This page is a guide to help you understand some of the current treatments used to treat early inflammatory arthritis.
What is combination DMARD therapy?
On diagnosis with inflammatory arthritis, it is common practice to be started on some of the medications in this leaflet, either individually or in combination, to reduce pain, swelling and stiffness in your joints.
It may take 3 - 4 months before you start to feel the benefit of these medications (6 or more weeks for Leflunomide). Steroids should provide more immediate (but short term) relief.
Your doses may be increased or decreased gradually at clinic appointments or new drugs may be added or taken away from your regime.
You will be given the first prescription (for 1 month duration) from the hospital. Further supplies of your medicine should be obtained from your GP. It is important you do not run out of your medication.
Keep all medicine out of the reach of children.
If you buy medicines from your local pharmacy, tell the Pharmacist you are on this medication.
Methotrexate – Once a week only
- This is a weekly medication, which should be taken on the same day each week.
- You should only be given 2.5mg strength tablets to make up your dose (e.g. a dose of 15mg would be six x 2.5mg tablets taken together, once a week).
- You will be prescribed another tablet, folic acid, which you will be advised to take on a particular day or up to 6 out of 7 days, but it should NEVER be taken on the same day as your methotrexate.
- Report the onset of sore throat, bruising, mouth ulcers, nausea, vomiting, abdominal discomfort, dark urine or shortness of breath immediately.
- If you do not tolerate the tablets, your clinician may recommend switching to an injectable version.
Sulfasalazine
- This is a medication that is usually taken twice a day and may colour your urine orange.
- You may be given tablets with an enteric coating (which should be swallowed whole and not taken at the same time as indigestion remedies) or plain tablets.
- The dose will be increased gradually at the beginning. The usual starting regime is:
| 500mg tablets | Morning | Evening |
|---|---|---|
| Week 1 | One tablet | |
| Week 2 | One tablet | One tablet |
| Week 3 | Two tablets | One tablet |
| Week 4 (onwards) | Two tablets | Two tablets |
Hydroxychloroquine
- This medication is usually taken once or twice a day, with or after food; the dose depends on your body weight and disease activity.
- You will require baseline and ongoing annual eye checks at your high street optometrist. When you have been on treatment over 5 years (or earlier if you have additional risk factors) you will be referred to have an ophthalmic (eye) examination at a specialist hospital; your clinician will discuss this with you.
Leflunomide
- This is usually a once daily tablet.
- You will need to have your weight and blood pressure checked at each monitoring visit.
Corticosteroids
- You may be given prednisolone tablets; your dose will be made up of a combination of tablets which should be taken together in the morning as a single dose and should be taken with or after food. Do not stop taking prednisolone tablets suddenly, without advice from your clinician.
- You may be given a methylprednisolone depo injection (Depo-Medrone) which is a long acting injection into the bottom muscle. This can also be arranged to help with a flare up by calling our advice line service.
- You may be brought in to our medical day case unit to receive a methylprednisolone intravenous (drip) infusion.
- Your consultant may choose to inject your most affected joints with a steroid directly.
- If you are prescribed corticosteroids, you should usually be supplied with two different steroid cards: a ‘Steroid Treatment Card’ (blue) and a ‘Steroid Emergency Card’ (red). If you are not given these, it may be that you do not require both on this occasion but please check with your clinician.
Other advice
DMARD therapy should not routinely be stopped for surgery although individualised decisions may be made depending on the type of surgery.
During a serious infection (if you require hospital admission and / or antibiotics given via a drip infusion), your methotrexate, leflunomide or sulfasalazine should be temporarily discontinued until you have recovered from the infection.
More information about the drugs is available via www.versusarthritis.org/ and National Rheumatoid Arthritis Society (nras) leaflet Medicines in Rheumatoid Arthritis (including information about side effects).
Blood monitoring
These drugs will need regular blood monitoring as stated in your clinic letter. Your GP can also check the monitoring requirements on the BNSSG website.
Routine blood monitoring includes full blood count (FBC), renal function (SeCr / eGFR), and liver function tests (LFTs).
Frequency
For new treatment
Routine blood tests every 2 weeks until on stable dose for 6 weeks, then every month for 3 months, then every 12 weeks.
Following a dose increase
Routine blood tests every 2 weeks until on stable dose for 6 weeks, then revert to previous schedule.
Exceptions
Sulfasalazine – standard monitoring schedule for 12 months then no routine blood tests required (unless combined with other treatment).
Hydroxychloroquine – no blood tests required (unless combined with other treatment).
Methotrexate in combination with leflunomide – continue on monthly monitoring longer term.
Preparation for your appointments
We want you to be active in your healthcare. By telling us what is important to you and asking questions you can help with this. The three questions below may be useful:
- What are my options?
- What are the possible benefits and risks of those options?
- What help do I need to make my decision?
References
Ledingham, J., Gullick, N., Irving, K. et al., on behalf of the BSR and BHPR Standards Guidelines and Audit Working Group, 2017. ‘BSR and BHPR guideline for the prescription and monitoring of non-biologic disease-modifying anti-rheumatic drugs’, Rheumatology, 56 (6) p865–868. Available at: doi.org/10.1093/rheumatology/kew479.
National Rheumatoid Arthritis Society (NRAS) (2017). Medicines in Rheumatoid Arthritis. Available at: nras.org.uk/product/medicines-in-rheumatoid-arthritis/
Versus Arthritis. Treatments: Drugs. Available at: www.versusarthritis.org/about-arthritis/treatments/
Rheumatology DMARD medication record form
A Rheumatology DMARD medication record form (compliance chart) is available on the printed copy of this patient information leaflet (NBT003100). Please ask your clinician if you would like a paper copy to complete.
It is important that you update your medication record form regularly and after any medication changes (and specify the date it has been updated).