By Dr. Jane B. Ayala, FACR and Dr. Thomas A. Rennie, FCR Board Certified in Internal Medicine and Rheumatology
DMARDs are a group of medications used to treat rheumatoid arthritis (RA) by slowing down or stopping the disease process—not just masking symptoms like pain or stiffness.
They work by calming the overactive immune system, reducing inflammation inside the joints, and helping prevent joint damage and deformity over time.
Types of DMARDs
1. Conventional (Traditional) DMARDs
These have been used for many years and are usually the first-line treatment for RA.
Common examples:
- Methotrexate (Trexall, Rasuvo): The most commonly prescribed DMARD. It helps control inflammation and slows joint damage.
- PEARL: we use low-dose Methotrexate different than the chemotherapy dosing, sometimes talking about Methotrexate is scarier than taking it. We supplement folic acid/folate to prevent side effects.
- Sulfasalazine (Azulfidine): Often used with methotrexate for added benefit.
- Leflunomide (Arava): Blocks immune cell activity that causes inflammation.
- Hydroxychloroquine (Plaquenil): A mild DMARD that helps control symptoms, often used in combination with others.
These medications may take 6–12 weeks to show improvement.
2. Biologic DMARDs
Biologics are targeted therapies made from living cells. They block specific parts of the immune system involved in RA inflammation.
Examples include:
- TNF inhibitors: etanercept (Enbrel), adalimumab (Humira), infliximab (Remicade)
- IL-6 inhibitors: tocilizumab (Actemra), sarilumab (Kevzara)
- B-cell or T-cell targeted drugs: rituximab (Rituxan), abatacept (Orencia)
They work differently than traditional DMARDs and are often used when methotrexate alone isn’t enough.
3. Targeted Synthetic DMARDs (JAK Inhibitors)
These are oral medications that block enzymes (JAKs) involved in the immune response.
Examples:
- Tofacitinib (Xeljanz)
- Upadacitinib (Rinvoq)
- Baricitinib (Olumiant)
They act quickly and can be used if traditional or biologic DMARDs aren’t effective.
Monitoring and Side Effects
Because DMARDs affect the immune system, regular blood tests are needed to check:
- Liver and kidney function
- Blood counts
- Infection risk
Common side effects may include nausea, fatigue, or mild liver irritation, but serious side effects (like severe infections) are possible.
Key Takeaways
DMARDs are the foundation of rheumatoid arthritis treatment. They help prevent long-term joint damage, disability, and improve quality of life. The most important thing is to start early and continue regular follow-ups with your rheumatologist to monitor your progress and adjust medications as needed.