Rheumatoid arthritis
Chronic autoimmune inflammatory joint disease. Predominantly affects small joints of the hands and feet. Untreated, it leads to joint destruction and disability.
ICD-10 M06.911 drugs
Also known as: RA
Drugs used for this condition
- AAdalimumabSecond line · Biologic – tumor necrosis factor alpha (TNFα) inhibitorBiologic for moderate-to-severe rheumatoid arthritis in patients with inadequate response to synthetic DMARDs (methotrexate, leflunomide, sulfasalazine) per EULAR 2022. Dose 40 mg subcutaneously every 2 weeks. Effective as monotherapy, but combination with methotrexate enhances response and reduces anti-drug antibody formation. Mandatory pre-treatment screening for latent tuberculosis (QuantiFERON or Mantoux, chest X-ray) and hepatitis B/C.
- AEtoricoxibSecond line · Selective COX-2 inhibitor (coxib)Used for symptomatic relief in rheumatoid arthritis as an alternative to non-selective NSAIDs in patients at high gastrointestinal risk (ulcer history, age over 65, combination with anticoagulants or steroids). Does not modify disease course – EULAR 2022 builds treatment around DMARDs (methotrexate, sulfasalazine, leflunomide) plus biologics when needed. RA dose: 60–90 mg once daily.
- ALeflunomideSecond line · Selective immunosuppressantsSecond-line in rheumatoid arthritis after methotrexate intolerance or inefficacy per EULAR 2022 and Spanish SER 2023. Starting loading dose 100 mg once daily for 3 days, then maintenance 10–20 mg once daily. Effect develops over 4–12 weeks. Comparable to methotrexate in efficacy (US301 trial); often used as monotherapy in MTX-intolerant patients or combined. Also suitable for psoriatic arthritis.
- AMethotrexateFirst line · Antimetabolites, folic acid analoguesPer EULAR 2023 and ACR 2021, methotrexate is the first-line anchor drug for rheumatoid arthritis. Start 7.5–15 mg weekly orally; with inadequate response or oral intolerance – subcutaneous 15–25 mg weekly. Concomitant folic acid 5 mg weekly the day after methotrexate is mandatory. Effect develops over 6–12 weeks.
- ASulfasalazineSecond line · Intestinal aminosalicylate and disease-modifying antirheumatic drug (DMARD)Second-line DMARD in rheumatoid arthritis per EULAR 2022 after methotrexate. Dose 2–3 g daily in 2–3 doses after titration from 500 mg. The 2014 Cochrane meta-analysis showed efficacy comparable to methotrexate and leflunomide. Often used in combination (methotrexate + sulfasalazine + hydroxychloroquine – triple therapy) when monotherapy is insufficient. Effect develops over 2–3 months.
- BAceclofenacSecond line · NSAID, acetic acid derivative, COX-1/COX-2 inhibitorUsed for symptomatic relief in rheumatoid arthritis as an NSAID alternative. Dose 100 mg twice daily. Does not modify disease – EULAR 2022 builds treatment on DMARDs (methotrexate, sulfasalazine, leflunomide). Patel 2011 meta-analysis showed efficacy comparable to diclofenac with fewer GI side effects.
- BBetamethasoneAdd-on therapy · Glucocorticoid for systemic useThe AEMPS Celestone Cronodose label allows intra-articular and periarticular injection in rheumatoid arthritis and intramuscular use in rheumatic conditions where a sustained effect is needed. Within the regimen betamethasone covers a flare and buys time until disease-modifying therapy works, while methotrexate and biologics drive the disease itself. The label warns that part of the dose is absorbed systemically after an intra-articular injection, which is counted in for anyone already on oral or parenteral corticosteroids. The same point leads to the central rheumatology interaction: an NSAID next to a systemic corticosteroid raises the risk of gastrointestinal ulcer and bleeding, and gastroprotection is discussed for the period of the combination.
- BHydroxychloroquineSecond line · Antimalarials, aminoquinolinesPer the EULAR 2022 update, hydroxychloroquine is used in mild rheumatoid arthritis or as part of combination therapy. Structural disease-modifying effect is weaker than methotrexate, so it is not first choice in active disease.
- BPrednisoneAdd-on therapy · Short-to-medium acting systemic glucocorticoidGlucocorticoid as bridge therapy at rheumatoid arthritis treatment start, while DMARDs (methotrexate, leflunomide) reach full effect. SER recommends short low-dose courses (prednisone ≤7.5 mg/day) tapered down over 3–6 months because of osteoporosis and metabolic complications.
- COmega-6 polyunsaturated fatty acids (linoleic acid and GLA)Add-on therapy · Essential polyunsaturated fatty acidsGamma-linolenic acid (GLA) from borage or evening primrose oil at 1.4–2.8 g/day delivered modest reductions in pain and morning stiffness in small randomised trials in rheumatoid arthritis. The Cochrane review CD002948 (2011) rated the effect as weak, inconsistent, and insufficient to replace disease-modifying therapy. Current EULAR 2023 and SER 2024 guidelines build treatment on methotrexate, biologics, and targeted JAK inhibitors. GLA can be considered as an adjunct to mainstay therapy after agreement with a rheumatologist, never as a substitute.
Marketing claims without evidence base
The drug is promoted for these uses outside international guidelines. Each entry below is analyzed against AEMPS, FDA, EMA, Cochrane and major RCTs.
How to read tiers A–F
Evidence tiers belong to the drug-indication pair, not to the drug as a whole: the same substance can be A for one condition and F for another.
- AStrong evidence – first or second line in international guidelines
- BRecommended in selected cases
- CStudy data contradict each other
- DBenefit not proven, no documented harm
- FDocumented harm, or risk without benefit