Conventional DMARDs in rheumatoid arthritis
Conventional DMARDs (disease-modifying antirheumatic drugs) are slow-acting drugs that change the course of rheumatoid arthritis, an autoimmune disease where the immune system attacks the joints.
Remember
A slow-acting drug that changes the course of rheumatoid arthritis points to a conventional DMARD rather than to a symptom-relieving drug: an NSAID (non-steroidal anti-inflammatory drug such as ibuprofen), a painkiller or a short-term steroid.
Memory aid
DMARDs work on the foundations (the disease), whereas NSAIDs and steroids repaint the walls (the symptoms).
Use the picture to remember that DMARDs work on the disease itself, whereas NSAIDs and steroids work on the symptoms.
Treatments for rheumatoid arthritis fall into two groups: those that relieve symptoms and those that change the disease. Conventional DMARDs belong to the second group.
Left alone, the disease follows its natural history, meaning the course it would otherwise take: persistent inflammation in the joints and damage to the bone, cartilage, tendons and ligaments nearby. DMARDs work by blocking the effects of the chemicals released when the immune system attacks the joints, and so they slow that course.
Conventional DMARDs are described as synthetic (made chemically) and non-targeted (they damp down immune activity broadly rather than blocking one chosen molecule). Examples of conventional DMARDs are methotrexate, sulfasalazine, hydroxychloroquine and leflunomide, and methotrexate is usually the first medicine given. They are inexpensive and effective.
Because DMARDs are slow-acting, a short course of steroids is often given to cover the wait. NSAIDs such as ibuprofen ease pain and inflammation but do not stop the disease getting worse. Biological drugs (injected medicines aimed at specific immune molecules) are usually added only if DMARDs alone have not been effective.
Treatment starts early, because early treatment reduces the risk of joint damage, and once a suitable DMARD is found it is usually taken long term. There is no cure for rheumatoid arthritis, and even in sustained remission European (EULAR) guidance advises that DMARDs may be tapered (reduced in dose) but should not be stopped.
Key facts
- Defining feature
- they are slow-acting drugs that change the natural history of rheumatoid arthritis, rather than only relieving symptoms.
- Examples
- methotrexate (usually the first medicine given), sulfasalazine, hydroxychloroquine and leflunomide.
- Type of drug
- synthetic (made chemically) and non-targeted, so they act broadly on the immune system rather than on one molecule, and they are not antibodies.
- Slow onset
- it can take a few months to notice a DMARD working, so a short course of steroids is often given to cover the wait.
- Early start
- treatment is started early, because early treatment reduces the risk of joint damage.
- Not a cure
- there is no cure for rheumatoid arthritis, and European (EULAR) guidance advises that even in sustained remission DMARDs may be tapered but should not be stopped.
- Methotrexate dosing
- it is given once weekly, not daily, because accidental daily dosing has caused deaths.
Exam traps
- Fast relief of pain and stiffness without altering how the disease progresses describes NSAIDs such as ibuprofen, not conventional DMARDs, which are slower to act but change the course of the disease.
- Conventional DMARDs are not introduced after biological drugs have failed, because they are started early and biological therapy is considered after an inadequate response.
- Short courses of steroids can bridge the wait for a DMARD to work, but a conventional DMARD is different, because people usually have to take it long term to control the underlying disease.
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