Disease Modifying Anti-Rheumatic Drugs (DMARD’s)

•  If you are being treated for cryo, chances are that you are on one of the drugs that I have listed here or are considering them as options with your doctor.
• DMARDs are a class of drugs commonly used to treat a variety of autoimmune disorders.
• Some were developed primarily for the treatment of cancer, malaria, or for preventing organ rejection in transplant patients.
• DMARDs are sometimes referred to as “steroid sparing” drugs because they often allow greater overall effectiveness at maintaining remission of autoimmune disorders when used in combination with low dose prednisone. In some cases more than one DMARD may be used in combination.
• Each DMARD is a bit different from the others, effectiveness varies from one condition to the next and the side effect profiles are also highly variable.
• Some DMARDs have a greater risk of potentially dangerous conditions and the patient must be monitored continuously for their safety.

Below , I have listed some common DMARDs in order of their basic action on the body, this list is not complete and you will want to search the internet and find further information on your favorite DMARD with regard to risks, safety, drug interactions, and side effects.

1. The following drugs include the antimalarial agents, are frequently slow to take effect and some have significant long-term side effects.
   1. gold (rarely used) Sometimes effective for rheumatoid arthritis). This treatment has been around since the Victorian era! It is not well understood and tends to cause increasingly severe side effects over time.
   2. hydrochloroquine (Plaquenil) An anti-malaral agent. Often used in combination with steroids, commonly used to treat Lupus.
   3. methotrexate commonly used for a variety of autoimmune disorders and may be used in cmbination with other DMARDs
   4. sulfasalazine Often used to treat Chron’s disease, may be used with other DMARDs.
   5. cyclosporine Developed to prevent organ rejection in transplant patients. This drug may have serious long term safety issues. It is sometimes used in cases where nothing else works.
2. The following drugs are the immunosuppressants. They can be slow to take effect and carry a risk from infection due to suppression of the immune system. Side effects vary, some are not so bad, but others have *significant* risks and side effects and the patient must be closely monitored.
   1. cyclophosphamide (cytoxan) Commonly used in oral and IV form, frequently used in combination with prednisone to force remission. Has a relatively big risk and side effect profile. This is generally viewed as a serious “big gun” that suppresses the immune system deeply.
   2. Imuran (Azathioprine) Commonly used to maintain remission after remission is established. Commonly used with low dose prednisone.
      1. Less risk and fewer side effects than cytoxan. Slower to take effect than cytoxan. Does not suppress the immune system as deeply as cytoxan.
      2. Imuran carries a small, but real risk of causing the immune system to die off rather quickly, so your blood counts must be monitored carefully.  Low white blood cells and low producing neutophils are a risk.
   3. leflunomide Sometimes used alone, but may be used with another DMARD, or a biological agent.
   4. mycophenolate-mofetil (cellcept) Originally developed to prevent organ rejection in transplant patients. Often used in combination with other DMARD’s, and more recently used in combination with biological DMARDs.
3. Biological Agents (so-called bDMARDs)
   1. Tumor Necrotic Factor (TNF) Inhibitors
   2. including etanercept, adalimumab, infliximab, certolizumab pegol, and golimumab,
4. Specific Biological Agents with specific targets (also called Monoclonal Antibody Therapy = MAB)
   1. These drugs are basically designer antibodies that have very specific targets.
   2. For example: rituximab (rituxin) targets B cells specifically.
   3. including anakinra, abatacept , rituximab, tocilizumab, and tofacitinib. These medications are often combined with methotrexate or other DMARDs to improve efficacy.

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*Author NOTES:

• Plaquenil is not a heavy hitter like the above immunosupressants are, but it is a lot safer and has fewer side effects, so if it works for you , it works…. and that is a good thing.
• If you need to take the medication , you take it.
• It is all about risk management. For a more serious situation a bigger risk may be warranted in order to gain more effectiveness. The doctor has to make this kind if decision… and so do you the patient. For example, using cyclophophamide with prednisone to force remission in a case of cryo is not unusual. Once remission is established, one can tansition to something like Imuran, methotrexate, or cellcept. Often a patient might not tolerate one of the medications very well, forcing a change to another.
• Some get along with imuran very well, so it is a good choice, and has less risk than staying on cyclophosphamde.
• Also, Imuran is a reasonably safe drug to stay on if you have to take it long-term. So it really boils down to risk management vs effecrtiveness and having a list of possible options.