Knowledge is power.

If you have rheumatoid arthritis it is useful to be aware of the main types of medication used in controlling rheumatoid arthritis and its symptoms. You should have a general understanding of how the different medications work and what they should achieve. You will probably need to read information leaflets because often it can be difficult to ask all the questions that you need to when you have an appointment with a consultant. This is mainly because of time constraints, but it is also because we as patients tend to worry that a question is pointless or inappropriate, or sometimes we just forget because there is often a long wait to be seen by the consultant. This has certainly happened to me, especially when I had to wait regularly over an hour with three small children. I had to remember to write questions out and take them in with me.

We need to know:

• what medication we are taking;
• how to take it; and
• why it is necessary.

The choice of medication should be discussed and we should be actively involved in decisions concerning medication. We need to be informed so that we can make an appropriate choice. Anyone who is taking medication for long-term use should be aware of possible side effects and the need for monitoring their condition.

As patients we need to take a share of the responsibility for managing our condition, but it is vital that we have information before we can take an active role. Ask for information leaflets, check the arthritis websites (see Useful Resources) and make a list of questions to ask when you see your consultant. Anyone who is not happy with the relationship that they have with their consultant is entitled to ask their doctor to refer them for a second opinion. In fact this may be useful anyway as all consultants have different opinions and it is often useful to listen to a different point of view. A lot of people are reluctant to do this in case it will jeopardise their relationship with their existing consultant. There is some truth in this and asking to see another consultant should be done tactfully via the GP.

There are so many medications available now for rheumatoid arthritis that it can be quite confusing understanding which drugs do what and why you are taking them. I will therefore outline the types of medication used for rheumatoid arthritis. This is only a basic guide and if a more detailed account is needed there are many books available as well as arthritis research campaign leaflets.

MEDICATION FOR RHEUMATOID ARTHRITIS

There are four types of drugs used to treat rheumatoid arthritis. These are:

• 1Analgesics.
• 2Non-steroidal anti-inflammatory drugs known as NSAIDs.
• 3Disease-modifying anti-rheumatic drugs known as DMARDs.
• 4Steroids.

Drugs have two names: the chemical ingredient name and the manufacturers’ ‘trade’ name which can be confusing.

1 Analgesics

These are primarily painkillers of various descriptions and do not need to be taken regularly but only when pain needs controlling. You should never take more than the recommended dose as they can be very damaging to internal organs, but the most common side effect is constipation. There are different classes of analgesics and some people may be able to tolerate one class but not another. The problem is that some analgesics are combinations of different classes. You need to be aware of this if a certain type causes you side affects or is dangerous for you. For instance paracetamol and codeine are often used in combined preparations and one may be tolerated but not the other. Many painkillers become less effective if used continually. It is better to control pain in other ways if possible. However it is almost impossible to concentrate on anything else if pain is very intense and in such a case there may seem to be little option.

This group includes: paracetamol, co-codamol, co-dydramol, until recently co-proxamol and di-hydrocodeine.

2 Non-steroidal anti-inflammatory drugs (NSAIDs)

This group works by controlling the prostaglandins that cause inflammation. They therefore reduce inflammation and the subsequent swelling and stiffness. Anyone with rheumatoid arthritis is likely to use these at some time. In mild disease they may be used on their own or with analgesics, or they may be used in conjunction with one or both of the next two groups as well as analgesics if the disease is more serious. These drugs work quickly, within an hour or two, and may last for up to eight or 12 hours or more if they are a slow release type. They need to be taken for at least five days to achieve the full anti-inflammatory effect. You should always take them with or after food so that the stomach is lined because of the potential side effect of stomach problems. They may also harm the kidneys or increase asthma.

This group includes: aspirin, ibuprofen, indomethacin and diclofenac.

There are now some new NSAIDs that should be kinder to the stomach. The older type of NSAIDs inhibit both cox-1 and cox-2 enzymes but cox-1 enzymes are beneficial in protecting the stomach. The new NSAIDs, however, are selective inhibitors of the cox-2 enzyme and so they should give fewer side effects, as there is still some cox-1 enzyme activity. New drugs are being developed in this group with further improvements in side effect profiles, but they all have the same strength and efficacy as other NSAIDs.

This new group of NSAIDs consists of: meloxicam (Mobic) etodolac (Lodine) and celecoxib (Celebrex.) and rofecoxib (Vioxx).

3 Disease-modifying anti-rheumatic drugs (DMARDs)

This group of drugs is used by anyone with more serious disease. People with indications of joint damage or extensive inflammation and stiffness will be advised to take them to control the rate of disease and limit damage to the joints. In fact many people are started on these drugs at an early stage nowadays, because there is a tendency to use aggressive treatment early on in order to try to prevent joint damage. They are slower to become effective and a step up dose is needed. This means a small dose is taken first then the dosage is gradually increased. It therefore takes up to three months for this type of medication to be fully effective. The medication does not provide a complete cure but only helps to slow down the disease as long as the medication is being taken. The disease is therefore likely to return if the medication is stopped. According to Mason and Smith1 in their book Rheumatoid Arthritis: Your Medication Explained it is common for DMARDs to work for only three to four years. It is also true that some types work for some patients and not for others.

Drugs in this group are immuno-suppressants, this means that they suppress the immune response. This in turn means that the rate that the joints are attacked and destroyed by the immune system is slowed down. These drugs need to be strong in order to work in this way and therefore you should always ensure that you are being monitored by regular blood tests. You should report any side effects. You should also be aware that some of the drugs in this group may affect fertility and this should be discussed with your consultant if you are intending to start a family. Some drugs may lower the sperm count: e.g. sulphasalazine, azathioprine and methotrexate. Some may affect the ova or cause miscarriages or birth defects: e.g. methotrexate and leflunomide and some may cause sterility. (See the Pregnancy and Arthritis booklet published by ARC for further information.2) The medication may need to be stopped three months prior to conceiving.

Examples of this group are: methotrexate, sulphasalazine, leflunomide, gold, hydroxychloroquine and azathioprine. Sometimes two of these drugs are combined, e.g. methotrexate and sulphasalazine.

There are also new drugs in this group. These are the anti TNF drugs. They are called etanercept and infliximab, trade names Enbrel and Remicade. These new drugs work in a different way. People with rheumatoid arthritis have excessive amounts of a protein called TNF and this increases inflammation. These drugs block the TNF and therefore reduce inflammation. They will only be prescribed if other drugs in this group have been tried and have failed and if the disease is very active. This is because of potential severe side effects and expense. The long-term side effects of these drugs are not known and therefore care should be taken, especially if you want to start a family. This group of drugs is given by injection rather than being taken in tablet form.

4 Corticosteroids (steroids)

These are given in tablet form or as injections. They are disease-modifying drugs as well as powerful anti-inflam-matory drugs and they have a very fast response. All in all they sound amazing, but of course such powerful drugs are likely to have serious side effects and if you are taking them you should make sure that you are well aware of these. There are both short- and long-term effects from steroid use and it is not unusual to find that people are not aware of these dangers. It is essential to understand all the implications of using them at the outset. If used for a long time (months) or at high doses they produce side effects. Also it is important to note that the body usually has its own supply of this chemical (cortisol) for controlling inflammatory responses in the body. If large doses are taken orally or by injection the body stops producing its own and this is why steroids should never be stopped instantly. They must be gradually reduced so that the body has time to restart its own production.

Another important factor is that steroids are so effective at suppressing the immune response, and therefore preventing the joints from being attacked, that they also make people more vulnerable to other infections and diseases. An example of a steroid used to treat rheumatoid arthritis is prednisolone.

NEW TREATMENTS

Research is always being carried out to find new treatments. These are often reported in newspapers and on the news and more recently on the internet. It must be remembered that new treatments have to undergo rigorous testing before being made available so nothing happens quickly. It is always a risk to take a new treatment because the long-term side effects will never be known unless the drug has been used for a long time for another condition. It is always necessary to bear this in mind and to weigh up the risks and benefits fully before agreeing to new treatments.

Research is continuing and two alternative approaches are being studied. These are:

• the prosorba column; and
• bone marrow stem cell transplants.

The prosorba column is a plasma exchange that removes all the antibodies from your blood that are thought to cause the rheumatoid arthritis. This procedure is done in hospital. It is not yet clear how often this would need to be done. It is also not clear whether new antibodies, when they are produced, will have the same defects as the ones that were removed.

Bone marrow stem cell transplants are supposed to remove the cells that are programmed to destroy the joints. This is still experimental at the time of going to press.

COMPLEMENTARY THERAPIES

There are also complementary approaches to treating rheumatoid arthritis.3

Homeopathy

This is a very traditional system of medicine that is based on treating like with like. Therefore in an inflammatory disease the treatment would be something to induce inflammation and then the body should respond by producing its own cure. Homeopathic remedies are available over the counter but you should see a practitioner if you are interested, because treatments are individual and there is no such thing as a cure for arthritis. The cure is specific to the individual being prescribed for. According to the arthritis research website a number of carefully controlled trials have been carried out and they suggest that homeopathy may help.

Supplements

There has been an increase in the use of supplements and complementary therapies in the last ten years or so and I have tried one or two myself. I have not yet found a supplement that works for me but I am still trying. The most commonly used supplement for arthritis is probably fish oil, often in the form of cod liver oil.

Some studies of cod liver oil have indicated positive results for people with rheumatoid arthritis. Volker et al4 carried out research on 50 subjects with rheumatoid arthritis over a 15-week period. The subjects’ clinical status improved. Harwood and Caterson5 discovered that the omega 3 fatty acids in cod liver oil switch off the enzymes that break down joint cartilage, therefore taking this supplement can reduce cartilage destruction and reduce pain and stiffness. The ARC6 website also indicates that olive oil has been found in some studies to be helpful to some people with rheumatoid arthritis. It is therefore worth giving these oils a try. They should be taken for about three months to give them a chance to work as they are not instant like prescription drugs.

Glucosamine sulphate has also become popular lately but I could not find any evidence indicating its beneficial effects for rheumatoid arthritis. However, studies on supplements and complementary treatments have not been conducted until recently. One study I looked at showed benefits for osteoarthritis and another one found no benefits. The Arthritis Bible7 summarises seven controlled trials with positive results but these are all for osteoarthritis.

In the 1970s a US research scientist called Harry Diehl discovered that he and other researchers could not induce arthritis in mice. He wanted to know what was protecting them and found out that they contained cetyl myristoleate (CMO), a previously unknown fatty acid. He tried to interest pharmaceutical companies in his discovery but was unable to. He did however launch CMO as a dietary supplement in 1991. A trial by Siemandi8 in 1997 gave very positive results for CMO. According to Dr Len Sands9 this supplement regulates the immune system and therefore does not need to be taken after the initial few weeks. This is lucky because it is extremely expensive! More research needs to be done on this product to verify the impressive claims that are made. The Arthritis Bible gives information on this supplement and others. It is a comprehensive guide to conventional and alternative treatments for arthritis and a very useful book on this subject.

I have also tried bromelin (from pineapple) and zingiber officinale (ginger), which are both reputed to be effective anti-inflammatories but unfortunately neither was as effective as my anti-inflammatory medication is for me.

The ginger has possibly been helpful but is still not as powerful as ibuprofen. I have not found any research on ginger or bromelin.

Lately I have also noticed that a lot of Chinese herbalists have opened shops. This is another route that you may like to pursue although I have not found any scientific research to offer on this subject.

All complementary therapies are just what they say – complementary and you do not need to stop taking conventional medication while you are trying out alternatives. Talk to your GP or rheumatologist about any complementary therapies that you would like to try. It is particularly important to check that homeopathic medications and supplements may be taken safely with any other medications you are already taking. Some supplements and pills can alter the reactions of medication and certain combination should not be taken together. It is also true that homeopathic remedies are unlikely to work if taken with strongly flavoured foods like coffee, peppermint or garlic.

It is important to recognise that taking medication for a long time means that the liver and kidneys will have extra to cope with. It is therefore a good idea to eat well and not take a lot of alcohol while you are taking medication regularly.

Obviously medication can be very effective in controlling rheumatoid arthritis, but in order to achieve the best possible outcome it is necessary to make adjustments and changes in many areas of life, and to make use of different treatments and therapies. The next chapters outline the many ways that you can help yourself to achieve optimum health and wellbeing even though you have rheumatoid arthritis.

A PERSONAL SCENARIO

As far as my personal situation goes I have never been very happy taking medication long-term, although I do recognise that there is a need to control the disease if joints are becoming damaged. It is a question of balancing the potential benefits against the potential harm.

In 1974, when I first had intense symptoms of rheumatoid arthritis but no diagnosis, I believe that my doctor felt there might have been psychological harm in telling me that I had rheumatoid arthritis when I was only 22. There may be some justification in this, but the damage to my joints was probably increased because I was not given any disease-modifying drugs and I was not referred to Occupational Therapy to learn about joint protection until I had had rheumatoid arthritis for nearly ten years. I carried on doing potentially damaging actions like lifting heavy prams, pushchairs and babies! Nowadays people are given disease-modifying medication early on. This probably slows up the disease process and limits the joint damage although it does not cure the rheumatoid arthritis. Hopefully some consultants will make a referral to Occupational Therapy as well as recommending medication so that patients can achieve the best quality of life and become an expert in managing their own condition.