Some of you may recall one of my previous posts where I attempted to dispel some of the myths commonly associated methotrexate. Don’t get me wrong, I frequently use methotrexate. It is considered gold standard for the treatment of rheumatoid arthritis. And this is despite the armada of new fancy medications coming onto the market. The American College of Rheumatology doesn’t call it the gold standard for nothing.
But sometimes it isn’t enough.
It’s estimated that about 30% of people achieve either remission or very minimal disease activity with methotrexate alone. That leaves the other 70%. Maybe this includes you? In this situation, your rheumatologist may either recommend you to combine methotrexate with another conventional disease modifying anti-rheumatic drug (DMARD) or either to combine it with a biologic DMARD. The decision is very complex and will vary from person-to-person and from rheumatologist-to-rheumatologist. Were there issues with the ability to tolerate the medication, allergies, other medical conditions, insurance coverage, safety profile concerns, etc? And then there’s just style.
In the best of situations, ALL people diagnosed with rheumatoid arthritis should be started on a DMARD as quickly as possible. For those who don’t really know me, the tone of this statement is very uncharacteristic of me. I loathe dogma and authoritarian statements in general. But when it comes to DMARDs and rheumatoid arthritis, people that receive these medications as soon as possible do better and have less joint damage. It’s important to achieve remission or have very minimal disease activity as soon as possible and as long as possible.
So what is a DMARD? For a medication to be considered a DMARD it has to change the course of the disease, for the better:), for at least one year. There should be improvement in either physical function, decreased swelling, or slowing/prevention of joint damage.
To understand why your doctor may want to start a biologic medication, it’s important to understand what is meant by a conventional vs. a biologic DMARD.
I would say there are two main differences between conventional DMARDs and biologic DMARDs: mechanism of action and cost. Conventional DMARDs do NOT directly target a specific type of inflammation. Biologics do. This means that biologics are a lot more molecular complex. This also means that they are A LOT more expensive. Even in countries like Canada, where the single payer system has the ability to negotiate prices with pharmaceutical companies, the price is still very high. I could on and on with this subject, but I’ll leave that for another post.
- Often used
- Not really used
- Mycophenolate, sometimes used for rheumatoid arthritis affecting the lungs
- Cyclophosphide, used for life or organ threatening disease
- Gold injections
- Tumor necrosis factor inhibitors
- Certolizumab pegol
- Interleukin-6 inhibitors
- Co-stimulation inhibitors
- JAK inhibitors
- B cell depletion
There are other medications that are coming down the pipeline, but these are the ones that are FDA approved and commercially available for the treatment of rheumatoid arthritis. There are other biologic medications like belimumab, apremilast, ustekinumab, and secukinumab that are used for other diseases like systemic lupus erythmatosus, psoriatic arthritis, and ankylosing spondylitis.
Triple therapy vs. methotrexate + biologic
Generally triple therapy refers to the simultaneous use of methotrexate + sulfasalazine + hydroxychloroquine for the treatment of rheumatoid arthritis. A Cochrane meta-analysis recently found that triple therapy typically is just as effective as methotrexate + a biologic or tofacitinib alone. So why is your doctor proposing going to a biologic medication instead of going to triple therapy? It certainly would be cheaper.
This is where I would say is one of the potential benefits of biologics: the ability to tolerate treatment long-term. Let’s put things into perspective. When you take an antibiotic, you may end up with some GI discomfort, diarrhea, some nausea, etc. You receive 7 days worth of treatment, the infection is gone, it usually takes a few more days for things to settle down, but then it’s done. When it comes to the vast majority of rheumatic conditions like rheumatoid arthritis, some form of medication is consistently needed to keep the disease in remission. If you stop, the disease flares. Don’t get me wrong, there are exceptions. Sometimes the disease goes into permanent remission or “burns out”. This is rare and definitely is not the rule.
The problem with triple therapy is that it tends to be very difficult to tolerate long-term. Most people could tolerate a few weeks, but we’re talking years, decades, lifetime. Many people stop one or more of the medications without telling their doctor, others take them sporadically. Basically, there’s a lot of non-compliance with treatment when people receive triple therapy.
It isn’t necessarily because those people are irresponsible. It’s that the medicines are making them feel sicker than their actual disease!
Simply put, biologics tend to be a lot easier to tolerate long-term and to bout SOME can be used as monotherapy i.e., you don’t need to combine with methotrexate.
Onset of action
I wouldn’t say that this is necessarily the most important factor when making a decision to go with a biologic instead of sticking to conventional DMARDs but I guess it could help tip the balance in certain situations. In general biologic DMARDs tend to work a little more quickly that conventional. This greatly varies from biologic-to-biologic. Generally conventional DMARDs taking between 3 – 6 months to fully work. It tends to be closer to the 3 month mark. For most biologics it can take up to 3 months. Certain ones like abatacept can take up to 6 months as well.
Most biologics cost over $ 1 100 per month. Mind you, hardly anyone actually pays $ 1,100 per month. Before starting a biologic medication, you doctor’s office will obtain authorization from your insurance company prior to prescribing the medication. When the medication is authorized, your doctor will send it to your prescription mail-order company, and then it will be mailed to you. Co-pays vary from $5 a script to a few hundred dollars in extreme cases. It really depends on your insurance coverage. It’s very important to keep your doctor but also your doctor’s medical secretary and if your doctor is extra lucky, your doctor’s patient advocate, appraised of all changes to your insurance. It can mean the difference between a $5 co-pay and a second mortgage. Most pharmaceutical companies have patient assistance programs. Some are better than others… and some are better advertised than others.
Conventional DMARDs are a lot cheaper. For example, methotrexate comes in 2.5 mg tablets. 20 tablets cost a little over $25. This is the price if you had no insurance and were paying completely out of pocket. Someone taking oral methotrexate will typical take between 24 to 40 tablets per month. For most people this is doable even without any insurance.
Conversely, if you were receiving etanercept and had no insurance, your out of pocket cost would be about $3,500 per month. Again, your doctor’s team will work to have the medication covered, but it’s still something to think about.
Method of delivery
This may be a non-issue for many people but it may be for some. Most biologics need to either be injected or infused. So far, only tofacitinib (rheumatoid arthritis) and apremilast (psoriatic arthritis) are taken orally. There are pros and cons for both injections and infusions but generally, if your needle phobic, this may be a problem. Infusions are time consuming because you need to come to the clinic to receive the infusion. They typically last between an hour to half a day depending on the medication. Some are dosed every month others every 8 weeks. Rituximab is every 6 months but this is an exception. Most injections are either given every week or every other week. Some are a lot less frequent like ustekinumab, but again this is an exception.
Conversely, all the conventional DMARDs are oral except for cyclosphosphamide and gold. I’ve never prescribe cyclophosphamide for rheumatoid arthritis… ever. First, we simply do not encounter many people with life-threatening complications caused by rheumatoid arthritis anymore because the vast majority of people with the condition are treated with DMARDs very early into their disease. Second, there are many other medications on the market that are a whole like better. Don’t get me wrong, there are certain very serious indicated clinical situations. Just wrote an order for it last week… my first in a year and it wasn’t for RA!
One of the big differences between conventional DMARDs and biologics is the infection risk. Biologic medications generally are a lot more immunosuppressive than conventional DMARDs. Again there are exceptions. For example, abatacept is generally thought to have less of an infection risk.
I have to stress that this does not mean that people taking biologics get a ton of infections. But it becomes extra important to keep up with routine vaccinations, adhere to proper hand washing, and try to stay away from high risk situations as much as possible. It may also not be such a great idea to be on a biologic if you are prone to getting infections. Let’s face it, no one wants 10 sinus infections in one year. It also may not be such a great idea to be one some of these biologics if you have very serious lung problems. I probably will try to avoid most biologics if someone has severe COPD requiring extra oxygen. Pneumonia could be life-threatening in this situation.
Another important noteworthy point, certain biologics can re-activate dormant infections such as tuberculosis, hepatitis B+C, and zoster. It’s important to screen for both tuberculosis and hepatitis B+C prior to initiation of therapy. You may need to start therapy for these latent infection prior to treatment with biologics. For zoster also known as shingles, you may benefit from the shot one month prior to treatment with biologics. The shingles shot is a live vaccine and should NOT be given while taking a biologic medication. Like I said, you need to wait a month. Please contact your rheumatologist for more information.
There are a few other items of concern but these vary from medication to medication irrespective of whether that medication is a conventional DMARD or a biologic. The following are items to consider when choosing the most appropriate medications.
- History of hepatitis C
- History of HIV
- History of a demyelinating disease like multiple sclerosis
- History of severe congestive heart failure
- History of lymphoma or leukemia
- History of melanoma
- History of a solid cancer within the last 5 years (e.g., breast cancer)
- History serious liver disease
- History of a serious kidney disease
- History of serious lung disease
- History of serious diverticulitis or bowel perforation
- History of gastric bypass surgery
- History of macular degeneration
- History of organ transplant
- Allergy history
- Current medications. Are there any possible drug interactions? (e.g., azathioprine and allopurinol should not be combined)
Having one of these does NOT mean you cannot take any biologic medication safely. It simply means that certain ones may not be such a good idea. For example, tumor necrosis inhibitors should not be taken by people suffering from multiple sclerosis.
I hope this helps clarify a few concerns that you may have had regarding biologic medications. Maybe I’ve caused you to think about things you had not thought about before? Choosing the best course of therapy can be very complex. There are so many things to think about and the down stream effects could be very serious.
Open communication and knowledge are key!
Rheumatology Secrets 3rd edition
Hazlewood GS, et al. Methotrexate monotherapy and methotrexate combination therapy with traditional and biologic disease modifying anti-rheumatic drugs for rheumatoid arthritis: A network meta-analysis. Cochrane Database Syst Rev. 2016 Aug 29;(8):CD010227. doi: 10.1002/14651858.CD010227.pub2.