Medications for Rheumatism

Rheumatism: medication selected individually

Depending on the clinical picture, various rheumatism medications can be considered. When making the selection, the doctor also takes into account, among other things, the stage of the disease as well as individual factors such as concomitant diseases or pregnancy.

Rheumatism drugs: The active ingredient groups

Basically, the following groups of active ingredients are available as rheumatism drugs:

  • Pain medications
  • Glucocorticoid preparations (“cortisone”)
  • Basic drugs (DMARD)

A doctor’s prescription is often needed for rheumatism medication. However, common painkillers such as ibuprofen, diclofenac or paracetamol are available without a prescription – but sometimes with restrictions. Diclofenac, for example, requires a prescription when used internally above a certain dosage. In lower dosages and for external use, diclofenac preparations are freely available.

Pain medication

The leading symptom of rheumatic diseases is pain. That is why painkillers are an important part of rheumatism therapy. Doctors distinguish between non-steroidal anti-inflammatory drugs (NSAIDs) and pure painkillers (analgesics).

The attending physician will select a suitable pain medication in the appropriate dosage for each patient. If necessary, he will also prescribe two or more preparations.

Non-steroidal anti-inflammatory drugs (NSAIDs)

This is particularly beneficial in inflammatory rheumatic diseases such as rheumatoid arthritis, ankylosing spondylitis or psoriatic arthritis. But NSAIDs can also be taken for other rheumatic diseases, such as an acute attack of gout – gout also belongs to the rheumatic group, or more precisely to the metabolic diseases that are associated with rheumatic complaints.

There are two groups of NSAIDs:

  • Selective COX-2 inhibitors (coxibs): Further development of the classic NSAIDs; approved in Germany are etoricoxib, celecoxib and parecoxib.

Of all NSAIDs, diclofenac, ibuprofen and naproxen are the most commonly used in rheumatism therapy.

Side effects

Other possible side effects of NSAIDs include kidney dysfunction (acute renal failure, analgesic kidney), cardiovascular problems (such as increased blood pressure, heart attack, stroke; not ASA or naproxen; diclofenac, on the other hand, is contraindicated), and water retention in the tissues (edema).

Pure painkillers (analgesics)

However, pure analgesics can also be useful in inflammatory rheumatic diseases under certain circumstances – for example, in the case of contraindications to NSAIDs and if treatment with basic medications alone cannot sufficiently relieve the rheumatic pain. Physicians will also prescribe analgesics for patients who cannot tolerate NSAIDs.

Analgesics alone are divided into two main groups:

  • Opioid analgesics: They inhibit the sensation of pain directly in the central nervous system (brain and spinal cord). There are low-potency opioids such as tramadol, tilidine(/naloxone) and codeine, and high-potency opioids, the strongest painkillers. Well-known representatives include fentanyl, morphine and oxycodone.

Side effects

Opioid analgesics can cause fatigue, nausea, vomiting, constipation, and urinary retention, among other symptoms. Opioids also choke off breathing and make you drowsy, which can be life-threatening if you overdose. In principle, they can also be addictive. However, if they are used under medical supervision and as a sustained-release preparation or patch (slow release of active ingredient), the risk of psychological dependence is very low.

Cortisone

Cortisone preparations mimic the action of the body’s own hormone cortisol (cortisol or hydrocortisone) and its precursor cortisone (cortisone). In this way, they can, among other things, inhibit inflammation (more strongly than NSAIDs). They also have an inhibitory effect on the immune system (immunosuppressive effect), which helps against excessive immune reactions.

Side effects

When cortisone is taken for a short time, dizziness, nervousness, headache, and/or euphoria occur most often. Very rarely, mental changes occur with hallucinations, delusions or anxiety.

Most side effects occur only when you take cortisone for a long time and in high doses.

Make sure to take a stomach protector, especially if you combine NSAIDs with cortisone preparations! Talk to your doctor about this!

Basic drugs (DMARD)

In particular, early initiation of treatment with DMARD rheumatism drugs can sustainably improve the prognosis.

Physicians distinguish between three groups of DMARDs:

  • Classical basic drugs: conventional synthetic DMARDs, or csDMARDs for short
  • Biologics: biotechnologically produced DMARDs, in short: bDMARDs
  • Targeted synthetic basic drugs: “targeted synthetic DMARDs”, in short: tsDMARDs

Classic basic drugs (csDMARDs)

This group includes rheumatism drugs with different modes of action. Some of them were originally developed to treat other diseases and only later found their way into rheumatism therapy. However, all classic basic drugs do not take effect immediately, but only after a few weeks or months.

Taking folic acid one to two days after methotrexate reduces side effects.

Other classic basic medications for rheumatism include:

  • Leflunomide (frequent alternative to MTX if the latter is not tolerated or may not be taken due to contraindications).
  • Sulfasalazine (also helps with chronic inflammatory bowel diseases such as Crohn’s disease)
  • Chloroquine or hydroxychloroquine (actually antimalarial drugs)
  • Ciclosporin (given to suppress the immune system after organ transplants and in autoimmune diseases).

In the past, gold preparations were also used as DMARDs. Because of their strong side effects, they are largely dispensed with today.

More information on the respective drugs, for example side effects, can be found in the corresponding drug articles.

Biologics (bDMARDs)

  • TNF-alpha inhibitors: These block the inflammatory messenger tumor necrosis factor-alpha. This group of active ingredients includes, for example, adalimumab, etanercept and infliximab.
  • Interleukin blockers: These inhibit the effect of various interleukins. These are messenger substances produced by white blood cells (leukocytes) to regulate immune reactions. Examples of interleukin inhibitors include tocilizumab and anakinra.

Biologics as rheumatism drugs are very effective: The drugs administered as injections or infusions work faster than classic basic drugs (csDMARDs) and effectively slow down the progression of the disease. However, they are very expensive.

Rheumatism biosimilars

However, they are not identical, but differ slightly from the original structure – unlike so-called generics (production in living cell cultures can never be copied identically). Like the originals, biosimilars are administered either as injections or infusions. Available biosimilars include etanercept, infliximab and rituximab.

Side effects

Biologics and biosimilars can make patients more susceptible to infections (including “dormant” infections) such as tuberculosis because they dampen the immune system. For this reason, doctors usually prescribe these rheumatism drugs only when, for example, treatment with classic basic drugs – including methotrexate – has not worked sufficiently (another reason for this is the high cost of the biotech drugs).

Targeted synthetic basic drugs (tsDMARDs)

Targeted synthetic DMARDs are among the latest drugs for rheumatic diseases with an inflammatory background. They specifically interrupt a signaling pathway within cells that promotes inflammation. Currently approved in Germany are:

  • the PDE-4 inhibitor apremilast: this active ingredient inhibits the enzyme phosphodiesterase-4 and is approved for the treatment of psoriatic arthritis.

Side effects

Tofacitinib may cause such things as headache, upper respiratory tract infections, high blood pressure, diarrhea, and nausea. With baricitinib, the most common adverse effects include increased cholesterol, upper respiratory tract and urinary tract infections, and nausea. Upadacitinib mainly causes upper respiratory tract infections, nausea, and cough.

Rheumatism drugs that suppress the immune system (immunosuppressants) make you more susceptible to infections. Therefore, pay attention to your vaccination status, which is usually also checked by the attending physician.

Other medications for rheumatism

For individual rheumatic diseases, other medications may also be considered – in addition to or as an alternative to the medications mentioned above. Some examples:

Gout

An acute attack of gout is preferably treated with non-steroidal anti-inflammatory drugs (NSAIDs). If necessary, the doctor also administers cortisone – for example as tablets or as an injection directly into the affected joint.

Osteoporosis

Calcium and vitamin D can only work properly if the affected person gets enough exercise.

If a patient has a high risk of bone fractures, special osteoporosis drugs can also be considered. These can either slow down bone loss (e.g., bisphosphonates, denosumab) or promote bone formation (teriparatide).

Fibromyalgia

Some fibromyalgia patients also benefit from anti-seizure (anti-epileptic) medications such as pregabalin.

Herbal rheumatism remedies

  • African devil’s claw root: According to the European Committee for Herbal Medicinal Products, it is considered a traditional remedy for mild joint pain. Therefore, it is used supportively, for example, in osteoarthritis and rheumatoid arthritis, and mostly as a finished preparation (e.g. capsules, tablets, ointment, balm). The tea from devil’s claw root is mainly recommended for mild digestive complaints.
  • Willow bark: Its anti-inflammatory and pain-relieving effect is based on the salicylic acid compounds it contains (the starting point for the anti-inflammatory and painkiller acetylsalicylic acid). In the form of capsules or as a tea, the medicinal plant is used, for example, for osteoarthritis and rheumatoid arthritis.
  • Birch: Birch leaf preparations (e.g. fresh plant press juice, drops, capsules, tea) can be used to support the treatment of rheumatoid arthritis and gout.
  • Arnica: The medicinal plant is only used externally! For example, rheumatic muscle and joint pain is treated with arnica cream, ointment or gel. Also available is arnica tincture, which can be used diluted for compresses.
  • Cayenne pepper: Applied externally (for example as an ointment or active ingredient patch), the pungents it contains trigger a pain and heat stimulus on the skin, which ultimately leads to longer-lasting pain relief – for example in osteoarthritis and rheumatoid arthritis.

Three pillars of phytotherapy for rheumatism

Often the use of herbal remedies for rheumatic complaints is based on three pillars:

  1. Metabolism stimulation and detoxification: With the help of medicinal plants such as birch, stinging nettle, goldenrod or dandelion, excretion via the kidneys is stimulated. Dandelion also stimulates the flow of bile, as do yarrow and milk thistle. Excretion via the intestines and skin can be promoted, for example, with wild garlic, garlic, elderberry and lime.
  2. External use of herbal rheumatism remedies: Ointments, rubs, poultices & Co. can locally and quickly relieve pain and inflammation and stimulate the metabolism, depending on the medicinal plant used. Suitable for this purpose are, for example, arnica, comfrey, cayenne pepper and mustard.

The Phytotherapie cannot replace a classical orthodox medical rheumatism treatment.