Understanding Rheumatic Disease Treatments: Conventional DMARDs vs. Biologic Medications

When it comes to treating rheumatic diseases like rheumatoid arthritis, lupus, and psoriatic arthritis, there are more medications available than ever before. Drugs that slow the progression of a rheumatic condition are called disease modifying anti-rheumatic drugs or DMARDs. Most DMARDs fall into two main categories: conventional synthetic DMARDs and biologic DMARDs. Targeted synthetic DMARDs are a third category and include medications like upadacitinib which target a signaling protein involved in inflammation. Despite these three medication categories, rheumatology healthcare professionals often refer to conventional synthetic DMARDs as “DMARDs” and biologic DMARDs as “biologics”.

This article will give a brief overview of these two main categories: “DMARDs” and “biologics”.

Examples:

• Methotrexate
• Sulfasalazine
• Hydroxychloroquine
• Leflunomide

Pros:

• Conventional DMARDs have been available for a long time and have been studied the most in terms of how well they work and potential complications or side effects.
• These medications are usually less expensive compared to biologic drugs, making them more accessible to patients.

Cons:

• It may take several weeks or even months for patients to feel the full benefits of conventional DMARDs.
• Some people may experience side effects like nausea, hair loss, or liver problems.
• Patients need regular blood tests to check for any potential side effects on their liver or blood cells.

Biologics (bDMARDs)
This group contains medications which were developed more recently than conventional DMARDs. These medications are called biologics because they contain proteins made by living sources (plant, bacteria, human, or animal cells). Medicines in this group are too complex to be made into a pill and are taken as injections under the skin or as an infusion into a vein. Biologics were designed to block specific parts of the immune system involved in causing inflammation. A biosimilar is a biologic medicine that is a close copy, but not an identical copy of a biologic.

Some examples include:

• Tumor necrosis factor (TNF) inhibitors: Examples include etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), certolizumab pegol (Cimzia), golimumab (Simponi)
• Anakinra (Kineret)
• Tocilizumab (Actermra) and sarilumab (Kevzara)
• Abatacept (Orencia)
• Rituximab (Rituxan)

Pros:

• Unlike pills, these medications don’t have to be broken down by your digestive system to be absorbed by your body, so they don’t typically cause side effects that sometimes occur with some pills, like stomach irritation, nausea, or diarrhea.
• Most biologics require less frequent dosing because they last for several days, weeks, or even months compared to a pill once or twice a day.

Cons:

• Biologic medications tend to be more expensive than conventional DMARDs, making them less accessible to some patients.
• Biologics are given as injections or infusions.
• Because biologics suppress the immune system, patients may have a higher risk of infections, including serious ones like tuberculosis.
• In some cases, a patient’s immune system will react to biologics as if they are an infection and make proteins that attack the medication.

Comparison:

• Conventional DMARDs are generally more affordable than biologics.
• Both types of medications can cause side effects, but biologics may have fewer side effects that impact the entire body because they target specific parts of the immune system.
• Conventional DMARDs are usually taken orally, while biologics are administered through injections or infusions.
• Regular blood tests to monitor for side effects may be needed for some medications in both groups.

Both conventional synthetic DMARDs and biologic medications can be effective at controlling rheumatic diseases. Medicines from both groups can be taken individually or in combination with other drugs depending on various factors, including the severity of symptoms, cost, potential side effects, and personal preferences. It's essential for patients to discuss their options with their healthcare professionals to find the treatment plan that works best for them. Both types of medications play vital roles in managing rheumatic conditions and improving patients' quality of life.