 33:1105.
- O'Dell JR, Mikuls TR, Taylor TH, et al. Therapies for active rheumatoid arthritis after methotrexate failure. N Engl J Med 2013; 369:307.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.