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What are disease-modifying antirheumatic drugs (DMARDs)? — DMARDs are medicines that partly turn off the body's infection-fighting system, called the "immune system." Doctors prescribe DMARDs for some diseases that happen when the immune system mistakenly attacks the body's own healthy tissues, such as your joints or your kidneys. These are called "autoimmune" diseases. Examples include rheumatoid arthritis and psoriatic arthritis.
DMARDs are usually prescribed by a specialist doctor, such as a "rheumatologist." They are typically part of a long-term treatment plan.
What do DMARDs do? — DMARDs work by blocking the effects of your immune system when it attacks your joints or other parts of your body. DMARDs are a key part of treatment because they can slow the spread of the disease and reduce the damage it causes to parts of your body over time. Doctors usually start DMARDs soon after they are sure you have an autoimmune disease that can cause damage to the joints. DMARDs will slow or prevent joint damage and help keep your joints working better.
When do DMARDs start to work? — DMARDs take weeks or months to work. Doctors can prescribe other medicines along with DMARDs while waiting for the DMARDs to start working. These other medicines could be a "nonsteroidal antiinflammatory drug" (NSAID), such as naproxen, or a steroid, such as prednisone. These medicines reduce stiffness and soreness.
Before starting a DMARD, your doctor might test you for tuberculosis (TB) and hepatitis. They might also check to see if your vaccines are current depending on what kind of DMARD you are going to receive.
What are the different kinds of DMARDs? — There are 3 main types of DMARDs: "conventional," "biologic," and "targeted synthetic." Some of these are listed in the table (table 1).
●Conventional synthetic DMARDs – Doctors usually prescribe conventional synthetic DMARDs first. These include medicines usually taken as pills, such as methotrexate, leflunomide, sulfasalazine, and hydroxychloroquine.
One common DMARD, methotrexate, is taken just 1 time per week, usually as a pill. Some people have been badly harmed by taking methotrexate too often. If your doctor prescribes methotrexate for you, always double-check the instructions with your doctor and pharmacist before you take it. Use a pill box and other reminders to make sure you take it correctly only 1 time per week. Do not drink alcohol if you take methotrexate.
●Biologic DMARDs – "Biologic" refers to the way these medicines are made. They are taken by an injection (shot) under the skin or through a thin tube that goes into a vein, called an "IV." The IV medicines are given in a doctor's office or clinic over a period of a half-hour or longer. Some of the biologic DMARDs and how they are taken are listed in the table (table 1).
Usually, doctors prescribe biologic DMARDs only if you do not get better while taking conventional synthetic DMARDs for several months, or if you have bad side effects while taking other DMARDs. People usually take biologic medicines along with a conventional synthetic DMARD, such as methotrexate.
Some people should not take biologic DMARDs. For example, if you have a serious infection, certain blood cancers, or heart problems, your doctor will decide whether or not a biologic DMARD is a good choice for you.
●Targeted synthetic DMARDs – These are medicines that work like biologic DMARDs and have similar risks and side effects, but are taken as pills. The available targeted synthetic DMARDs are all a type of medicine called "JAK inhibitors." Although some people want to try these because they come in a pill instead of a shot, these medicines can have added risks in some cases. For this reason, your doctor might want you to try a shot or IV medicine first.
Will I need to use more than 1 DMARD? — Maybe. If your symptoms do not improve enough after a few months of treatment at a full dose, your doctor might switch your medicine. You might get a different DMARD or a combination of 2 or 3 different DMARDs.
What about side effects? — Side effects depend on the specific DMARD you are taking. They are usually mild and might include loss of appetite, nausea, headache, or diarrhea. DMARDs can also cause serious side effects in a small number of people. You will need to see your doctor on a regular basis to check for possible problems caused by DMARDs. This usually includes regular blood tests. Talk to your doctor or nurse about any side effects that bother or worry you.
How long will I need to take a DMARD? — If you are taking a DMARD and it is working well, your doctor might keep you on it for a while. This will help keep symptoms from flaring up and protect your body from being damaged by the disease.
To know how the medicine is working, your doctor can ask questions about how you feel, examine you, and order imaging tests. Imaging tests create pictures of the inside of your body. Doctors can use them to see how your joints are doing, and then change your DMARD medicine or dose if needed. This is another reason why you should have regular appointments with your doctor when you are taking a DMARD.
Will I still have symptom flares after I start a DMARD? — Possibly. DMARDs can decrease how often symptoms "flare up" or get worse, and how severe the symptoms are. But in some cases, they cannot stop symptoms completely. If your disease flares up, your doctor might need to change your DMARD or adjust the dose. They might also need to give you additional medicines.
What if I want to get pregnant? — Many DMARDs are not safe to take when trying to get pregnant, during pregnancy, or during breastfeeding. Talk with your doctor if you or your partner could become pregnant.
For more detailed information about your medicines, ask your doctor or nurse for the patient handout from Lexicomp available through UpToDate. It explains how to use each medicine, describes its possible side effects, and lists other medicines or foods that can affect how it works.
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