How long do you need to take a disease-modifying antirheumatic drug (DMARD) for rheumatoid arthritis until it reaches its full effect? It depends on which one you are using. However, it does take a while, says Dr. Eric M. Ruderman, a rheumatologist at Northwestern Medicine Rheumatology in Chicago. In fact, he says, DMARDs were previously called SARDs, which stands for slow-acting antirheumatic drugs.
According to Ruderman, it usually takes 6 to 12 weeks of taking DMARDs for a response to occur. Why does it take so long? To explain that, it helps to understand what DMARDs accomplish.
How do DMARDs work for RA?
In the past, nonsteroidal anti-inflammatory drugs (NSAIDs) such as Ibuprofen and Naproxen were the main treatment for rheumatoid arthritis (RA). They treat joint pain and inflammation, but do not prevent joint damage. If these did not help, your rheumatologist might consider prescribing a DMARD, a newer medication.
This has changed in the last 15 to 20 years, says Ruderman. Nowadays, DMARDs are prescribed as soon as you are diagnosed with RA. Why? „We are aware that simply treating symptoms does not really cover the problem. You need to treat the underlying disease. This is how you achieve the best results in the long term,“ he says.
Each type of DMARD works differently. But they all go beyond treating symptoms by blocking inflammation and slowing down the disease process. This minimizes joint damage and complications that inflammation caused by RA can lead to, such as heart problems, says Ruderman.
„People really need to be started on a disease-modifying drug from the beginning, because our goal nowadays is not just to relieve the symptoms, but to put people in remission if we can. And we can most of the time,“ says Ruderman.
NSAIDs and corticosteroids are also an important part of an RA treatment plan, but they only improve symptoms caused by inflammation. DMARDs are the foundation, as they work with your immune system to slow down or even stop the disease.
Why does it take so long for DMARDs to work?
Since a DMARD medication treats underlying inflammation, „it won’t work overnight,“ says Ruderman. People often see some benefit immediately, but it usually takes longer for symptoms like swollen, painful joints, and morning stiffness to ease, he says.
„The other complicating factor is that there are dosing issues, especially with Methotrexate,“ says Ruderman.
Your rheumatologist will likely start you on a low dose for about a month. If this is not enough, your doctor may increase the amount. It usually takes about three months for you and your doctor to determine if the medication is working. With some types of DMARDs, it can take up to six months for the maximum benefit to take effect, he says.
What are the different types of DMARDs?
Your doctor can choose between conventional DMARDs, which fight inflammation by acting on your entire immune system, and biological DMARDs, which target specific proteins involved in the immune response.
DMARD medications used in RA include:
- Leflunomide (Arava)
- Methotrexate (Rheumatrex, Trexall)
- Biological DMARDs known as tumor necrosis factor inhibitors, such as Adalimumab (Humira), Certolizumab (Cimzia), Etanercept (Enbrel), Golimumab (Simponi), and Infliximab (Avsola, Inflectra, Remicade, Renflexis).
- Biologics called B-cell inhibitors, including Rituximab (Rituxan, Ruxience, Truxima).
- Biologics called selective co-stimulation modulators, such as Abatacept (Orencia).
- Janus kinase inhibitors like Baricitinib (Olumiant), Tofacitinib (Xeljanz), and Upadacitinib (Rinvoq).
Methotrexate is usually the first DMARD that doctors prescribe for people with RA. Hydroxychloroquine, Leflunomide, and Sulfasalazine are also common treatments.
According to Ruderman, it usually takes the longest for Leflunomide and Methotrexate to reach their full effectiveness.
Biological DMARD medications work faster. „We often expect to see noticeable benefit within about six weeks, sometimes even sooner,“ says Ruderman.
The newer kinase inhibitors, including Tofacitinib and Upadacitinib, work the fastest, he says. „I usually expect to see a benefit within a month,” he says.
What does successful treatment look like?
The ideal result is remission.
„That’s our goal, especially when we treat people early,“ says Ruderman. „It’s hard to say for sure, but in 60 to 75% of cases, we can actually put people in remission.“ This may require several attempts with different medications.
Ruderman defines remission as having no swollen, painful, or tender joints. You might have one or two days a week when you don’t feel well, or morning pain, but that quickly improves. „Most of the time, you just don’t feel like the disease is a problem in your life,“ he says.
If you have been suffering from RA for years, you have likely already suffered significant damage, says Ruderman. This is because older treatments were not as effective. DMARDs cannot reverse past damage caused by RA. However, they can slow down the progression of the disease and prevent further joint damage.
How do you know which medication is best for you?
Although RA treatments have come a long way, there is no way to predict which medication will work best for you. You may need to try three or four medications to find one that brings results.
„It’s great that we have so many good drugs and they all work really well,“ says Ruderman. „We just don’t have a good way to choose between them.“
How long do you have to take DMARDs?
If you have found something that works, you should be able to use it for 15-20 years before needing to try something else. Previous research has shown that completely stopping your medication, even if you are in remission, leads to a flare-up of symptoms.