Vivian Bykerk, MD, associate attending rheumatologist at the Hospital for Special Surgery, associate professor of medicine at Weill Cornell Medical College, provides an overview of what patients should know about biologic therapies versus conventional disease-modifying anti-rheumatic drugs.
What should patients understand about biologic therapies versus conventional disease-modifying anti-rheumatic drugs?
All of them are intended to reduce this sequence of immune infiltrates and proliferation inside of joints that causes destruction. All of them have a role in doing that. The conventional [disease modifying anti-rheumatic drugs] DMARDs are the older therapies that we used to use. Some of them are excellent. Our baseline, or our base case of therapy, is methotrexate, and when used properly, it can get lots of people into remission. Methotrexate, when used sometimes with another conventional DMARD—or even 2–can get people under good control, so nobody should ever diss those, and in a way, they’re safer.
And so, we like the conventional DMARDs, but the problem with them is some people have side effects, as they could have side effects to anything. It’s hard to remember always to take the medication. There are some conventional DMARDs you have to take 4, 6 times a day, which is not so easy. Some people have trouble with weekly, and some people don’t take all [of it], they vary it, and so it doesn’t have a chance to be as effective as it could be. Usually in situations where people tend to vary it, they have some fear about it, or they may be having side effects, and it would be much better if they would speak to us, so we can work around them rather than just reducing doses.
The methotrexate is also very good at reducing the body’s rejection of biologics. So, on occasion, biologics—they’re still foreign proteins–and the body can reject them. Methotrexate limits that rejection, and we see in study after study after study, that when you combine methotrexate and a biologic, even if the methotrexate is at a lower dose, those people do better over time. Biologics are proteins. These are the ones that have to either be injected or infused, but basically, they’re proteins, and they’ve been made to reflect something in the body.
There are some that have been made to be like receptors we normally make, and some of them have been made to be other antibodies targeting a receptor or targeting something in that immune process that is going on. And now, we have targeted synthetic DMARDs, and those basically have the power of a biologic, but they’re a pill. They now target specific pathways inside cells to treat the disease.