Rheumatoid arthritis can be devastating and unpredictable. It attacks joints and can leave people twisted, crippled and in pain.
Ever since the 1950s doctors have been looking for drugs to ease pain and undo damage. When cortisone-type drugs were first introduced, they were perceived as wonder drugs. Patients felt immense improvement after starting a course of therapy with prednisolone, prednisone or dexamethasone. It wasn’t until years later that consequences such as weight gain, cataracts, glaucoma, hypertension, muscle wasting, ulcers or diabetes were detected. It became clear that these “miracle” drugs came at a high price. One other long-term outcome of high-dose prolonged therapy with corticosteroids is osteoporosis. As one noted rheumatologist put it, these drugs “melt bone.”
When so-called non-steroidal anti-inflammatory drugs were introduced, they were enthusiastically received. The belief was since they were “non-steroidal” they would not have serious side effects (like cortisone). Drugs like diclofenac (Voltaren), etodolac (Lodine), flurbiprofen (Ansaid), ibuprofen (Motrin), indomethacin (Indocin), ketoprofen (Orudis), nabumetone (Relafen), naproxen (Naprosyn), piroxicam (Feldene) and sulindac (Clinoril) helped ease pain, but not surprisingly they came with their own set of drawbacks. Stomach ulcers, hypertension, kidney problems, irregular heart rhythms and perhaps even heart attacks and strokes may result.
When the new “biologic” medications were introduced in the late 1990s, investigators hoped that these TNF blockers would fundamentally alter the course of rheumatoid arthritis. The new “miracle” drugs included adalimumab (Humira), certolizumab (Cimzia), etanercept (Enbrel), golimumab (Simponi) and infliximab (Remicade). Because they calm an overactive immune system they were expected to dampen inflammation and even reverse the disease process.
Why are we not surprised that it took years to learn that there were unexpected complications? The FDA has warned that these drugs can increase the risk of certain cancers (lymphoma and leukemia). People who never had psoriasis may develop this skin problem when they stop the medicine. Because these drugs suppress the immune system, both bacterial and fungal infections may become life threatening. Liver damage is another rare but very serious reaction.
Now the FDA has approved another brand new medicine for rheumatoid arthritis. Like so many of its predecessors it is being heralded as a potential “blockbuster” against a very serious disease. But patients should be aware that Actemra (tocilizumab) may also have a dark side. In Japan, where it has already been on the market for years, this immune system modulator has been linked to serious infections and deaths. The drug can cause life-threatening allergic reactions (anaphylaxis), gastrointestinal perforations, headache, hypertension, elevated liver enzymes or cholesterol. Like other immune-suppressing drugs, there is concern that Actemra may increase the risk of cancer.
Rheumatoid arthritis patients may be glad to have another option, since the current treatments leave much to be desired. Patients should be aware, however, that most arthritis drugs are double-edged swords and can do a lot of damage as well as good.
