What are Traditional DMARDs?
Disease-modifying anti-rheumatic drugs (DMARDs) are effective at reducing inflammation associated with psoriatic arthritis (PsA). There are different types of DMARDs: traditional (or non-biologic), biologic, and target-specific. These drugs work to slow and prevent damage to joints, enabling people with PsA to maintain function and quality of life. This is why they are called “disease-modifying”—they can interrupt the processes that cause joint damage in psoriatic arthritis.1
Traditional DMARDs include:
Methotrexate may be sold under the brand names Trexall™, Otrexup®, Rheumatrex®, and Rasuvo®. In addition to being used as a treatment for PsA, methotrexate has been used for decades to treat psoriasis. It helps with pain and swelling, and as a DMARD, it can help slow the progression of the disease. The most common side effects of methotrexate include nausea, vomiting, and abnormalities in liver function tests. Side effects are more likely with higher doses.2
Azulfidine is a sulfa drug that reduces the pain and inflammation of PsA and can prevent damage to the joints that occurs with disease progression. Most patients can tolerate sulfasalazine with few side effects. The most common side effects are nausea, abdominal discomfort, diarrhea, vomiting, headache, and loss of appetite. Side effects may be reduced by beginning on a low dose and slowly increasing the dose over time (titration). Abdominal side effects generally improve over time. Azulfidine can cause temporary infertility in men (fertility returns after the medication in stopped).3,4
Arava is an immunodulatory drug that inhibits the production of immune system cells. It suppresses the overactivity of the immune system that occurs in autoimmune diseases like PsA, reducing pain and inflammation and preventing long-term damage that can occur with disease progression. The most common side effect experienced with leflunomide is diarrhea and generally improves with time. Other side effects include alopecia, rash and headache.5,6
Antimalarial drugs can be used to treat joint inflammation in some patients with PsA. Antimalarials are named because of their initial benefit in treating malaria, however, their mechanism of action, including the ability to absorb reactive oxygen to decrease inflammation, can benefit people with PsA. The two most commonly used antimalarials in the treatment of psoriatic arthritis are Plaquenil® (hydroxychloroquine) and Aralen® (chloroquine phosphate). Aralen has not been approved by the U.S. Food and Drug Administration (FDA) to treat conditions other than malaria. However, physicians sometimes prescribe Aralen for inflammatory conditions like PsA.7,8
Plaquenil is generally well tolerated by patients. The most common side effects are nausea and diarrhea, which often improve over time. Taking the medication with food can decrease these side effects. Other serious side effects may occur such as retinal disorder. Follow your health care provider's recommendation for eye exams.9
Aralen may cause side effects such as headache, loss of appetite, diarrhea, upset stomach, abdominal pain, hair loss, skin rash or itching, and mood or mental changes.8
The most common side effects for Methotrexate, Azulfidine (sulfasalazine), Arava (leflunomide), Antimalarial drugs are listed here, but these are not a complete list of side effects for these medications.
Editorial Note: On April 24, 2020, the FDA announced that there have been reports of serious heart rhythm problems in patients with COVID-19 treated with hydroxychloroquine or chloroquine. Because of these reports, the FDA cautioned against the use of hydroxychloroquine or chloroquine for COVID-19 outside of a hospital or a clinical trial. Close supervision by a medical team is strongly recommended. Hydroxychloroquine and chloroquine can cause abnormal heart rhythms. If you are receiving hydroxychloroquine or chloroquine for COVID-19 and have an irregular heartbeat, dizziness, or fainting, call 911 right away.
Editorial Note: On March 19, 2020, the FDA approved the testing of two drugs, chloroquine (hydroxychloroquine) and remdesivir, to treat people with COVID-19. Chloroquine and hydroxychloroquine are also used to treat malaria, lupus, and rheumatoid arthritis. Both have been used for decades and are generally inexpensive and safe to use as prescribed. Remdesivir is an experimental antiviral drug that has not yet been approved for use in the U.S. or any other country. However, it has been tested in animals to fight MERS and SARS, two other serious infections in the coronavirus family. It is in the very early stages of being tested in humans to fight the Ebola virus.