Are biologics better than Methotrexate for my RA at 47?

Hello,

Welcome to icliniq.com.

I have read your query and can understand your concern.

I​‍​‌‍​‍‌ realize how frustrating it might be for you to have increased morning stiffness despite being on Methotrexate and Hydroxychloroquine. Rheumatoid arthritis (RA) is a long-term condition in which the body’s immune system attacks itself. For some patients, conventional DMARDs may not be sufficient to control the inflammation or slow down the disease. In cases like that, it makes sense to increase the treatment. I'll break it down for you here.

The symptoms you are showing are in line with the situation when a person with rheumatoid arthritis is still active and is not responsive to the DMARDs (disease-modifying antirheumatic drugs) that the patient is currently taking. There are several reasons why this might happen, one of which is ongoing inflammation, another being the natural progression of the disease, and the last one is the complications that may have arisen.

To determine the activity of the disease and the safety of the treatment, it is recommended that you do the following:

1. Complete blood count (CBC).
2. Repeat ESR (erythrocyte sedimentation rate) and CRP (C-reactive protein) to check if there is still inflammation.
3. Tests to check the functionality of your kidneys (RFTs).
4. Tests to check the functionality of your liver (LFTs).
5. Random blood sugar (RBS).
6. It might also be necessary to take pictures of the affected joints through X-rays or ultrasound to determine the level of the damage or the presence of synovitis.

To identify any infections before the start of biologic therapy, the following are strictly required:

1. Chest X-ray.

2. Sputum AFB (sputum acid-fast bacilli, only if clinically indicated).

3. Screening for Hepatitis B and C.

4. HIV (human immunodeficiency virus) testing.

Different diagnoses to consider include:

1. Rheumatoid arthritis flares up despite therapy.

2. Drug-resistant or progressing rheumatoid arthritis (RA).

3. Another inflammatory arthritis (such as psoriatic arthritis or lupus overlap).

4. Concomitant infection.

5. Arthritis due to crystals (very unlikely but still possible).

The most probable cause is rheumatoid arthritis with active disease and related problems.

Ways to manage the disease that we have thought of:

In the first instance, we take current DMARD (disease-modifying antirheumatic drugs) therapy and ensure we are on Methotrexate at a sufficient level while continuing daily folic acid supplementation.

In case the disease activity does not decrease, biologic therapy like Adalimumab can be considered. Biologics are proven to be much more effective as a drug-based therapy and thus can be used to decrease inflammation, joint damage, and Overall progression of the disease. The combination of a biologic plus Methotrexate is the very most effective treatment.

Supportive measures are very important as physical therapy, joint protection, good pain management, the use of medicated shoes, and the use of supports for the chair when sitting or doing household tasks for a longer time.

In terms of safety for long-term use, biologic medications might lead to a higher likelihood of getting infections in the lungs, bladder, or tuberculosis (a bacterial infection that usually affects your lungs) reactivation. There is a small chance of cancer or blood diseases occurring. Besides that, there is a possibility of experiencing injection site reactions or allergic reactions. Regular checkups can help prevent these problems from happening.

I highly recommend that you follow up regularly, in particular, if initiating or changing biologic therapy. We will examine your test results, check how active your disease is, see how well the treatment is working, and if there are any side effects, make necessary changes to therapy to maintain joint function during follow-ups, among other things. Hospital visits can be kept to a minimum by scheduling video calls for checking your labs, discussing symptoms, and giving medication instructions.

I hope this answers your query.

Please let me know if I can assist you further.

Thank you.