Biologic drugs for rheumatoid arthritis: the rewards may come with risks

The Bottom Line

  • Rheumatoid arthritis causes swelling, pain, loss of function and in the worst cases, joint and bone deformities.
  • Treatment typically involves disease-modifying antirheumatic drugs (DMARDs) to improve symptoms and prevent further damage to the joints.
  • A relatively new type of drug called biologics, taken in combination with traditional DMARDs, may improve symptoms better than either biologics or DMARDs alone, but can also increase the risk of serious infections.
  • If you have rheumatoid arthritis, ask your doctor whether adding biologic drugs to your treatment plan is advisable.

Aside from possibly giving you an advantage in forecasting the weather (“It’s going to rain – I can feel it in my bones”) there’s not much to like about rheumatoid arthritis. It’s a painful and often frustrating chronic condition that causes inflammation of the small joints – typically in the hands and feet – resulting in stiffness and swelling that can eventually wear down the bones and cause the joints to become deformed (1).

Rheumatoid arthritis is an autoimmune disease, meaning that it occurs when a person’s immune system mistakenly attacks their own tissue. There is no cure so treatment involves controlling symptoms and preventing damage to the joints with disease-modifying antirheumatic drugs (DMARDs). Methotrexate is one such drug, commonly prescribed to rheumatoid arthritis sufferers (1).

Within the past decade a new class of drug was developed for people who were no longer getting relief from traditional DMARDs. “Biologics” work by suppressing triggers in the immune system that cause inflammation. There are several types of biologic drugs, for example etanercept, adalimumab and rituximab.

Numerous studies have shown that biologics help to prevent joint erosion and provide relief for arthritis symptoms (3) – so many in fact that a comprehensive review conducted in 2013 was updated just a year later to incorporate even more recent evidence (4).The 2014 review included results from 108 studies involving participants who had rheumatoid arthritis or were at high risk of developing the condition. The studies included a variety of biologic drugs. Study participants were given biologics alone, methotrexate (or another ‘traditional’ DMARD) alone, or a combination of both and were assessed after at least six months of treatment.

What the research tells us

What was the verdict? Consistent with prior studies, biologics were found to be effective in reducing pain and inflammation, with the greatest improvement resulting from a combination of both biologics and traditional DMARDs.

But that seemingly strong vote of confidence for biologics comes with a cautionary note: the report did not address the safety of the medications. As these drugs alter the immune system, there continues to be considerable debate in the medical community over whether biologics can increase the risk of serious infections, such as tuberculosis.  A comprehensive 2015 systematic review on the topic (including 106 randomized controlled trials and over 42,000 patients) found there was no noticeable increase in the number of serious infections for people taking low doses of biologic drugs, but the risk was greater at standard and high doses (5).

So should people avoid biologic drugs after all? As with most drugs and procedures, their benefits need to be weighed against the risks, which are different for everyone. Patients’ age, medical history, overall health, the stage/severity of the condition, as well as their own values and preferences will help doctors determine if adding biologic drugs to their treatment plans is advisable, and if so, the optimal dosage.

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  1. Vis M, Guler-Yuksel M, Lems WF. Can bone loss in rheumatoid arthritis be prevented? Osteoporos Int. 2013;24:2541-2553.
  2. Lopez-Olivo MA, Amezaga UM, McGahan L et al. Rituximab for rheumatoid arthritis. Cochrane Database Syst Rev. 2015; CD007356.
  3. Tugwell P, Singh JA, Wells GA. Biologicals for rheumatoid arthritis. BMJ. 2011; 343:d4027.
  4. Nam JL, Ramiro S, Gaujoux-Viala C et al. Efficacy of biological disease-modifying antirheumatic drugs: a systematic literature review informing the 2013 update of the EULAR recommendations for the management of rheumatoid arthritis. Ann Rheum Dis. 2014;73:516-528.
  5. Ionnidis JP, Karassa FB, Druyts E et al. Biologic agents in rheumatology: unmet issues after 200 trial and $200 billion sales. Nat Rev Rheumatol. 2013; 9:665-673.
  6. Singh JA, Cameron C, Noorbaloochi S et al. Risk of serious infection in biological treatment of patients with rheumatoid arthritis: a systematic review and meta-analysis. Lancet. 2015; 386:258-265.

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