Arthritis, Biologics, and You
By: Dr. Asia Mubashir, Rheumatologist
If you watch TV, you’ve likely heard of such drugs as Xeljanz and Humira for treatment of rheumatoid arthritis (RA), an autoimmune disorder in which the immune system attacks healthy joint tissues. Numerous commercials show men and women experiencing relief from the pain and joint damage of RA and enjoying active lives. We see women traveling to visit a friend’s baby, braiding a child’s hair, and playing soccer with the kids. We see a man diving off a pier and fastening his wife’s necklace. Is this new class of drugs, called biologics (short for biologic response modifiers), the answer to living well with RA? Of course we expect commercials to paint a beautiful, enticing picture, but biologics may in fact be an important option if you are one of the 1.5 million Americans with RA. In this article, I will share with you some basic information about biologics so that you can make informed choices for your health and well-being.
Unlike the more common osteoarthritis, which involves a wearing away of joint cartilage, RA causes inflammation in the joints, which leads to joint swelling, joint stiffness, joint pain, weakness, and fatigue. These symptoms can interfere with work and activities of daily living. Over time the joints can become permanently damaged and deformed, and range of motion can be affected. The average age of onset is between 30 and 50 years, and RA mostly affects women (70%). RA is a progressive disease, and permanent damage to joints can occur within 1 to 2 years of onset. It is very important to be diagnosed and treated by a rheumatologist promptly after symptoms occur.
What treatment options exist for RA?
Where do biologics fit in?
Options for treatment of RA include physical and occupational therapy, exercise, and medications. Keeping the joints flexible and learning how to perform tasks in a less painful way is important, but medications are required to lessen pain, reduce swelling, and slow the progression of the disease. A rheumatologist might prescribe the following: analgesics such as acetaminophen (e.g., Tylenol), anti-inflammatories such as corticosteroids and NSAIDS (e.g., Advil, Aleve), and disease-modifying anti-rheumatic drugs, called DMARDs (e.g., methotrexate).
Unlike analgesics and anti-inflammatories, which reduce pain and swelling, DMARDs actually slow or prevent the progression of RA. Conventional DMARDs have been in use since the 1920s, but a newer class of DMARDs called biologics was introduced in the late 1990s and is continuing to be developed. Unlike conventional DMARDs, which suppress the immune system in general, biologics—so-called because they are made from genetically engineered proteins—target a specific component of the immune system that is involved in RA.
How are biologics administered?
In comparison to conventional DMARDs, biologics are more complex to administer. Right now, only one biologic drug comes as a pill. Most biologics are injected directly under the skin (intramuscular) or administered directly into a vein via a needle. Your doctor may use the term “infusion therapy”; this usually refers only to intravenous administration of medication, but sometimes can also include intramuscular injections.
You or a caregiver can be taught how to administer prefilled syringes (called “auto-injectors”) at home, but for infusions, you may spend an hour or more at your doctor’s office or the hospital. Dosing frequency varies. Infusions are administered anywhere from every 4 weeks to every 6 months.
Are biologics expensive?
Does insurance cover this treatment option?
Biologics are more expensive than older drugs, but studies indicate that they are more effective and have fewer risks. Insurance companies do cover biologics, though generally only after you’ve tried conventional DMARDs. If cost is still a concern, you can apply to the drug manufacturer for copay assistance or, if you do not have insurance, for a reduction in price. Your doctor’s office should be able to guide you in this process.
Are there any side effects of biologics?
Yes, there are some. Biologics delivered by injection may cause pain and rash at the injection site (seen in less than 30% of patients). Patients may experience an allergic reaction to infusions that feels like the flu, with fever, chills, nausea, and headache. Biologics may lessen ability to fight infections, and a dormant infection might become active again. This is why your doctor will likely have you take a tuberculosis test before starting one of these drugs. Certain biologics have also been shown to increase risk for certain types of cancers.
In short, please ask your rheumatologist about the side effects of the particular biologic that is being recommended. Be sure to share any concerns that you might have so that your doctor can take them into consideration.
Summing Up and Looking Forward
Advances in biologics have helped people with RA live with less pain and more mobility by slowing the progression of joint damage. Scientists are working to figure out how to know which DMARD will work best for each individual from the start. Being able to identify the right treatment via a genetic or blood marker would mean patients get the right treatment right away as well as save money spent on ineffective treatments. Researchers are also trying to determine ways of diagnosing RA earlier so that treatment can begin before much damage is done to joints. Advances over the past 20 years have vastly improved the lives of people with RA, and future discoveries will certainly lead to even better treatment options, if not a cure.
Dr. Asia Mubashir is the Medical Director of St. Mary’s Rheumatology. Dr. Mubashir has trained under world leaders in the field of Rheumatology, specifically Rheumatoid Arthritis, SLE (Lupus), Scleroderma and Sjogren’s Syndrome. She has extensive clinical and research experience. St. Mary’s Rheumatology, located at St. Mary’s Regional Medical Center in Lewiston, is dedicated to the diagnosis and treatment of people with rheumatic conditions. Dr. Mubashir is currently accepting new patients. For more information, please call 207-777-4459.