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RA Treatment: The Future Is Now

By

Chris Iliades, MD

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How Biologics Work

The treatment of rheumatoid arthritis (RA) has come so far and so fast in the last few years that you could say the future of RA treatment is now here. RA is an autoimmune disease, which means that the body’s defense system, called the immune system, is out of order. Normally the immune system attacks foreign invaders like viruses and bacteria. The attack takes the form of redness and swelling, known as inflammation. In RA, the immune system attacks the lining inside your joints, called the synovium.

Not long ago, all doctors could do was to treat the symptoms of RA, using drugs that fought the effects of inflammation. Next, doctors began to use disease-modifying anti-rheumatic drugs, or DMARDs, to control RA symptoms and reduce joint damage. Most rheumatologists initially treat RA with weekly methotrexate injections. Doctors are also using a newer kind of DMARD, called biologics. They are made from living organisms and help stop the immune response before inflammation happens.

The goal of treatment is no longer just to reduce symptoms. Now the goal is to bring about remission. Remission means less than 15 minutes of morning stiffness and no joint pain or swelling for at least three months.

Here's a closer look at today’s biologics, and what is coming soon.

Today’s Biologics

If you haven't responded to other DMARDs, such as methotrexate, you might be a candidate for biologic DMARDs. Commonly used biologics include adalimumab (Humira), etanercept (Enbrel), infliximab (Remicade), and abatacept (Orencia). Every RA case is different and there are many factors for you and your doctor to consider.

Biologics offer the best chance for remission, but they have some drawbacks:

  • They're expensive. Even with insurance, they can cost hundreds of dollars a month.

  • Because they block parts of the immune system, biologics can also increase the risk for infection and some types of cancer.

  • Because they are made of large molecules, biologics need to be given by injection or infused directly into a vein.

Today’s Newest Drug

In November 2012, the U.S. Food and Drug Administration (FDA) approved a new oral drug for RA—tofacitinib, which will go by the brand name Xeljanz. People with moderate to severe RA, who have not responded to the older DMARDs, are good candidates for this drug. It works differently than the biologics and, because it is a smaller molecule, it is given as a pill twice a day. Here are the basics of the new oral drug:

  • It works by blocking inflammation in a different way than the biologics, so it may help people who do not respond to biologics.

  • It may be less expensive than the biologics because it is a simpler molecule.

  • It starts to show benefits in as little as two weeks.

  • It will take time until all the long-term side effects are known, because this is a whole new class of drug.

  • Two more oral drugs in this class are in development and may be available soon.

Tomorrow’s Biologics: Biosimilars

One of the biggest drawbacks of biologics is their cost. Biosimilars are generic versions of biologics. Like other generic medications, they will become available as drug company patents run out. Presumably, biosimilars will be much less expensive. Here are the basics on biosimilars:

Biosimilars will need to go through a testing period before the FDA lets them become available for prescription.

It will probably be several more years before they hit the market. This is because biologics are big and complicated molecules, which makes it hard for generic drug makers to copy them exactly.

Key Takeaways

  • The new goal of rheumatoid arthritis treatment is to go beyond symptom treatment to disease remission.

  • Biologic DMARDs block the pathways of RA inflammation, preventing joint pain, swelling, and damage.

  • Xeljanz is an approved biologic drug that blocks inflammation in a new way and can be taken in pill form.

  • Generic biologics, called biosimilars, are coming and should reduce the high cost of current biologic treatment.

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Medical Reviewers: William C. Lloyd III, MD, FACS Last Review Date: Dec 31, 2015

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