By Mark W. McFarland, DO
As an Orthopaedic Specialist, I regularly treat patients who suffer from Osteo-arthritis, which is an inflammatory condition that often occurs in the joints of people as they progress from middle into old age. This “wear and tear” arthritis does not affect everyone, but many people will have it in some part of their body by the time they become a senior citizen.
Much more rarely seen are the types of arthritis caused by autoimmune disorders, such as rheumatoid and psoriatic arthritis. These forms of arthritis can be painful, destructive and debilitating to the joints of those who suffer from them. Some RA sufferers have become permanently bedridden, or wheelchair bound, unable to work or function in society, due to the deformity caused to their joints by their disease. In the past, a person with a diagnosis of RA could easily envision a lifetime of pain and disability, watching helplessly as their bodies and twisted and deformed due to the onslaught of their disease. Not a pretty picture!
Thankfully, a new form of medication has been developed that is helping to arrest the devastation caused by these and other autoimmune diseases. These medications are called Biologics, and they have revolutionized the treatment of RA and Psoriatic Arthritis. Because of their efficacy, they are in high demand by consumers. However, there are risk factors to be considered. Patients being treated for RA and PA will be prescribed Biologics by their Rheumatologist, not by their Orthopaedist. However, for our purposes here, I will discuss the pros and the cons of using Biologics.
Biologics differ from drugs in that live animal or plant cells are used to manufacture them vs. being synthesized in a lab out of chemical components, as drugs are. Biologics are very complex, large molecules or bundles of molecules, and recombinant DNA technology has been used to create many of them on the market today. The chemical components used to make drugs are well-defined, but all of the components of a manufactured biologic may be unknown. The process used for drug manufacturing can be changed extensively with little to no effect on the final product; however, the manufacturing process for biologics must be strictly controlled. All starting materials must be of the best quality to ensure uniformness of the final product, which contributes to the manufacturing cost of a Biologic drug.
The Biologics are proteins, derived from human genes, which are genetically-engineered to constrain defined parts of the immune system that drive the inflammatory response. Inflammation is the principal culprit in arthritis that causes joint destruction, and pain. Patients can be relieved of much the pain and debilitation caused by their conditions and live more normal lives, by the slowing of this inflammatory response. The ability to suppress a small part of the immune system to relieve inflammation is considered a great advance because the whole immune system does not have to be compromised to see meaningful results.
The specific areas of the immune system that Biologics suppress are varied, but most do one of three things: 1) block a chemical activator of inflammation called TNF (tumor necrosis factor); 2) block chemical signals that activate T cells (a type of white blood cell central to the functioning of the immune system); or 3) block a chemical messenger called interleukin-1. All of these processes trigger inflammation, and the Biologic helps to keep that in check.
Some of the most commonly prescribed Biologics, that you may have heard of or seen advertised in magazines or on TV, are:
These medications are often used to treat other autoimmune diseases, as well as Arthritis, such as; Crohn’s Disease, Lupus, Psoriasis, Ulcerative Colitis, Vasculitis, Systemic Sclerosis, Ankylosing Spondylitis, and Inflammatory Skin Diseases.
Biologics can benefit patients who have not been helped by any other drug or treatment. They and can be given alone or with other anti-inflammatory medications or drugs, such as methotrexate, which is a chemotherapy drug found to help arthritis. Most Biologics are administered by IV or injection, although one is available in pill form. Patients are advised to consider the potential side-effects of Biologics carefully. About 30% of those using Biologics report redness and soreness at their injection site. Other commonly reported side effects include respiratory tract infections, colds, high blood pressure, rash, headaches, nausea, vomiting, diarrhea, and back pain.
Patients, who are considering taking Biologics, must be tested for Tuberculosis, and some physicians recommend testing for Hepatitis before being cleared to get the medication. Patients, who have multiple sclerosis, HIV, congestive heart failure or any other condition in which their immune system is compromised, are not candidates to receive the medication. Patients, who are considering surgery, should wait until after surgery to start the medication due to the increased risk of infection. Taking a Biologic while pregnant is not recommended as the effects on the fetus have not been fully described. Vaccinations with live viruses should be avoided while taking Biologics.
Once you have made the decision to start a Biologic, it is important to note that if you stop taking the medication, your symptoms will return, and your disease will continue to progress. Sometimes, a patient will respond well to a Biologic when they first start taking it and then quit responding to it after taking it for a while. Your Rheumatologist will carefully monitor your progress, or lack thereof while you are on a Biologic and consider changing you to a different one if you do not see the desired results.
If you have RA or PA or have been recently diagnosed, please consider all the facts carefully before you make a decision to take a Biologic. In conjunction with your Rheumatologist and after considering your age, general health, lifestyle and activity level, you can make the most informed decision about your treatment options.
Mark W. Mcfarland, DO, is a Fellowship-trained, Board-Certified Orthopaedic Spine Specialist whose areas of expertise include: Spine and total/partial Joint Replacement of the Knee. Dr. McFarland practices at Orthopaedic & Spine Center in Newport News, VA.