Rheumatoid arthritis treatment option: tumor necrosis factor (TNF) blockers

(February 25, 2018)

The most common kind of arthritis is osteoarthritis, a disease of the joints causing stiffness, pain, and reduced movement. It can occur in the hands, shoulders, spine, knees, hips, and arms. While typically occurring in middle age or later, sports injuries or other factors causing repetitive stress on the joints (e.g. being overweight) can cause it to occur at earlier ages. According to National Institutes of Health (NIH), osteoarthritis affects around 23% of adults in the U.S.

Rheumatoid arthritis (RA) is a less common kind of arthritis, affecting around 1.5 million adults in the U.S. More prevalent in women than in men, it often strikes during a patient's 40s or 50s, with symptoms beginning slowly but getting worse over time. It is an autoimmune disease causing pain, stiffness, malformation, and swelling in the joints of the hands and fingers. As part of the autoimmune response, the enzymes released by the body attack its own healthy tissue and also cause the linings of the joints to be destroyed. There appears be a genetic component to this disease but exactly how is not clear; environmental factors also seem to play a role.

Treatment options include medicines for reducing symptoms and medicines that reduce inflammation and help put the disease in remission. For symptom reduction, many patients take NSAIDs (nonsteroidal anti-inflammatory drugs like ibuprofen). In addition to NSAID pain medications, early treatment may include 'DMARD' (Disease modifying anti-rheumatic drugs) such as methotrexate as well as corticosteroids like prednisone. Methotrexate has common side effects of fatigue and nausea. Click here to read patient experiences for Methotrexate taken for RA. Unfortunately, many of the RA drugs have severe side effects risks. Methotrexate, available as an injectable or pill, has a black box warning for toxicities to bone marrow, liver, and lungs.

A third class of drugs for rheumatoid arthritis is the 'tumor necrosis factor blockers,' or TNF inhibitors. They are more expensive than the DMARD drugs but can be highly effective. A new drug in this class, sarilumab (brand name Kevzara), was just recently approved in 2017. It is taken either alone or in conjunction with a DMARD drug.

The TNF blockers have a black box warning stating that patients using it are at increased risk of developing serious and sometimes fatal infections due to bacterial, mycobacterial, invasive fungal, viral, or other opportunistic pathogens. The drugs work by suppressing the body's inflammation-causing substance called Tumor Necrosis Factor (TNF). This helps stop the disease progression of rheumatoid arthritis, but it also suppresses the immune system's ability to fight bacteria and viruses that cause illnesses like tuberculosis and shingles. Patients on these drugs have to be carefully monitored for signs of infection.

Most of the TNF blocker medications are self-administered subcutaneously by injection; see list below for maintenance dosing frequency regimens. The exception is Remicade, which is administered intravenously by a health care provider. The third column provides the AskaPatient average patient rating score (5=highly effective, 1=not effective). Click drug name to read patient reviews for TNF blockers that were taken to treat rheumatoid arthritis.

Tumor necrosis factor blockers Rating
Enbrel injection 1X a week 3.7
Humira injection every other week 3.2
Remicade I.V. every 8 weeks 3.6
Simponi injection 1X a month 3.4
Sources and additional reading:
U.S. National Library of Medicine's Arthritis article at PubMed Health
FDA Patient Drug Labels
The Arthritis Foundation: Rheumatoid Arthritis