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Disease-Modifying Antirheumatic Drugs (DMARDs)

Reviewed by: HU Medical Review Board | Last reviewed: January 2023

While there is no cure for axial spondyloarthritis (axSpA), there are treatments to help reduce pain and inflammation. The main treatment goals are to reduce pain and stiffness as well as improve your quality of life.1

Treatment usually involves maintaining a healthy lifestyle and taking more than one kind of medicine. There are different kinds of drugs available to treat axSpA. Disease-modifying antirheumatic drugs (DMARDs) help reduce inflammation and slow the progression of axSpA.1-3

How do DMARDs work?

DMARDs stop inflammation by blocking certain proteins, hormones, and enzymes in the body. DMARDS can help reduce pain and stiffness in your joints and protect bone health. They are usually taken by mouth or injected.3,4

DMARDs suppress, or turn down, your body's overactive immune system. This helps reduce inflammation. When taken as directed, DMARDs may help slow down the progression of axSpA. They take effect slowly, so it can take several weeks or months for you to start feeling better. DMARDs are not made to provide fast relief of symptoms.3,4

Examples of DMARDs

There are different types of DMARDs, including:4

  • Conventional (traditional)
  • Biologic and biosimilar
  • Targeted synthetic

Sometimes, doctors may recommend that you take more than one type of DMARD at the same time. This is called combination DMARD therapy. Combination therapy has been shown to help people with axSpA, even if only one of the drugs helped on its own.3,4

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Conventional, or traditional, DMARDs have been used to treat different types of arthritis for a long time. They suppress your overall immune system. This type of drug is not usually used when axSpA involves only the spine.4,5

Traditional DMARDs used to treat axSpA include:3

  • Methotrexate
  • Sulfasalazine

Methotrexate has a boxed warning, the strictest warning from the US Food and Drug Administration (FDA). It has this warning because it can cause serious side effects, including severe allergic reaction and death. It also can harm an unborn baby.6

Biologics and biosimilars

Biologics are usually added when symptoms are severe or other drugs do not provide relief. Biologic drugs are made from living cells. Biologic DMARDs work on specific parts of the immune system. Biosimilar drugs are similar to biologics and have no measurable difference in their effectiveness, action, and safety.3,7,8

Biologic and biosimilar drugs used to treat axSpA include:3,7,8

  • Adalimumab (Humira®)
  • Certolizumab pegol (Cimzia®)
  • Etanercept (Enbrel®)
  • Golimumab (Simponi® and Simponi Aria®)
  • Infliximab (Remicade®)
  • Infliximab-abda (Renflexis®)
  • Infliximab-axxq (Avsola®)
  • Infliximab-dyyb (Inflectra®)
  • Ixekizumab (Taltz®)
  • Secukinumab (Cosentyx®)

Several biologic and biosimilar drugs used to treat axSpA have a boxed warning, the strictest warning from the FDA. They have this warning because they can increase your risk of serious infections and certain cancers.9

Targeted synthetic

Targeted synthetic DMARDs are the newest type of DMARD. These DMARDs are usually prescribed when other drugs do not provide symptom relief or when inflammation is severe.2,10

Janus kinase (JAK) inhibitors are a type of synthetic DMARD used to treat certain cases of axSpA. JAK inhibitors target specific immune system processes. JAK enzymes are important for immunity and inflammation. JAK inhibitors block the activity of JAK enzymes. This way, the drugs help reduce pain and improve function in people with axSpA.2,10

Two JAK inhibitors have been approved by the FDA to treat adults with certain cases of axSpA:11,12

  • Tofacitinib (Xeljanz®)
  • Upadacitinib (Rinvoq®)

Both Xeljanz and Rinvoq have boxed warnings, the strictest warning from the FDA. They have these warnings because they increase your risk of severe and life-threatening conditions, including:11,12

  • Serious infections, including tuberculosis (TB)
  • Heart attack, stroke, or death in people over 50 who also have heart disease
  • Certain cancers, including lymphomas and lung cancers
  • Blood clots

What are the possible side effects?

All DMARDs can cause side effects, but not everyone will experience them. Side effects can vary depending on the specific drug you are taking. The most common side effects include:4

  • Upset stomach
  • Vomiting
  • Diarrhea
  • Injection site reaction
  • Rash
  • Hair loss
  • Extreme tiredness
  • Changes in weight

These are not all the possible side effects of DMARDs. Talk to your doctor about what to expect when taking DMARDs. You also should call your doctor if you have any changes that concern you when taking DMARDs.

Other things to know

Some DMARDs are only prescribed when damage from axSpA is visible on X-rays or MRI scans. This type of axSpA is known as radiographic axSpA or ankylosing spondylitis (AS). Talk to your doctor about which DMARDs might be right for you.7

Your doctor will choose one or more DMARDs based on a number of factors, including:3-5

  • Severity of your axSpA
  • Balance of the drug's side effects versus benefits
  • Cost of the drug
  • Ease of taking the drug regularly

DMARDs work on your immune system. Because of this, they can increase your risk of infection. Report any signs of infection to your doctor right away, including:4,13

  • Fever
  • Chills
  • Sore throat
  • Unusual fatigue

Your doctor may also suggest you get certain vaccines or take other medicines to help prevent infections while taking DMARDs. Talk to your doctor about the best way for you to stay healthy and safe while on this treatment.3

Before beginning treatment for axSpA, tell your doctor about all your health conditions and any other drugs, vitamins, or supplements you are taking. This includes over-the-counter drugs. Also tell your doctor if you are pregnant or plan to become pregnant while taking medicine for axSpA.