Rheumatoid Arthritis: medications and paying cash

Overview

Rheumatoid arthritis (RA) is a chronic autoimmune disease: the immune system attacks the synovium, the inner lining of the joints, which becomes inflamed and thickened and can destroy cartilage and bone. It often occurs in a symmetrical pattern, most commonly in the wrists, hands and feet, though any joint can be affected, and it can also affect the heart, lungs, eyes, skin, nerves and blood vessels. Symptoms include pain, tenderness, swelling and warmth in more than one joint, stiffness that is worse in the morning or after rest and lasts longer than 30 minutes, fatigue, occasional low-grade fever, loss of appetite and weight loss, and firm lumps under the skin called rheumatoid nodules. Flares are times when symptoms suddenly appear or get worse. Women are two to three times more likely than men to have RA, the risk rises with age, and long-term smoking, family history and certain genes raise the risk. There is no single test: diagnosis combines the history and exam, blood tests such as rheumatoid factor, anti-CCP, ESR and CRP, and imaging, and a rheumatologist usually leads treatment. There is no cure, but early treatment can keep symptoms from getting worse and damaging the joints, with the aim of remission or near remission.

Disease-modifying antirheumatic drugs (DMARDs) are started early, and methotrexate is the most commonly used. For RA, methotrexate tablets are taken once a week, starting at 7.5 mg, and the label warns that taking it every day by mistake has caused deaths. Its boxed warning covers serious toxic reactions, and it must not be taken in pregnancy for arthritis; blood counts, liver tests and kidney function are checked at the start and periodically, heavy alcohol use raises the risk of liver damage, and folic or folinic acid is recommended alongside it. Hydroxychloroquine (Plaquenil) is labeled for acute and chronic RA in adults; it can cause irreversible damage to the retina, so a baseline eye exam is recommended within the first year, and it can also affect the heart rhythm and cause severe low blood sugar. Leflunomide (Arava) is labeled for active RA in adults, starting with 100 mg a day for three days and then 20 mg a day; its boxed warning covers harm to an unborn baby and severe liver injury, and because the drug stays in the body for a long time, the label describes a washout procedure with cholestyramine or activated charcoal. Delayed-release sulfasalazine (Azulfidine EN-tabs) is labeled for RA that has not responded well enough to salicylates or other NSAIDs; it is not taken by people allergic to sulfonamides or salicylates, can turn urine or skin orange-yellow, and needs regular blood count and liver tests. Azathioprine (Imuran) is labeled for active RA, carries a boxed warning about cancer with long-term immune suppression, and is dosed with attention to TPMT and NUDT15 enzyme activity along with blood counts.

When these are not enough, biologic DMARDs are added. Adalimumab (Humira) and etanercept (Enbrel) are TNF blockers labeled for moderately to severely active RA, alone or with methotrexate; they are given by injection under the skin, their boxed warnings cover serious infections, including tuberculosis, and lymphoma and other cancers reported in children and teenagers treated with TNF blockers, and a TB test comes before the first dose. NSAIDs and corticosteroids ease pain and inflammation, but used alone they do not prevent joint damage. Meloxicam, celecoxib (Celebrex), nabumetone and diclofenac tablets are labeled for the signs and symptoms of RA, and each of these labels carries a boxed warning about heart attack and stroke and about stomach bleeding, ulcers and perforation, and says not to use them around heart bypass surgery. Prednisone is labeled for short courses to get through a flare, with low-dose maintenance in selected cases, and after long use it is tapered rather than stopped suddenly. Many RA medicines raise the risk of infection, so vaccines may be recommended, and RA raises the risk of heart disease and osteoporosis, especially with steroids. Staying active, keeping a healthy weight, not smoking, limiting alcohol, physical and occupational therapy, and joint surgery in some cases are part of treatment too.

Choosing between the options when you pay cash

Most of the conventional RA medicines are sold as generics: methotrexate tablets, hydroxychloroquine, leflunomide, azathioprine, meloxicam tablets (the Mobic brand has been discontinued), nabumetone and diclofenac tablets. Form matters in a few cases. Methotrexate also comes as oral solutions: Jylamvo is labeled for adults with RA, while Xatmep is labeled only for children, so the two are not swapped. Plain sulfasalazine tablets are generic but are labeled only for ulcerative colitis; the delayed-release EN-tabs are the form labeled for RA, and whether a generic of that form is in stock varies, so check before you fill. Meloxicam tablets, capsules and orally disintegrating tablets are not interchangeable even at the same strength, and meloxicam capsules are labeled only for osteoarthritis. Among diclofenac products, the delayed-release and potassium tablets list RA, Arthrotec (diclofenac with misoprostol) lists it only for people at high risk of ulcers and must not be taken in pregnancy, and Zipsor capsules are labeled only for acute pain.

Adalimumab and etanercept are biologics given by injection under the skin, so a cash quote depends on which product is written. Several biosimilars of Humira are approved, and some are listed as interchangeable while others are not; etanercept also has approved biosimilars. A quote applies only to the exact product, form, strength and quantity on the prescription, so ask for it that way.

Medicines at a glance

How the medicines in this group are supplied and usually taken. Each guide has the full details.

• Methotrexate
  Tablets (generic and Trexall), Oral solution (Xatmep and Jylamvo), Single-dose autoinjector for use under the skin (Rasuvo)
  Generic: Yes · See the guide
• Hydroxychloroquine
  Tablets (Plaquenil, Sovuna and generic)
  Generic: Yes · Once a week
• Sulfasalazine
  Tablets (Azulfidine and generic), Delayed-release tablets (Azulfidine EN-tabs and generic)
  Generic: Yes · See the guide
• Leflunomide
  Film-coated tablets
  Generic: Yes · Once a day
• Meloxicam
  Tablets (generic), Capsules (generic), Oral suspension (Zybic and unbranded)
  Generic: Yes · Once a day
• Celecoxib
  Capsules (Celebrex and generic), Oral solution (Elyxyb), Oral suspension (Vyscoxa)
  Generic: Yes · Once or twice a day
• Adalimumab
  Single-dose prefilled pen or autoinjector, Single-dose prefilled syringe, Single-dose vial for institutional use only (some biosimilars, such as Hadlima)
  Generic: Yes · See the guide
• Etanercept
  SureClick autoinjector, Prefilled syringe, Enbrel Mini cartridge (AutoTouch reusable autoinjector)
  Generic: No · Once a week
• Diclofenac
  Delayed-release and extended-release tablets, diclofenac sodium (generic), Tablets, diclofenac potassium (generic), Capsules (Zipsor and generic)
  Generic: Yes · Twice a day
• Azathioprine
  Tablets (generic and Imuran), Tablets (Azasan)
  Generic: Yes · Once or twice a day
• Nabumetone
  Coated tablets
  Generic: Yes · Once or twice a day
• Prednisone
  Tablets (generic), Delayed-release tablets (generic), Oral solution (generic)
  Generic: Yes · Four times a day

Medications

Which of these is right for a given person is a decision for the prescriber. The guides explain what each drug is, how it is supplied, and why its cash price varies between pharmacies. No page on this site shows a price; prices come from pharmacies responding to your actual prescription.

Questions worth asking

• Which day of the week do I take my methotrexate, and what should I do if I miss it?
• Which blood tests and eye exams do I need for my RA medicines, and how often?
• Is the sulfasalazine on my prescription the delayed-release form, and can the pharmacy get it?
• Which vaccines should I have before or during treatment, and what signs of infection should I report?
• Can I take an over-the-counter pain reliever, or drink alcohol, with my RA medicines?

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