Hydroxychloroquine or sulfasalazine may be beneficial in people with low disease activity. Because DMARDs might take months to become fully effective, Dr. Piecyk recommends prescription NSAIDs or short-term prednisone to patients who cannot perform specific daily activities, as this may provide more immediate pain and stiffness relief.
Corticosteroids are short-term temporary medications used to bridge between therapies or reduce flares until long-term medicines take effect. Patients are frequently concerned about side effects such as weight gain, inability to sleep, the beginning of diabetes, or poor glucose control. Dr. Goodman recommends monitoring a patient’s response to therapy and changing the dose, mode of administration, or medication during the first one to three months of treatment. This necessitates regular follow-up evaluations.
“I am more likely to add a second DMARD or a biologic to patients with poor prognostic indicators after three months on methotrexate,” Dr. Piecyk explains.
Also, remember that smoking and anti-citrullinated protein antibody positivity are known prognostic indicators of poorer outcomes.
A More In-Depth Look at DMARDs
Methotrexate, through modifying the immune system, alleviates every day RA symptoms and minimizes the risk of long-term joint damage. The recommended weekly dose is 20–25 mg. In early RA, methotrexate monotherapy achieves remission 30–40% of the time. 3
Patients who do not respond well to oral methotrexate (or who experience adverse gastrointestinal side effects) may benefit from subcutaneous methotrexate.
4 Methotrexate is more bioavailable when administered subcutaneously than when administered orally. 5 “A higher relative bioavailability of the medicine implies a larger effective dose for the patient, which may better control symptoms and RA development compared to a lesser dose,” Dr. Piecyk notes.
Patients, on the other hand, are frequently hesitant to administer a self-injection. “I tell patients that the needle is little, that there should be no gastrointestinal side effects, and that if this drug is helpful, they may not need more medication,” Dr. Piecyk explains.
Dr. Bykerk reminds patients that despite methotrexate’s potential for adverse effects such as hair loss and feeling ill, more than 85 percent of patients have few problems with it. If issues arise, patients can always try a different drug. As a result, she believes it’s worth giving it a shot because the advantages exceed the risks. She will usually reevaluate a patient who has started on methotrexate after 8–12 weeks.
“If I notice a positive response, I may propose continuing the treatment or adding other DMARDs.” However, if the response is insignificant and the severe disease burden, I will propose a self-injectable biologic therapy. This necessitates a more in-depth discussion because patients are interested not only in administering injections and learning how to minimize infection risk but also in having an idea of the financial cost.”
According to Dr. Piecyk, self-injectable biologics are becoming more popular as an alternative to intravenous infusions. For example, both abatacept and tocilizumab were previously exclusively available as intravenous infusions. “Many patients would want to make fewer visits to the doctor’s office,” she explains.