By Hope Starkman, MD
Rheumatoid Arthritis is a disorder characterized by Inflammation. Inflamed joints will become red, warm or hot, tender and swollen. Left alone without treatment, inflamed joints may become dysfunctional and deformed. Many of the older therapies like Ibuprofen, Naprosyn and even Prednisone act to treat inflammation in a general way by blocking prostaglandins, the chemicals that cause an inflammatory response. Newer and more state of the art treatments have been developed to target more specific chemical causes of the inflammatory response.
There are many different chemicals referred to as cytokines that are involved in inflammation. These tend to be secreted by the cells of inflammation into the joints and tissues. Once present, they not only exacerbate a chemical inflammation, but also help to recruit even more cells like neutrophils and lymphocytes to the site which result in a cascade of even more inflammation. The viscous cycle continues until, somehow, the cycle is broken.
Several different types of Cytokines include, but are not limited, to tumor necrosis factors and interleukin. Newer drugs thru various mechanisms of actions help to stop or limit the production of these chemicals. Some of these drugs include Enbrel. Humira, Remicade, Orencia, Cimzia, Simponi, etc.
Rituxan is a biologic that targets receptors on B lymphoctes to reduce them in number and thus limit inflammatory responses.
Anakinra(Kiniret (r)) is an interleukin 1 receptor antagonist which also is helpful in limiting inflammation.
The newest group of Biologic agents are the Jak-2 inhibitors which inhibit small molecules resulting
in inflammation. These are the first oral (pill form) biologics to become available.
Biologic agents are very expensive and can cost up to 2000 dollars a month, therefore most insurance companies will require patients with Rheumatoid Arthritis have have failed, been intolerant to or inadequately responded to some of the older but accepted therapies like Methotrexate, Arava, Imuran or Plaquenil, especially Methotrexate. This is called “ step therapy”.
All medications used in the treatment of Rheumatoid Arthritis, as in all other medical conditions have risks, benefits and alternatives. These will not be discussed here. The decision to treat with a biologic agent must be tailored to specific patients and their specific situations and needs.