Whether you’re taking steroids or nonsteroidal anti-inflammatory drugs (NSAIDs) to control your symptoms or using disease-modifying anti-rheumatic drugs (DMARDs) to manage your RA condition, you and your doctor should discuss any potential side effects that can occur during your treatment. Here are eight RA medication side effects to be aware of.
NSAIDs and Stomach Problems
NSAIDs, which block the inflammation of RA, can be present in both prescription drugs and over-the-counter drugs like ibuprofen. The most common side effects are stomach problems like heartburn and belching, but you can minimize these risks by taking the medication with food. “NSAIDs can cause cardiac, renal, and gastrointestinal issues, so patients should be mindful of this prior to starting them,” says Ryan Matthew, MD, a rheumatologist at Ohio State University Wexner Medical Center in Westerville, Ohio. There is also increased toxicity risk, he adds, so it is important to have a conversation with your doctor about the safest use and dosage.
NSAIDs and Bleeding
Using NSAIDs can irritate the lining of your stomach, which can then lead to bleeding. (And unfortunately, taking the medication with food might not help.) “If you are frequently taking over-the-counter NSAIDs, you need to let your doctor know,” says Dr. Horowitz. Your provider might be able to give you a medication that will reduce your risk of bleeding while taking NSAIDs. And in the meantime, you can further cut your risk by avoiding alcohol.
Steroids and Toxicity
Steroids in RA management get symptoms under control quickly. But they may also cause high blood pressure, weight gain, high blood sugar, and decreased bone health. “Guidelines are shifting away from frequent steroid use given the long-term toxicity and increased infection risk associated with steroids,” says Dr. Matthew. They are useful for controlling an acute flare, but should overall be used sparingly, if possible. By limiting your exposure, your doctor can help protect you from steroid side effects.
Methotrexate Fatigue
Trexall (methotrexate) is usually the first DMARD used for RA management. Methotrexate does more than relieve symptoms — it also slows down the disease, states the Johns Hopkins Arthritis Center. Trexall is given once a week as an injection or can be taken in pill form. Common side effects include nausea, headaches, and fatigue. But by taking methotrexate at night, you may be able to minimize these problems. Likewise, you can avoid feeling nauseous if you opt for an injection under the skin. Taking folic acid, a B vitamin, along with methotrexate, may also help limit side effects, Horowitz says.
Methotrexate Liver Damage
The most serious side effect of methotrexate is liver damage. (That’s why people with existing liver disease aren’t good candidates for this medication, according to the Johns Hopkins Arthritis Center.) “Liver function should be checked prior to initiation of methotrexate and then again two to three weeks after starting the medication,” says Matthew. After that, the rheumatologist will recheck lab work every three months if patients are on a stable dose. The risks and benefits should be discussed thoroughly with your doctor beforehand. To avoid liver damage while taking the medication, limit alcoholic drinks to a maximum of one or two per week.
Triple Therapy and Eye Damage
Combining methotrexate with two other DMARDs may be an option if methotrexate alone isn’t enough to achieve good RA management, according to Johns Hopkins. One of the drugs used in this triple therapy is hydroxychloroquine, a malaria drug that’s effective for some cases of RA. For this particular DMARD, the most serious possible side effect is eye damage, according to the American Academy of Ophthalmology. Although you should have an eye exam by an eye specialist within six months of starting this drug (and be rechecked at regular intervals recommended by your rheumatologist), you should tell your doctor immediately if you start having eye pain, sensitivity to light, or vision changes, says Horowitz.
Biologic Drugs and Infection
Your doctor may recommend biologic drugs if older DMARDs are not helping manage the symptoms of RA. “The biggest worry with biologics is an increased risk of infection,” Horowitz says. Before you begin treatment with biologic drugs, your doctor is likely to test you for tuberculosis and hepatitis because biologics weaken your immune system and could reactivate those infections. And if you have another active infection, your doctor may want to wait until you recover. Once you begin using biologics, wash your hands frequently, avoid people who are sick, and tell your doctor if you develop a cough, fever, or symptoms of a cold.
Biologic Drugs and Other Issues
“There is a small theoretical risk for cancer, psoriasis, and heart failure with certain biologic treatments, but for most patients this small risk is outweighed by the potential benefits of biologic treatment,” says Matthew. Your best defense against all RA medication side effects is to be informed and follow all your doctor’s instructions carefully. You should call your rheumatologist for instructions on adjusting your medications in the event you have COVID-19, Horowitz adds.
