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Rheumatoid Arthritis Part 3

Posted by Eamonn Brady on

Long term medication options for rheumatoid arthritis

Eamonn Brady is a pharmacist and the owner of Whelehans Pharmacy, Pearse St, Mullingar. If you have any health questions e-mail them to


This is the final of three articles on rheumatoid arthritis (RA). Disease modifying anti-rheumatic drugs (DMARDs) are core to treatment as they slow down or stop the progression of the condition and prevent joint deformities. They allow people enjoy a normal life. 


Disease-modifying antirheumatic drugs (DMARDs)

DMARDs help ease symptoms and slow the progression of RA. The earlier a DMARD is started, the more effective it is. They must be started by a consultant rheumatologist; therefore, it is important to seek treatment with a rheumatologist early if showing signs of RA.


The most commonly used DMARDs include methotrexate, hydroxychloroquine and sulfasalazine. Methotrexate is often the first choice DMARD for RA. It can be taken on its own or in combination with another DMARD. Side effects of methotrexate can be sickness, diarrhoea, mouth ulcers, hair loss or hair thinning, and rashes on the skin. Regular blood tests to monitor blood count and liver are required as methotrexate can cause serious liver and blood count problems. Most people tolerate methotrexate well and more than 50% of patients take it for at least five years.


Methotrexate improves symptoms by 50-80%, slows the rate of joint destruction and improves function and quality of life. Doses of methotrexate up to 20mg weekly may be needed. Injection form may be considered in severe acute RA, if oral treatment is ineffective or in those unable to tolerate oral methotrexate. It takes 6 to 12 weeks for methotrexate to start working. Methotrexate may be combined with biological treatments. It is very important to emphasise that methotrexate is a weekly dose.


Sulfasalazine has a slow onset of effect (1 - 3 months). Patients may need to discontinue long-term treatment of sulfasalazine due to gastrointestinal complaints.


Hydroxychloroquine takes several weeks to exert its effect. It has been reported to be less effective than the other DMARDs but is well-tolerated; therefore, it may be useful in mild disease or in combination therapy. It can cause eye damage so regular eye checks are needed.



Azathiaprine (Imuran®) and Ciclosporin (Neoral®) tend to be reserved for severe RA, when other DMARDs are ineffective or inappropriate. They tend to be last line as they have potential serious side effects, mainly due to their suppression of the immune system. 


Biological treatments

Biological treatments are a newer form of treatment for RA. They include TNF-alpha inhibitors (etanercept , infliximab, adalimumab and certolizumab), rituximab and tocilizumab. Etanercept (Enbrel®) and adalimumab (Humira®) are most commonly prescribed biological treatments for RA in Ireland. In general, biological agents are reserved for patients with moderate to severe active RA where conventional DMARDs have failed. They are usually taken in combination with methotrexate or sometimes with another DMARD. They work by stopping particular chemicals in the blood from activating the immune system to attack the lining of joints. They are given by subcutaneous injection. Side effects from biological treatments are usually mild and include skin reactions at the site of injection, infections, nausea, fever and headaches.


Educate yourself about your condition

Whelehans Pharmacy, in conjunction with Arthritis Ireland (Westmeath Branch) host a Rheumatoid Arthritis Information event next week (Wednesday Oct 12th at 6:45pm) in Greville Arms Hotel Mullingar. Admission is free.


Guest speaker for the evening is Consultant Rheumatologist from Midland Hospital Tullamore, Killian O’Rourke MD MSc FRCP FRCPI. Dr O’Rourke will give first-hand information on RA along with self-help tips including information about surgery and aftercare. He will take questions from attendees.


Chartered physiotherapist Kevin Conneely MISCP of HealthStep Physiotherapy Mullingar will discuss role of physiotherapy in Rheumatoid Arthritis (RA).  The final speaker is pharmacist Eamonn Brady MPSI who will discuss medication.

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