Shots for rheumatoid arthritis

Adalimumab for rheumatoid arthritis

How well does adalimumab work to treat rheumatoid arthritis and how safe is it?
To answer this question, scientists analyzed six high quality studies. The studies tested over 2300 people who had rheumatoid arthritis for more than 10 years. People had either injections of adalimumab or fake injections. Some studies also tested people taking methotrexate in combination with adalimumab or the fake injections. This Cochrane Review provides the best evidence we have today.

What is rheumatoid arthritis and how can adalimumab help?
Rheumatoid arthritis is a disease in which the body’s immune system attacks its own healthy tissues. The attack happens mostly in the joints of the feet and hands and causes redness, pain, swelling, and heat around the affected joints. Adalimumab is a “biologic” that is injected into the body to decrease pain and swelling and slow the progress of rheumatoid arthritis. Adalimumab is a new drug that was approved for injection at a dose of 40 mg every other week. It is usually prescribed when other disease modifying anti-rheumatic drugs (DMARDs) do not work well.

How well did adalimumab work?
More people improved with all doses of adalimumab plus methotrexate than with fake injections plus methotrexate. After 24 weeks:
– 43 out of 100 people showed a 50% improvement with 40 mg of adalimumab every other week plus methotrexate
– 9 out of 100 people showed a 50% improvement with fake injections plus methotrexate
This means that 34 more people out of 100 benefited from receiving adalimumab plus methotrexate than fake injections plus methotrexate.
More people had improved symptoms with adalimumab alone than with fake injections, but the improvement was not at much as when adalimumab was taken in combination with methotrexate.
After 52 weeks, x-rays showed that 20 mg of adalimumab every week or 40 mg every other week slowed joint damage more than fake injections.

Were there any side effects?
Minor side effects included reactions where the needle was injected, headaches, allergy-like symptoms, and colds. Some people went to hospital because of serious side effects. Most side effects occurred about the same amount for people taking adalimumab and people taking fake injections.
– 5 out of 100 people had serious side effects with 40 mg of adalimumab every other week plus methotrexate
– 7 out of 100 people had serious side effects with fake injections plus methotrexate
This means that 2 more people out of 100 had a serious side effect from receiving fake injections plus methotrexate than adalimumab plus methotrexate.
One study showed that people who received adalimumab had more serious infections such as tuberculosis and cancer than people who took fake injections. Long-term side effects still need to be studied.

What is the bottom line?
There is “Gold” level evidence (www.cochranemsk.org) that in people with long-standing rheumatoid arthritis who do not respond to DMARDs, adalimumab at 40 mg every other week plus methotrexate decreases pain and swelling.

5 Types of Medication That Treat Rheumatoid Arthritis (RA)

Most people who have rheumatoid arthritis take some type of medication. Medications for RA typically fall into five categories: Non-steroidal anti-inflammatory drugs (NSAIDs); steroids; disease-modifying anti-rheumatic drugs (DMARDS); biologics; and janus kinase (JAK) inhibitors.

See Pain Medications for Arthritis Pain Relief

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A rheumatologist can recommend a tailored plan to treat your rheumatoid arthritis symptoms.
See Rheumatologist’s Role in Patient Care

When prescribing a medication, a physician will take into account the patient’s age, disease activity, and other medical conditions, but each patient is unique. Figuring out which medication or combination of medications work best for an individual can be challenging and often requires a process of trial and error.

See Rheumatologist for Arthritis Treatment

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1. NSAIDs

Most people with RA are advised to take a non-steroidal anti-inflammatory drug to decrease pain and inflammation. NSAIDs are sold over-the-counter, under such names as Advil and Aleve, as well as by prescription, under names such as Mobic and Celebrex.

See Pill-Swallowing Techniques and Alternatives to Oral Medications

2. Steroids (Corticosteroids)

Fast-acting steroids, such as prednisone, are particularly useful during initial treatment, before other RA medications have had a chance to take effect (often 12 weeks or more).

One advantage of steroids is that they can be injected into joints. Injected steroids can provide targeted pain relief to one or two painful joints with limited side effects.

Experts recommend taking the lowest possible dose of steroids and advise against relying on them longer than necessary. Steroids’ effectiveness often diminishes over time—meaning the longer a person takes a steroid, the less likely it is to relieve symptoms. In addition, people who take steroids continuously for several months or years can experience side effects such as weight gain, increases in blood pressure, diabetes, and heart disease.

See Cortisone Injections (Steroid Injections)

3. Methotrexate and Other Traditional DMARDs

Disease-modifying antirheumatic drugs (DMARDs) are used used to slow or stop rheumatoid arthritis by suppressing the immune system. The generic names for commonly used DMARDs include:

  • Hydroxychloroquine
  • Methotrexate
  • Sulfasalazine
  • Azathioprine
  • Lefludomide

Methotrexate is often the first drug prescribed for people newly diagnosed with rheumatoid arthritis. RA patients take this medication weekly, alone or in combination with other medications.

High dose methotrexate is also used to treat some cancers. RA patients take significantly lower doses than cancer patients.

See Treatments for Rheumatoid Arthritis (RA) in Hands

4. Biologics for Rheumatoid Arthritis

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Biologic drugs target and prevent a specific reaction from happening, stopping the inflammatory process.

This class of medications, called biologic response modifiers, is technically a subset of DMARDs. They may be used with traditional DMARDs or as an alternative to them. Biologics:

  • Disrupt certain parts of the cascade of events that lead to RA inflammation and have the potential to stop the disease process.
  • Increase a person’s risk of infection and tend to be expensive. Because of these potential downsides, biologics are used when methotrexate or other DMARDs prove insufficient or cause unacceptable side-effects.
  • May become less effective and/or cause worsening side effects over time. The doctor and patient can work together to monitor changes and decide if and when switching medication is advisable.

See Biologics for RA and Other Autoimmune Conditions

Biologics fall into four categories: Tumor necrosis factor (TNF) inhibitors; Interleukin (IL) inhibitors; B-cells inhibitors; and T-cells inhibitors. These medications are administered by injection or infusion. Examples include Remicade, Enbrel, and Humira.

See The Science Behind Biologics

In This Article:

  • What Is Rheumatoid Arthritis (RA)?
  • Rheumatoid Arthritis (RA) Symptoms
  • Risk Factors for Rheumatoid Arthritis (RA)
  • Rheumatoid Arthritis (RA) Diagnosis
  • Rheumatoid Arthritis (RA) Treatment
  • 5 Types of Medication That Treat Rheumatoid Arthritis (RA)
  • Surgery for Rheumatoid Arthritis (RA)
  • Rheumatoid Arthritis Overview Video

Testing for Tuberculosis
Before taking any type of biologic medication, a person must be tested for tuberculosis. People who have latent tuberculosis carry the Mycobacterium tuberculosis bacterium without having tuberculosis symptoms. If a person with latent tuberculosis takes immune-suppressing biologic medications the bacterium can multiply and cause symptomatic tuberculosis.

See Risks and Side Effects of Biologics

5. Janus Kinase (JAK) Inhibitors

JAK enzymes are essential messengers in the immune system’s inflammatory process. When JAK enzymes bind with other cells, called X cells, they trigger inflammation. JAK inhibitors bind to JAK enzymes, preventing them from binding with X Cells and stopping the inflammatory process.

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The first FDA-approved JAK inhibitor is called Tofacitinib, and it is sold under the names Xeljanz and Xeljanz XR (extended release).

As with biologic mediations, people considering taking JAK inhibitors must have a tuberculosis test.

People taking JAK inhibitors are advised to work with their doctors to monitor risks and side effects.

Joint Injections for Rheumatoid Arthritis

Steroids and RA: Proceed With Caution

Relief may come with a downside. Every time a joint gets a steroid injection, there’s the chance of infection, and that risk increases with each injection in that joint. Infections caused by joint injections are quite rare, however, occurring in fewer than 1 in 15,000 corticosteroid injections.

More important, though, is that if you might already have some kind of infection, you shouldn’t get a steroid injection, warns Scott Zashin, MD, a clinical professor of medicine in the division of rheumatology at the University of Texas Southwestern Medical School in Dallas. Injections should also be avoided if you have any type of skin condition, such as psoriasis or eczema, where the injection will be given.

Side effects of steroid injections, although uncommon, include a permanent thinning of the skin where the steroid was injected. From a cosmetic standpoint, this can be bothersome to some people. Other side effects include a weakening of the tendons and loss of skin color, Dr. Zashin says.

A joint or muscle can be injected with steroids up to three times a year. After several injections, your doctor should consider another type of treatment because of the side effects of steroid injections and the increased risk of infection.

Relief…But for How Long?

The length of time that a steroid injection is effective varies from person to person. “Hopefully, it will be several months,” White says. If RA goes into remission (a state in which disease activity is low and symptoms are few), steroids may not be needed again for a long time.

However, in people having difficulty keeping their RA under control, a joint injection may bring relief for only a week or two, and “then you may feel even more pain before the pain resolves,” White says. She also advises that you should “stay in close contact with the doctor who gave the injection to make sure the pain you’re experiencing is not from an infection.”

Regeneron Pharmaceuticals, Inc., and Sanofi announced that the US Food and Drug Administration (FDA) has approved Kevzara (sarilumab) injection to treat adults with moderate to severe rheumatoid arthritis (RA).

This treatment is recommended in patients with RA who have had an inadequate response or demonstrated intolerance to one or more disease-modifying antirheumatic drugs (DMARDs), such as methotrexate (MTX).

Kevzara®, a human monoclonal antibody that binds to the interleukin-6 receptor (IL-6R), may be used as monotherapy or in combination with MTX or other DMARDs. The recommended dosage is 200 mg once every 2 weeks in the form of a subcutaneous injection, which can be self-administered. Users can reduce the dosage from 200 mg to 150 mg once every 2 weeks, as needed.

The approval of Kevzara was based on data from approximately 2900 adults with moderate to severe RA with an inadequate response to previous treatment regimens. In 2 Phase 3 clinical trials, Kevzara plus background DMARDs demonstrated statistically significant, clinically meaningful improvements.

In the MOBILITY study, treatment with Kevzara and MTX reduced signs and symptoms, improved physical function, and demonstrated significantly less radiographic progression of structural damage vs placebo and MTX. At Week 24, the Kevzara 200 mg and 150 mg groups had a greater improvement in the primary end point vs placebo as measured by 20% improvement in the American College of Rheumatology 20% improvement (ACR20) criteria (66% and 58% vs 33%, respectively).

In the TARGET study, patients treated with Kevzara and a DMARD had reduced signs and symptoms, and improved physical function vs placebo and a DMARD. At Week 24, the Kevzara 200 mg and 150 mg groups showed a greater improvement in the primary end point vs placebo as measured by achieving an ACR20 response (61% and 56% vs 34%, respectively).

“Today’s approval in the US not only underscores our ongoing commitment to making a difference in the lives of patients, but also demonstrates our drive to accelerate science and medicine in immunology,” Olivier Brandicourt, MD, chief executive officer, Sanofi, said.

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Infusion Therapies

If you are prescribed a biologic drug or any of the treatments below, you’ll receive those infusions or injections in the comfort of our offices, even on Saturday.

If the biologic drug prescribed for you is not listed on this page, we still may offer infusions of it. Talk to your rheumatologist or call our office and ask—215-657-6776.

You doctor or nurse will discuss potential side effects some patients experience with these treatments. You can also read more about each medicine and its side effects on each drug’s website.

Rheumatoid Arthritis Treatments

REMICADE® (infliximab)

Remicade is classified as a tumor necrosis factor (TNF)-inhibitor and helps stop inflammation and joint damage. When used with methotrexate to treat rheumatoid arthritis (RA), infusions of Remicade can reduce signs and symptoms, help prevent further joint damage, and improve physical function for patients with moderately to severe RA.

Remicade is also used to treat:

  • Psoriatic Arthritis (PsA)
  • Ankylosing Spondylitis (AS)
  • Plaque Psoriasis
  • Crohn’s Disease (CD)
  • Ulcerative Colitis (UC)

Remicade is given by intravenous (IV) infusion in our offices. If you are prescribed Remicade, after your first three doses, you will most likely return for about 6 infusions per year. Each infusion takes up to 2 hours.

ORENCIA® (abatacept)

ORENCIA is used in adults to reduce signs and symptoms of moderate to severe rheumatoid arthritis (RA). It may prevent further bone and joint damage and improve physical function.

ORENCIA may be used alone or with other RA treatments.

If you are prescribed ORENCIA, after your first three doses, you will come to the office for an intravenous (IV) infusion every 4 weeks. Each infusion takes 30 minutes.

RITUXAN® (rituximab)

Rituxan is used with methotrexate to treat adult patients who have moderately to severely active rheumatoid arthritis (RA). It is often used for patients who have not responded well to other RA treatments.

Rituxan reduces signs and symptoms of RA and can slow progression of joint and bone damage. Patients who receive infusions of Rituxan often see improvements that can last through six months.

The drug is also approved to treat Wegener’s granulomatosis and microscopic polyangilitis.

If you are prescribed Rituxan, you will come to the office for IV infusions at a frequency determined by your doctor based on your diagnosis.

ACTEMRA® (tocilizumab)

ACTEMRA is a prescription medicine called an interleukin-6 (IL-6) receptor inhibitor.

It is used to treat adults with moderately to severely active rheumatoid arthritis (RA).

ACTEMRA blocks a substance in the body called interleukin-6 which is overproduced by people with RA. Improvements of RA symptoms have been reported within a few weeks after starting treatment.

If you are prescribed ACTEMRA, you’ll receive an intravenous (IV) infusion given over 1 hour every 4 weeks.

CIMZIA® (certolizumab pegol)

CIMZIA is a medicine used to treat adults with moderately to severely active rheumatoid arthritis (RA). It is referred to as an “anti-TNF therapy.” By blocking tumor necrosis factor (TNF)-alpha, CIMZIA helps reduce the inflammation, stiffness and joint damage RA causes. CIMZIA may be taken with or without other RA medications like methotrexate. Cimzia® is also used to treat Psoiatic Arthritis (Psa) and Ankylosing Spondilitis.

In clinical trials, CIMZIA has been shown to reduce RA pain, stiffness, and fatigue in as fast as 1 to 2 weeks. Many patients experienced lasting relief at both 6 months and 1 year.

If you are prescribed CIMZIA, you’ll come to our offices to receive an injection under the skin. After your first 3 doses, you’ll need a new injection every 4 weeks.

SIMPONI ARIA® (golimumab)

SIMPONI ARIA is used in combination with methotrexate for adults with moderate to severe rheumatoid arthritis (RA). Different patients see different results but, in general, this medicine has been proven to help:

  • relieve the pain, stiffness, and swelling of RA
  • stop further joint damage
  • improve your ability to perform every day activities with less difficulty

If you are prescribed SIMPONI ARIA, you will come to our offices to receive an infusion through a needle placed in your vein, usually in your arm. After two starter doses, 4 weeks apart, you will return for an infusion once every 8 weeks. Each infusion takes about 30 minutes.

Lupus Treatment

BENLYSTA® (belimumab)

BENLYSTA is a prescription medication used to treat adults with active systemic lupus erythematous (SLE or lupus), who are receiving other lupus medicines.

BENLYSTA is a biologic therapy that works by reducing certain cells in your immune system that can make lupus active.

If you are prescribed BENLYSTA, you will come to the office for an intravenous (IV) infusion given over 1 hour every 4 weeks. Preparation time before the infusion may vary. For the first three infusions, you’ll need an infusion every two weeks. After the first three, you’ll come in every 4 weeks for an infusion.

Osteoporosis Treatments

PROLIA® (denosumab)

Prolia is a prescription medication for the treatment of osteoporosis in postmenopausal women who have an increased risk for fractures. The drug can help reduce fracture risk and strengthen your bones.

Prolia is also used to increase bone mass in men with osteoporosis who have a high risk for bone fracture. It is also used to treat patients who have not benefitted from or are unable to tolerate other available osteoporosis treatments.

If you are prescribed Prolia, you will come to the office to receive a shot of the drug once every 6 months.

RECLAST® (Zoledronic acid)

Reclast is the only FDA-approved once-a-year osteoporosis treatment. Reclast, along with daily calcium and vitamin D, helps to increase bone density, protecting and strengthening your bones.

Reclast is approved for:

  • Treatment and prevention of osteoporosis in postmenopausal women
  • Reducing the incidence of new bone fractures in patients at high risk of fractures (those with recent low-trauma hip fracture)
  • Treatment to increase bone mass in men with osteoporosis
  • Treatment of Paget’s disease of the bone for both men and women

If you are prescribed Reclast, you will come to our office to receive one dose through intravenous (IV) infusion treatment once a year. The infusion takes at least 15 minutes to administer.

BONIVA® (imandronate sodium injection)

BONIVA injections are prescribed for osteoporosis treatment in women who have completed menopause. The drug helps build and maintain bone density to help reduce bone fractures.

BONIVA injections are an alternative for patients who have difficulty with medicines taken by mouth.

Your doctor or nurse practitioner may prescribe BONIVA injection for any of the following reasons, including if you:

  • Have difficulty swallowing
  • Forget to take your osteoporosis pills
  • Cannot sit or stand for 30-60 minutes
  • Are taking many other pills
  • Do not want to fast (postpone food or drink) before taking the medicine

If you are prescribed BONIVA, you will come to the office to receive an injection once every three months.

Gout Treatment

KRYSTEXXA® (pegloticase)

KRYSTEXXA is used as a treatment of chronic gout in adults. It is usually given after other gout medications have been tried without success.

Gout is caused by a build up of uric acid in your blood. KRYSTEXXA is an enzyme that breaks down uric acid so that it can be eliminated from the body in urine.

If you are prescribed KRYSTEXXA, you will receive it through intravenous (IV) infusion at a frequency determined by your doctor based on your diagnosis. Each infusion takes about 2 hours with an additional 60 minutes for observation to make sure you don’t have a bad reaction to it.

Ulcerative Colitis and Crohn’s disease

ENTYVIO® (vedolizumab)

ENTYVIO® is a medicine used in adults with moderate to severe ulcerative colitis (UC) when certain other medicines have not worked well or cannot be tolerated. ENTYVIO® may help to reduce some symptoms, and maintain remission, reduce or stop the use of corticosteroids, and improve the way the lining of your large intestine looks to your healthcare provider.

ENTYVIO® is a medicine used in adults to treat moderate to severe Crohn’s disease (CD) when certain other CD medicines have not worked well or cannot be tolerated. ENTYVIO® may help to begin reducing some symptoms, possibly achieve remission, and reduce or stop the use of corticosteroids.

If you are prescribed ENTYVIO® you will receive your treatment intravenously. Each infusion takes 30 minutes. After your first initial 3 doses, you will receive an infusion every 8 weeks.

CIMZIA® is a medicine used to treat adults with moderately to severely active rheumatoid arthritis (RA). It is referred to as an “anti-TNF therapy.” By blocking tumor necrosis factor (TNF)-alpha, CIMZIA® helps reduce the inflammation, stiffness and joint damage RA causes. CIMZIA® may be taken with or without other RA medications like methotrexate. Cimzia® is also used to treat Psoiatic Arthritis (Psa) and Ankylosing Spondilitis.

In clinical trials, CIMZIA® has been shown to reduce RA pain, stiffness, and fatigue in as fast as 1 to 2 weeks. Many patients experienced lasting relief at both 6 months and 1 year.

If you are prescribed CIMZIA®, you’ll come to our offices to receive an injection under the skin. After your first 3 doses, you’ll need a new injection every 4 weeks.

STELARA® (ustekinumab)

Stelara® is a prescription medicine classified as an interleukin-12 and 23 antagonist used to treat adults with Crohn’s, active psoriatic arthritis and psoriasis.

Stelara® for the treatment of Crohn’s disease can help in reducing symptoms of Crohn’s disease and possibly go into remission. For the treatment of Crohn’s patient the initial treatment starts with a one-time intravenous infusion followed by subcutaneous injections every 8 weeks.

Stelara® for the treatment of psoriatic arthritis and psoriasis works by targeting an underlying cause of an overactive immune system. Stelara® for the treatment of psoriatic arthritis and psoriasis starts with the administration of an initial subcutaneous injection followed by an injection at 4 weeks then a continued treatment every 12 weeks.

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