What are Disease Modifying Anti Rheumatic Drugs (DMARDs)?

DMARDs are a group of prescribed medications that Rheumatologists often recommend to   dampen down the body’s immune system in diseases when, by mistake, the immune system attacks the body’s own joints and other tissues. Examples of these ‘autoimmune’ types of diseases include Ankylosing Spondylitis, Sjogren’s Syndrome, Rheumatoid Arthritis and Psoriatic Arthritis.

The DMARDs work by blocking immune system pathways to limit the immune system attacking your joints or other parts of your body. By altering the underlying disease pathways (‘disease modifying’), they reduce pain, swelling and stiffness.

Before starting a DMARD, your Rheumatologist will check that the DMARD is going to be suitable for you, and this will usually involve having investigations such as bloods tests and a chest X-ray, and it may also include a check for other diseases, such as  tuberculosis or hepatitis that can complicate treatment with DMARDs. If it is safe to go ahead and start  DMARDs, your Rheumatologist will advise you to also ensure certain vaccinations are up-to-date.

How quickly do DMARDs work?

DMARDs are slow-acting and take weeks or months to work, but your Rheumatologist can prescribe other medicines such as steroids to try and control your symptoms whilst waiting for the DMARD to act.

Once you are taking a DMARD, your Rheumatologist will see you regularly in clinic and may organise blood tests, X-rays, ultrasounds and MRIs of your joints to check the DMARD is working well enough.  If your joints do not settle down after a few months of treatment, your Rheumatologist may suggest switching to another DMARD or trying a combination of DMARDs.

What are the different kinds of DMARDs?

Conventional  DMARDs

Rheumatologists usually try  conventional / traditional DMARDs first. Commonly used conventional DMARDs include Methotrexate tablets, which are taken once a week along with a Folic Acid tablet (not a DMARD, but used to limit the risk of side effects) the day after. Other DMARDs include  Sulfasalazine, Leflunomide and Hydroxychloroquine, which are usually taken daily by mouth.

The Methotrexate molecule.

Methotrexate Tablets

Biologic DMARDs

‘Biologic’ refers to the way these medicines are manufactured, and these are newer drugs. Biologic DMARDs are prescribed if conventional DMARDs aren’t sufficiently effective or if patients experience significant side effects with the conventional drugs.

Biologic DMARDs include Tocilizumab, Adalimumab, Etanercept and Infliximab.

They are usually given by regular injection under the skin at home or into a vein in hospital. Often, biologic DMARDs are given along with a conventional DMARD, such as Methotrexate.

The molecular-level mechanism of action of Adalimumab.

Some people can’t have biologic DMARDs (for example, patients with infections, cancers or heart problems), so your Rheumatologist will check that it is safe to try these and will ask for certain tests before your start.

Do DMARDs have side effects?

All these medications can have side effects, and the types experienced are dependent on which DMARD(s) you are taking. They are usually mild, but DMARDs can also cause serious side effects in some people. Your Rheumatologist will give you advice on what side effects you may experience and will organise regular follow-ups to monitor you closely for the development of any potential side effects. It is likely you will need to have regular blood tests as part of a recommended monitoring schedule.

How long will I need to take a DMARD for?

It is likely that if a DMARD is working well without serious side effects, you will require it for the longer-term. Many patients have been treated safely for prolonged periods (years) with these.

What about  fertility, pregnancy and breast feeding?

Many of the  DMARDs are not safe to take when trying to get pregnant, during pregnancy or when breast-feeding. Some affect fertility in men and women. Your Rheumatologist can discus which DMARDs are suitable in these situations.

Further information

Further information on specific DMARDs can be found at the following Versus Arthritis links:

• Hydroxychloroquine
• Leflunomide
• Methotrexate
• Sulfasalazine
• Tocilizumab
• Adalimumab
• Etanercept
• Infliximab

In this post

• How quickly do DMARDs work?
• What are the different kinds of DMARDs?
• Do DMARDs have side effects?
• How long will I need to take a DMARD for?
• What about  fertility, pregnancy and breast feeding?
• Further information

Dr Simon Paul.
MB BS, FRCP(UK), BSc, MFSEM, DipSEM
Consultant Rheumatologist and Sports Physician
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