Tumor Necrosis Factor Inhibitors
Tumor necrosis factor alpha is a pro-inflammatory cytokine produced by macrophages and lymphocytes. It is found in large quantities in the rheumatoid joint and is produced locally in the joint by synovial macrophages and lymphocytes infiltrating the joint synovium. TNF is one of the critical cytokines that mediate joint damage and destruction due to its activities on many cells in the joint as well as effects on other organs and body systems. TNF antagonists were the first of the biological DMARDS to be approved for the treatment of RA. These drugs began to enter the market for rheumatoid arthritis in 1999 and are now considered a part the ACR recommendations for treatment of RA. There are currently five TNF inhibitors FDA approved for the treatment of RA etanercept , infliximab , adalimumab , certolizumab pegol , and golimumab . Etanercept is a soluble TNF receptor-Fc immunoglobulin fusion construct infliximab, adalimumab, and golimumab are monoclonal antibodies and certolizumab pegol is an anti-TNF antigen binding domain-polyethylene glycol construct. While differing in structure, the efficacy and safety of the drugs is similar across the class in reducing the signs and symptoms of RA, as well as in slowing or halting radiographic damage, when used either as monotherapy or in combination with methotrexate.
Data Abstraction And Data Management
To ensure accuracy, two reviewers will independently review all titles and abstracts. We will use Abstrackr, an online citation screening tool, to review title and abstract records and manage the results.24 We will then retrieve the full text for all citations deemed potentially appropriate for inclusion by at least one of the reviewers. Two team members will independently review each full-text article, including any articles that peer reviewers suggest or that may arise from the public posting process, for eligibility. Any disagreements will be resolved by a third team member or consensus. We will maintain a record of studies excluded at the full-text level with reasons for exclusion and will include this list in our final report.
After we select studies for inclusion, we will abstract data into categories that include the following: study design, eligibility criteria, intervention , additional medications allowed, methods of outcome assessment, population characteristics, sample size, attrition , results, and AE incidence. A second team member will verify abstracted study data for accuracy and completeness.
What Should I Watch For After Starting Humira
HUMIRA can cause serious side effects, including:
Common side effects of HUMIRA include injection site reactions , upper respiratory infections , headaches, rash, and nausea. These are not all of the possible side effects with HUMIRA. Tell your doctor if you have any side effect that bothers you or that does not go away.
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Diclofenac Sodium Topical Gel
Voltaren gel 1% is an NSAID for topical use. This means you rub it on your skin. Its approved to treat joint pain, including in your hands and knees.
This drug causes similar side effects to oral NSAIDs. However, only about 4 percent of this drug is absorbed into your body. This means you may be less likely to have side effects.
Be Aware Of The Side Effects With Biologics
The following side effects are rare, but they can be serious or life-threatening:
- Serious skin or lung infections
- Skin cancers
- Serious allergic reactions
Other side effects are less serious: minor infections, headache, and reactions at the injection site. People usually dont change treatments because of these side effects.
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Rheumatoid Arthritis Drugs: Nsaids
NSAIDs work by blocking an enzyme that promotes inflammation. By reducing inflammation, NSAIDS help reduce swelling and pain. But they are not effective in reducing joint damage. These drugs alone are not effective in treating the disease. They should be taken in combination with other rheumatoid arthritis medications.
As with glucocorticoids, you should use them for brief periods — they can cause severe digestive tract problems. Which type, if any, your doctor prescribes may depend upon your medical history. If you have a history of liver, kidney, heart problems or stomach ulcers, it’s best to not take these drugs. Ask your doctor whether any new NSAIDS producing fewer side effects are available.
Examples of NSAIDs:
Connect With Others Who Understand
On myRAteam, the social network for people with rheumatoid arthritis and their loved ones, more than 150,000 members come together to ask questions, give advice, and share their stories with others who understand life with RA.
Have you been given chemotherapy to treat your RA? Share your experience in the comments below, or by posting your story on myRAteam.
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Side Effects And Risks Of Nsaids
Like all medications, NSAIDs come with a risk for side effects and other risks.
Side effects are more common if you are taking high doses for long periods, are older, or have serious health conditions. OTC NSAIDs will have fewer side effects compared to stronger prescription NSAIDs.
Possible side effects of NSAIDs include:
- Gastrointestinal: Stomach aches, nausea, diarrhea, etc.
- Stomach ulcers: Can bleed and lead to anemia
- Liver or kidney problems
- Heart and circulation problems including heart failure, heart attack, and stroke
The FDA advisory panel has deemed Celebrex as safe as other NSAIDs when it comes to its cardiovascular risks. The panel also recommended changing the labeling to reflect that it still poses a threat to heart health. Research on celecoxib shows it has a lower risk for GI problems, including bleeding and ulcers, compared to other NSAIDs.
If you experience severe side effects from NSAIDs, stop using the medication and let your healthcare provider know.
Some kinds of NSAIDs interact negatively with other medications. This means they can affect how other medicines work and can increase the risk for side effects.
Medications that might interact with an NSAID include:
Dont Take Too Much
You should call 911 if you or someone else experience serious signs of an overdose, including seizures, breathing troubles, or loss of consciousness.
Who Shouldnt Take NSAIDs
Talking To Your Doctor About A Medication Switch
If youre in chronic pain, your rheumatologist wants to know. Its not okay to just feel fine or live with it for several good reasons.
I dont want my patients to be living in pain, says Leah Alon , MD, a rheumatologist in New York City. Chronic pain is related to depression and acute pain is related to anxiety. Pain also impacts your relationships, your ability to care for your family, and your ability to find and maintain a job.
If your medication isnt working well enough and RA inflammation persists, it can cause permanent damage to the joints. Once you get damage to the joint, there is no way back, says Dr. Alon. You can prevent further damage, but you cant correct the damage that was already done.
Whats more, since untreated RA can cause systemic or all-over inflammation, it can have a negative impact on many parts of your body, including skin, lungs, heart, nerves, and kidneys.
If youre anxious about trying a new medication or are afraid you cant afford it, dont hesitate to let your rheumatologist know. We want to understand all of your concerns surrounding your medication so we can help guide you and make recommendations, says Dr. Schulman.
When it comes to considering a treatment change, its always a we make together.
Here are a few questions you can ask your rheumatologist if youre considering a treatment change:
The good news is that there are more medications than ever to treat RA and manage pain.
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Whats The Age Of Onset For Rheumatoid Arthritis
RA usually starts to develop between the ages of 30 and 60. But anyone can develop rheumatoid arthritis. In children and young adults usually between the ages of 16 and 40 its called young-onset rheumatoid arthritis . In people who develop symptoms after they turn 60, its called later-onset rheumatoid arthritis .
Tips For Rheumatoid Arthritis Pain Management
Other than the pain itself, rheumatoid arthritis can cause many other problems and disruptions in life. There are some things you can do to stay healthy and reduce your pain. These are in addition to your regular treatments.
Here are some tips to help you with your rheumatoid arthritis pain management and coping with the disease:
Dont smoke: Smoking can have serious health consequences on rheumatoid arthritis patients. Smoking causes inflammation, which can complicate these disease and cause more pain.
Be conscious of your use of joints: Try reducing the stress on your joints by being conscious of your daily activities. Picking up items and turning door handles can add pressure to your joints causing them to feel sore. Look for ways to adjust your daily habits and limit the aggressive use of your joints.
Talk to your doctor and rheumatologist: If you still feel pain despite treatment, or you notice new pain, be sure to communicate with your physician and your rheumatologist. There may be additional pain relieving options available.
Seek emotional support: Deal with any stress or trauma you may feel by joining a support group of other rheumatoid arthritis patients. Professional counseling may also help improve your mood and help you to remain positive.
If you continue to experience chronic pain, there are several options for you to try. Talk to your rheumatologist about rheumatoid arthritis pain management options that are right for your individual case.
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How Medications Work To Ra Treat Pain
Heres a look at how different kinds of RA medications work to help manage your disease and minimize pain:
Nonsteroidal anti-inflammatory like ibuprofen and naproxen sodium can be used for breakthrough pain symptoms.
Glucocorticoids , also called corticosteroids or steroids, can be used short-term for quick pain relief from a flare. However, if the flare is sustained over time, they are less likely to be effective and the patient becomes at risk for the many side effects of steroids, says Dr. Goodman.
DMARDs, or disease-modifying antirheumatic drugs, can both block RA inflammation and help prevent the production of anti-drug antibodies. They may take several months to build up in a patients system and take effect, says Dr. Schulman. The most commonly used DMARD for RA is methotrexate, along with hydroxychloroquine , leflunomide , and leflunomide .
TNFi biologics can reduce inflammation and pain by targeting tumor necrosis factor proteins that sends signals to your body, leading to inflammation. TNFi biologics include adalimumab , certolizumab pegol , etanercept , golimumab , and infliximab .
Non-TNFi biologics, block different kinds of chemicals that cause inflammation and pain. For rheumatoid arthritis, these medications include abatacept , anakinra , rituximab , sarilumab ,and tocilizumab .
Will Changing My Diet Help My Rheumatoid Arthritis
When combined with the treatments and medications your provider recommends, changes in diet may help reduce inflammation and other symptoms of RA. But it wont cure you. You can talk with your doctor about adding good fats and minimizing bad fats, salt and processed carbohydrates. No herbal or nutritional supplements, like collagen, can cure rheumatoid arthritis. These dietary changes are safer and most successful when monitored by your rheumatologist.
But there are lifestyle changes you can make that may help relieve your symptoms. Your rheumatologist may recommend weight loss to reduce stress on inflamed joints.
People with rheumatoid arthritis also have a higher risk of coronary artery disease. High blood cholesterol can respond to changes in diet. A nutritionist can recommend specific foods to eat or avoid to reach a desirable cholesterol level.
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Treating Spinal Osteoarthritis May Take A Combination Of Therapies
Talk with your doctor about your neck and/or back pain to make sure your diagnosis is accurate and current. Remember that certain types of back problems are degenerative, meaning they may change, improve, or worsen with time. Management of your spinal arthritis pain may involve more than 1 medication or therapy. You have choices, and your doctor can work with you to find the right drug or combination of medications and therapies to ease your spinal osteoarthritis symptoms.
Electrical Nerve Stimulation for Arthritis Pain. Arthritis Foundation Web site. https://www.arthritis.org/living-with-arthritis/treatments/natural/other-therapies/electrical-stimulation-knee.php. Accessed October 29, 2018.
Other Immunomodulatory And Cytotoxic Agents
Some additional immunomodulatory drugs are used in RA including azathioprine , and cyclosporin A . Rarely cyclophosphamide and d-Penicillamine are used. Because the potential of high toxicity, these agents are typically utilized for life-threatening extra-articular manifestations of RA such as systemic vasculitis or with severe articular disease that is refractory to other therapy.
Azathioprine has some activity in rheumatoid arthritis but may take 8-12 weeks to see an effect. It is a purine analog that can cause bone marrow suppression and lowering of blood cell counts particularly in patients with renal insufficiency or when used concomitantly with allopurinol or ACE inhibitors. Increased risk of secondary malignancy due to azathioprine is controversial. Screening for levels of the enzyme thiopurine methyltransferase is recommended before initiating therapy with azathioprine. Certain individuals have deficiencies in this enzyme that metabolizes azathioprine with a concomitantly increased risk of toxicitiy for the medication. Side effects include nausea, and alopecia. Blood tests to monitor blood counts and liver function tests are necessary for patients on azathioprine.
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Social And Emotional Support
One of the most important tools for managing a chronic condition like RA is support. It can make a big difference in your treatment to have a doctor and other medical staff you feel comfortable with as part of your care team. Support from friends and family can also help you get through flare-ups and challenging days.
It can also be helpful to connect with other people living with RA. A support group can give you a place to share struggles and triumphs with people in a similar situation. To find an RA support group, check out:
- MyRAteam.MyRAteam is an online social network and support system for people with RA.
- Rheumatoid Arthritis Support. Rheumatoid Arthritis Support is an online forum where you can connect with other people with RA.
- Live Yes! Connect Groups. Offered by the Arthritis Foundation, Live Yes! Connect Groups are online support groups for people with RA.
- Arthritis Introspective. Arthritis Introspective is focused on young and middle-aged adults living with rheumatoid and other forms of arthritis. You can find an Arthritis Introspective support group in your area using their locator service.
What Are The Goals Of Treating Rheumatoid Arthritis
The most important goal of treating rheumatoid arthritis is to reduce joint pain and swelling. Doing so should help maintain or improve joint function. The long-term goal of treatment is to slow or stop joint damage. Controlling joint inflammation reduces your pain and improves your quality of life.
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Rheumatoid Arthritis Drugs: Dmards
If you’ve been diagnosed with rheumatoid arthritis, your doctor may recommend that you begin treatment with one of several types of DMARDs within a few months of diagnosis. One of the most important drugs in the arsenal for treating rheumatoid arthritis, DMARDs can often slow or stop the progression of RA by interrupting the immune process that promotes inflammation. However, they may take up to six months to be fully effective.
DMARDs have greatly improved the quality of life for many people with rheumatoid arthritis. These RA drugs are often used along with NSAIDs or glucocorticoids however, with this type of medication, you may not need other anti-inflammatories or analgesics.
Because DMARDs target the immune system, they also can weaken the immune system’s ability to fight infections. This means you must be watchful for early signs of infection. In some cases, you may also need regular blood tests to make sure the drug is not hurting blood cells or certain organs such as your liver, lungs, or kidneys.
Examples of DMARDs:
â¢ May cause blood clots
â¢ Tears in the stomach and intestines are possible
Who Has A Higher Risk Of Complications
Stomach ulcers or bleeding are more likely to occur in people who
- are over 65 years old,
- have other serious diseases, especially gastrointestinal conditions like or ulcerative colitis,
- have already had gastritis , a stomach ulcer or stomach bleeding,
- have an infection with Helicobacter pylori ,
- drink a lot of alcohol,
- take blood-thinning heart medicines, for example anticoagulants like warfarin or acetylsalicylic acid,
- take a selective serotonin reuptake inhibitor antidepressant,
- take corticosteroids , or
- take several anti-inflammatory painkillers at the same time.
NSAIDs can sometimes be a problem for people who have kidney disease too.
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What Can Be Done For Ra Pain
It should be stressed that adequate suppression of inflammation is the first step in managing RA pain. However, since the pain in RA may have multiple causes, a combination of treatments is often required. Most patients who have RA will be familiar with many of the treatments listed below:
A. Non-drug therapy for pain
B. Drug therapy for RA pain
The usual drugs used for treating the inflammation of RA are:
- non-steroidal anti-inflammatory drugs such as ibuprofen, diclofenac and naproxen
- disease modifying anti-rheumatic drugs , including methotrexate, hydroxychloroquine or sulfasalazine the biologics including anti-TNF or anti-interleukin 6 therapies, rituximab and abatacept and JAK inhibitors
- corticosteroids .
Most studies of RA focus on anti-inflammation therapies, and in large studies, it is not always practical to work out how much of an individuals pain is due to tendon and osteoarthritis pain.
It is uncommon to find one drug that relieves all arthritis pain for any one person. The medications commonly used to treat musculoskeletal pain, including that associated with RA, are:
This is commonly used for joint pains, although it seems to have only mild joint pain-relieving effects. It is generally safe in doses up to 2 grams daily. Very high doses or high regular use together with heavy alcohol intake can lead to liver damage.
OTHER MEDICATION OPTIONS