Dr. Rohini Handa answers questions on the various drug updates and developments that have expanded the scope of rheumatology practice in the last decade. Discussed here are DMARDs and other drugs used in the treatment protocol for rheumatic arthritis, lupus, and ankylosing spondylitis.

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Here are 9 FAQs on DMARDs and their use in rheumatic disease treatment.

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Question 1. Can you elaborate on DMARDs therapy and its side effects?

Dr. Rohini Handa: Pharmacology is the science of selective toxicity. Why would you call it a medicine if it was bereft of side effects? So all medicines have side effects but if you monitor your patients well, you reduce the frequency of side effects but you don’t eliminate them altogether.

With methotrexate, leflunomide, sulfasalazine and HCQ, you look at the white blood cell counts, the haemoglobin, the LFT and KFT every two to three months. In a well-controlled patient, you may check these parameters once in four months, most of them tend to do well.

We work on the principle of probability and possibility, so side effects are possible but should you run into problems with transaminitis, you scale down the dose or temporarily withhold and reinstitute later. Monitoring holds the key, it cannot be a ‘fit and forget’ approach. By no means can you do that, it would be a cavalier approach to rheumatic diseases as these patients require treatment for life.

About the duration of treatment, the answer is indefinite; it is like diabetes or cholesterol issues except that here you de-escalate your treatment.

1. The first strategy is containment. If a patient was on HCQ, methotrexate, leflunomide and steroids, once you achieve disease control, you contain the disease, then you maintain the disease control, and then you reduce the treatment.
2. Once the disease is controlled, you withdraw corticosteroids, then leflunomide, then withdraw HCQ in a gradual manner, and ultimately, if the patient still experiences good control, then reduce methotrexate from 15 mg a week to 12.5 mg.
3. Six months later, the person could also do with 10 mg, but, you need periodic assessment. You need to measure and treat, and you escalate or de-escalate according to the disease activity.

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Question 2. What kind of DMARD doses should be administered in pregnancy and what would be the drug of choice?

Dr. Rohini Handa: The first message to be conveyed to female patients is that rheumatic disease are compatible with marriage and pregnancy. There is a gender bias in these rheumatic diseases, but even the most traumatic diseases like a lupus or rheumatoid arthritis (RA) are indeed compatible with marriage and pregnancy.

Three drugs in RA are allowed during pregnancy, hydroxychloroquine (HCQ), sulfasalazine and low-dose prednisolone . You can use these drugs singly or in combination. We prefer using HCQ and sulfasalazine, and if the disease activity is present then we also add low-dose prednisolone to the treatment protocol.

If it is a lupus patient, azathioprine is allowed during pregnancy and anti-TNS biologics like enbrel or infliximab can be used for an expecting woman.

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Question 3. Is HCQ preferred over sulfasalazine?

Dr. Rohini Handa: The size of the sulfasalazine tablet is big, which is why patients don’t like it. The benefits of HCQ extend beyond joints, it lowers sugar level and controls lipid levels, so it works bi-directionally. If you are not sure whether your patient has a lupus or Sjogren’s overlap, HCQ helps there as well. Also, the combination with methotrexate is synergistic. There was a time when sulfasalazine was widely used, however, since the time leflunomide has become available, the use of sulfasalazine has gone down.

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Question 4. For how many years can a patient take methotextrate?

Dr. Rohini Handa: There was a time when we would talk about a cumulative dose of 1.5 grams; that’s no longer true now. No one does a surveillance-level biopsy and counts the number of grams or milligrams of methotextrate. You need to monitor your patient with liver function; if liver function and serum albumin are alright, you can continue it for decades. We have patients who have been on methotextrate for 20-25 years, so it is the status of the disease in the patient that is a factor in determining the duration. If your patient does well, remember to de-escalate your dose. You could have a patient who can do well on just 5 mg a week, when the starting dose could have been 15 or 20.

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Question 5. Are there any new drugs for ankylosing spondylitis?

Dr. Rohini Handa: We have five biologics available in our country – infliximab, etanercept, golimumab, adalimumab, and secukinumab, which are now relatively affordable and can be used for ankylosing spondylitis. Four of these are anti-TNF agents and one is an IL-17 blocker.

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Question 6. How successful is TNF blocker in the management of ankylosing spondylitis?

Dr. Rohini Handa: TNF blocker, for a patient of ankylosing spondylitis, is the difference between existing and living. A person who cannot move or laugh freely, cough or sneeze without holding his ribs, can start living; can turn sides, sneeze, and laugh. Not only that, his working capacity increases, fatigue goes down, and if cost was not an issue, there is no reason for people with ankylosing spondylitis to suffer.

There is a caveat, however, that biologics do not work for everyone. Fifteen to twenty percent of the people would have primary or secondary non-response to biologics and the trick lies in selecting your patients and then resort to ‘switching ‘; if he doesn’t respond to one, you switch to the other, which is a science in itself.

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Question 7. Are patients on methotextrate for RA at a risk of catching COVID-19?

Dr. Rohini Handa: People say that if someone is stable and is on drugs, it doesn’t really put them at risk unless there are comorbidities determining the outcome, like diabetes, obesity, and hypertension. Otherwise, the risk is not inordinately high and no guidelines recommend discontinuation of anti-rheumatic drugs.

Disclaimer-

This document is a transcription of the video, produced for audience with bandwidth limitations that could possibly restrict them from viewing it. While it is believed to be accurate, it is not warranted to be so. Divergence in format is to be expected.

The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The author, Dr. Rohini Handa is a Senior Consultant Rheumatologist from Delhi.