Combination Therapy for Rheumatoid Arthritis

Rheumatoid arthritis is no longer the disabling condition it was in the past, thanks in large part to combination therapy – taking more than one RA medicine at a time. 

For example, combining two disease-modifying antirheumatic drugs (DMARDs) or combining the DMARD methotrexate with a biologic agent can lessen symptoms such as joint pain as well as slow joint damage — greatly improving quality of life for people with RA.

Combination therapy has produced a sea change, says James R. O’Dell, MD, Larson professor of internal medicine and chief of rheumatology and immunology at the University of Nebraska Medical Center in Omaha, Neb.  “It is very gratifying to go to clinic now,” he says. Instead of counting the number of people in wheelchairs, Larson says, “You see the majority of your patients doing great and living a normal life.”

If your doctor recommends combination therapy, work with him to tailor a treatment plan that is right you. Here are answers to some of the questions you may have about combination therapy for RA.

What can I expect if I go on combination therapy?

It’s not yet possible to know in advance which combinations of drugs will work for a specific patient. So you can expect some trial and error and tailoring to get the best result for you.

After you are diagnosed, you may start on monotherapy, which means taking a single drug, usually the DMARD methotrexate. Methotrexate can suppress an overactive immune system and slow or stop joint damage. It is used in combination with virtually every other drug, says Mark C. Genovese, MD, professor of medicine and co-chief of immunology and rheumatology at Stanford University Medical Center in Palo Alto, Calif.

Then your rheumatologist may increase the dose, as needed, to evaluate its effectiveness and any side effects. If your disease does not respond well to the first drug, the doctor may add a biologic. Biologics can work quickly to reduce joint pain and swelling. They also help turn down the inflammatory response and improve physical function.

Finding the biologic that works best for you can take some time. Genovese says that patient and physician preferences, as well as cost and insurance coverage, are also a part of the decision-making process.

Do some combinations work better and produce fewer risks than others?

Although many doctors combine methotrexate with a biologic, that’s not necessarily better than combining two DMARDs. O’Dell lists methotrexate, sulfasalazine, hydroxychloroquine, and leflunomide among the DMARDs that have been used together. “Work with a rheumatologist to find a therapy or combination that will get your disease to a low level of activity,” O’Dell says.

Rheumatologists don’t combine two biologics because of the higher risk of infections.

Although methotrexate doesn’t often cause liver toxicity, your doctor will carefully monitor your liver function. Many RA medications can also cause bone marrow problems. Doctors closely watch for these potential risks.

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