Pros, cons of rheumatoid arthritis drugs—and an FDA alert on Enbrel

Rheumatoid arthritis can be debilitating. So doctors and patients had high hopes a few years ago for TNF blockers, a class of drugs that promised to revolutionize treatment by targeting the inflammation that underlies the disease. But it turns out that the drugs, which interfere with a protein called tumor necrosis factor, can increase the risk of life-threatening infections and certain cancers. Now new evidence helps quantify those risks and provides guidance on when and how to use TNF blockers and other rheumatoid arthritis drugs.

The FDA has issued a new boxed warning about infections, including serious infections leading to hospitalization or death that have been observed in patients treated with etanercept (Enbrel). Infections have included bacterial sepsis and tuberculosis. The warning advises doctors to screen patients for latent tuberculosis infection before beginning Enbrel, and recommends patients educate themselves on the symptoms of infection and be closely monitored for any signs and symptoms of infection during or after treatment with the drug.

A recent analysis found that two TNF blockers, adalimumab (Humira) and infliximab (Remicade), could cause one serious infection for every 59 patients who take them for at least several months and one cancer for every 154 patients who take them for several months to a year. And a March 2007 study found that many newly diagnosed patients can do just as well starting with a combination of older, safer, and cheaper drugs. Considering the complexity, cost, and limited evidence, our consultants offer this strategy for improving your arthritis symptoms:

• Make sure a rheumatologist, not just a general practitioner, helps you sort through the treatment options. And don't forget to include nondrug options such as tai chi or other gentle exercises.
• Try methotrexate, alone or combined with other older drugs, before escalating to the vastly more expensive TNF blockers. Generic methotrexate costs about $675 a year, compared with about $10,000 to $16,000 for the TNF blockers.
• See your doctor regularly, especially when symptoms are not controlled.
• If side effects are intolerable or a treatment isn't producing good results, talk to your doctor about switching to a different dose or drug or trying a different combination of medications.

Comments

[Al Seekamp]

As an RA patient who had a life threting infection after two Enbrel injections I would like to second the advice presented in this article particularly that on infection education. We almost didn't respond fast enough because we didn't understand the speed at which the infection became deadly.