DMARDs

DMARDs, or disease-modifying antirheumatic drugs, are a class of medicines used to treat inflammatory autoimmune conditions by slowing or altering the underlying immune process. Unlike nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids, which mainly relieve symptoms, DMARDs aim to reduce joint damage and preserve function. They are central to the management of rheumatoid arthritis and are used in psoriatic arthritis, ankylosing spondylitis, juvenile idiopathic arthritis, and related diseases.

DMARDs are divided into conventional synthetic (csDMARDs), biologic (bDMARDs), and targeted synthetic (tsDMARDs) agents. csDMARDs include methotrexate, hydroxychloroquine, sulfasalazine, and leflunomide. bDMARDs are antibodies or fusion proteins that block specific immune targets, such as TNF inhibitors (etanercept, adalimumab, infliximab, certolizumab) and non-TNF agents (abatacept, rituximab, tocilizumab, secukinumab, ustekinumab). tsDMARDs are small molecules that interfere with intracellular signaling, notably JAK inhibitors (tofacitinib, baricitinib, upadacitinib); PDE4 inhibitors like apremilast are included in some classifications.

DMARDs may be used alone or with other therapies such as NSAIDs or low-dose corticosteroids while the DMARDs take effect. Methotrexate is a common anchor drug, often combined with a biologic. Onset of full effect is variable, typically weeks to months, and treatment is adjusted based on disease activity and tolerability.

Safety and monitoring are important. Baseline and periodic labs assess liver and kidney function and blood counts; infection risk is monitored throughout therapy. Screening for latent tuberculosis before TNF inhibitors, vaccination considerations, and guidance on pregnancy and lactation are routinely addressed. Some agents can cause hepatotoxicity, cytopenias, lipid changes, or increased infection risk.

In practice, DMARDs aim to suppress disease activity, slow radiographic progression, and improve function. Choice of agent depends on disease type, comorbidities, patient preferences, and prior response, with many patients receiving combination regimens and ongoing monitoring to optimize outcomes.