Rheumatoid arthritis treatment: Balancing odds of drug working vs chance of side effects

Rheumatoid arthritis treatment: Balancing odds of drug working vs chance of side effects

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This is a conversation I thought I’d share as it seems to touch on very pertinent concerns.

As you know, I write a bit about Methotrexate as it seems to be quite a maligned drug. These posts are popular and this particular conversation took place on the comments section of Why Methotrexate is My Current Go To Drug in Rheumatoid Arthritis.

Rosiet is 8 months post-RA diagnosis and is at the point of contemplating Methotrexate.

Rosiet: "I am trying very hard to educate myself as I move through this disease. I am not sure yet if your words have comforted me to the degree of accepting the Methotrexate, but at least, it has given me more information.”

While there is so much information on the internet, it can be so confusing for someone faced with a chronic illness.

They can read scary things about the disease. They can read scary things about medication. They can read confusing and sometimes, contradictory info about a variety of treatments, potions, remedies and snake oils. They can also research medications, and get wildly different opinions.

I take this as a reminder that we rheumatologists need to keep improving information and resources for patients to access. Patient support associations also need to become more visible so that people looking online actually come across their services.

Rosiet: "And, what I am just figuring out is that none of these drugs have much of a 'success' rate nor longevity to them. I am understanding that odds for each drugs effectiveness are relatively low to a high chance of side effects and that after an amount of time they stop working . . . and, you have to spin the wheel again . . .”

I'm wrote back as I did not agree with that assessment but I can understand how someone trying to find information online can be led to that opinion.

Rheumatoid Arthritis is not one single disease that acts the same way in every patient.

There is variability of severity, there are different outcomes for different patients, there are differences in how well people respond to medications, and of course, side effects occur in some and not in many others.

So it’s not that easy to determine the likely success rate of a particular medication in any one patient. It’s also not easy to say with certainty whether a patient will have a side effect or not.

Rheumatologists do try to make these assessments as they weigh up the history, the findings on examination, other health issues the patient may have and various test results.

For Rheumatoid Arthritis, "success" depends on many factors. Some of these include:

  • the window of opportunity: earlier treatment leads to better outcomes
  • treating-to-target: use of medications & close monitoring of response with swapping of medications as needed to get a better response
  • poor prognostic factors: how aggressive the disease is, how many joints are affected, how much inflammation is present clinically or using imaging or blood tests
  • negative factors such as periodontal disease, smoking, excess weight, etc

As a guide, Methotrexate works best early in the RA disease course with a good chance to achieve a remission state - around 40% using Methotrexate as the sole disease-modifying agent (DMARD).

This does not mean 60% do badly.

They will not have as good control of the disease and to obtain better control, changes or addition in medication therapy need to be considered.

Rosiet: "So, you would say that I, as newly dx'd, have a decent chance for full remission considering the Plaquenil has given me some relief on it's own. And, it is a matter of running through each drug to find a 'tolerance to healing' ratio? I will admit that after not being able to take the sulfasalazine and looking toward the MTX and it's myriad of side effects I am feeling apprehensive, at best. Along the line of the 'tolerance to healing' ratio, in your opinion is there a gray area where side effects are accepted to a degree with good drug response?”

My response:

In general, Plaquenil would be considered a weak DMARD on it's own. Most of us would start with Methotrexate as 1st line DMARD for Rheumatoid. I suppose there are occasions when rheumatologists would use Plaquenil at the start, for eg, if pregnancy was being pursued, or the prognosis of your type of Rheumatoid was considered very good (based on a range of features including those I listed previously).

There are of course gray areas.

Any treatment decision is a balance between the probability of a good result vs the possibility of a side effect.

Have you had similar worries to Rosiet you haven’t voiced?


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