This drug class can slow down progression of the disease but it’s more toxic than NSAID’s.
Hydroxychloroquine (Plaquenil): The onset of action is 3 months. Can we wait 3 months to see if a drug is working for a RA patient? We’d probably add another NSAID until this worked. This was originally a drug for malaria. Our concern for this drug is not the reversible corneal opacity (luckily the vision clears up if you stop taking it) but the problem is the irreversible retinal damage, so we have to do objective ongoing eye checkups to make sure the vision is not getting worse.
Intra-articular steroids: When steroids are given orally, it goes through their systemic circulation, they retain fluid, gain weight and become huge. They blow up. An alternative to steroids are intra-articular steroids which are medicines injected directly into the joint space of a painful, inflamed arthritic joint. They are usually long-acting steroids so it doesn’t have to happen often. But we are limited to about 3 joints because there’s a risk of introducing the steroid into the blood stream. Intrathecal steroid injection is associated with a high risk of infection like meningitis. Once you introduce bacteria into a joint through a joint it’s very bad because you can’t inject an antibiotic into there.
Consequences of prolonged use of systemic steroids:
- Adrenal suppression
We have two options: An injection called gold sodium thiomalate (Myochrisine) patients have to take monthly or literally a gold tablet called auranofin (Ridaura) that must be taken daily.
Again, they may slow progression of the disease but not stop it.
Potential reactions: Renal damage. Bone marrow depression causing a decrease in WBC and an increase in infections. Patients must be routinely monitored once a month to make sure there’s no renal damage or bone marrow depression.
These have a high risk of cancer. They may be better drugs due to their stronger capability to slow progression but the risk increases with them.
- Anakinra (Kineret) – inj – Inhibits interleukin-1 inflammation
- Etanercept (Enbrel) – inj – Inhibits tumor necrosis factor (TNF) inflammation
- Leflunomide (Arava) – inj – Inhibits immune modulator inflammation
These drugs are cancer, chemotherapy drugs but in lower doses. Yes they can kill cancer cells, but they can also kill normal cells. When a patient goes through cancer chemotherapy, one of the side effects is decreased immune system and higher risk of infection. That’s the property we want with RA because RA is an auto-immune disease so we want to suppress our own immune system so we utilize low doses of cancer chemotherapy drugs. The consequences of these drugs are that they are carcinogenic. They can treat cancer but can also cause a cancer and infection.
Examples: azathioprine, methotrexate (Rheumatrex), cyclophosphamide