Arthritis Medications Guide

ARTHRITIS
MEDICATIONS
A CONSUMER S GUIDE
Endorsed by the Canadian Rheumatology Association
www.arthritis.ca
1.800.321.1433
WELCOME
CONTENTS
This is a very exciting time in the treatment of arthritis. Several new medications
have recently been developed to combat joint pain and inflammation, and more
are on the way! Many of these medications are safer and more effective than ever
before, expanding the treatment options for people with arthritis.
Welcome
A word about medication safety
The way in which doctors treat arthritis has changed. We now know that, for the
best long-term health, as well as prevention of bone and joint damage, inflammatory
arthritis (such as rheumatoid arthritis) needs to be treated early and aggressively.
Think of arthritis like a fire in the joints. Imagine there was a fire in your kitchen.
If you left it burning, it would eventually destroy the kitchen and likely spread to
other rooms in the house. The same is true for rheumatoid arthritis. If you leave
the fire of arthritis burning, it will eventually damage the bones and cartilage.
The idea is to get the fire put out as quickly as possible to prevent the joints from
becoming damaged. Again, if your kitchen was on fire, it might take two or three
fire trucks with their hoses to put the fire out. The same is true for arthritis. It
might take two or three different medications to put the fire out. With this new
approach to arthritis, we are helping more and more people lead normal, active
lives for years to come.
An Introduction to Arthritis
6-8
What is arthritis?
Osteoarthritis and inflammatory arthritis
Living with Arthritis
I have been diagnosed with arthritis

Treating your arthritis
Symptom Control
Pain management
10
Non-medical techniques for pain control
11
Non-prescription medications for pain

Acetaminophen
Ibuprofen and Acetylsalicylic acid (ASA)
Topical medications
12-13
Prescription medications for pain

Commonly prescribed narcotics
14-18
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs and COXIBs)

Although medications are only part of arthritis treatment, they are a very important
part. Arthritis Medications: A Consumers Guide is designed to help answer some of
your questions about these medications. You should also discuss any questions
you have with your doctor or your pharmacist. The more you know about your
disease and your medications, the better off you will be.
Andy Thompson, MD FRCPC
We now know that, for the best longterm health, as well as prevention of
bone and joint damage, inflammatory
arthritis needs to be treated early and
aggressively.
What are NSAIDs?

What types of arthritis are NSAIDs used for?
How long do NSAIDs take to work?
What is the typical dose of NSAIDs?
Which NSAID is right for you?
What are COXIBs?
Commonly prescribed NSAIDs
Is there anybody who should avoid or be careful taking NSAIDs and COXIBs?
What are the side effects of NSAIDs and COXIBs?
Do I need any monitoring while I am taking NSAIDs?
How can I help to minimize the side effects of NSAIDs?
What are the risks of heart attack and stroke with NSAIDs and COXIBs?
What topical NSAIDs are available?
Protecting Your Stomach
19-20
Why is protecting the stomach important?

Who should receive medication to protect the stomach?
What medications are used to protect the stomach?
Misoprostol
Proton Pump Inhibitors
www.arthritis.ca
Joint Injections
20
Hyaluronan injections (viscosupplementation)

Corticosteroids
Medications for Symptoms and Disease Control

Disease-Modifying Anti-Rheumatic Drugs (DMARDs)
21
22-35
What are DMARDs?

How long do DMARDs take to work?
Commonly prescribed DMARDs
Which DMARD is right for me?
How long will I have to take my DMARD?
What about side effects?
Azathioprine (AZA)
Gold
Hydroxychloroquine (HCQ)
Leflunomide (LEF)
Methotrexate (MTX)
Sulfasalazine (SSZ)
Corticosteroids
35-40
What are corticosteroids?

Commonly used steroids
How long do corticosteroids take to work?
Which steroid is right for me?
How long will I have to take corticosteroids?
Steroid injections
Prednisone
Biologics
The need to effectively monitor new drugs once they have been approved and
introduced into the market has been a key issue for The Arthritis Society for several
years. This helps to ensure that unfavourable side effects are reported, documented
and addressed. All medications have potential side effects, whether they are
taken by themselves or in combination with other herbal, over-the-counter and
prescription medications. It is therefore important for patients to discuss the
benefits and potential side effects of all their medications with their doctor.
In an effort to make it easier for consumers to report side effects from health
products, Health Canada has released a new online form. The form can be found
at www.hc-sc.gc.ca/dhp-mps/medeff/report-declaration/index-eng.php#a1
or www.hc-sc.gc.ca/dhp-mps/medeff/report-declaration/index-fra.php or
via Health Canadas MedEffect website www.healthcanada.gc.ca/medeffect or
www.santecanada.gc.ca/medeffet. A PDF version of the form can be downloaded and mailed to Health Canada using a downloadable postage paid label
(www.hc-sc.gc.ca/dhp-mps/medeff/report-declaration/index-eng.php#a1
or www.hc-sc.gc.ca/dhp-mps/medeff/report-declaration/index-fra.php).
Consumers can still report side effects by calling toll-free at 1-866-234-2345.
?
40-60
What are biologics?

Commonly prescribed biologics
How long do biologics take to work?
Which biologic is right for me?
How are biologics administered?
How long will I have to take my biologic?
What about side effects?
Abatacept
Adalimumab
Anakinra
Certolizumab Pegol
Etanercept
Golimumab
Infliximab
Rituximab
Tocilizumab
Index
A WORD ABOUT MEDICATION SAFETY
FOR THE MOST CURRENT INFORMATION ON ARTHRITIS MEDICATIONS,

VISIT WWW.ARTHRITIS.CA.
Limitations of the Guide

guide does not replace your doctors advice it is essential that you see your
This
doctor for proper diagnosis and treatment if you have joint pain and swelling for
longer than six weeks.
guide focuses on the treatment of osteoarthritis and rheumatoid arthritis in
This
adults only. Treatment of other types of arthritis (including juvenile arthritis) is
not included.
taking medication for another long-term health problem (such as heart,
Ifliveryouandarekidney
conditions, high blood pressure, ulcers or asthma), you should
discuss possible drug interactions with your doctor or your pharmacist. Also, if
you are allergic to a specific medication, inform your doctor and your pharmacist.
are pregnant, trying to become pregnant or breastfeeding, you must inform
Ifyouryoudoctor,
since certain medications can be passed on through the placenta or
into a mothers milk. Speak to your doctor about your individual circumstances.
61-63
www.arthritis.ca
AN INTRODUCTION
TO ARTHRITIS
WHAT IS ARTHRITIS?
The word arthritis literally means inflammation of the
joint (arth meaning joint and itis meaning inflammation).
Inflammation is a medical term meaning pain, stiffness,
redness and swelling.
WHAT IS INFLAMMATORY ARTHRITIS?

Each joint in the body is lined by a thin layer of tissue called
synovium. The synovium is responsible for making small
amounts of fluid to keep the normal joint lubricated. In cases
of inflammatory arthritis, for some reason, the bodys immune
system becomes confused and begins to attack the synovium.
Chemicals released by the bodys immune system
cause swelling, pain and stiffness of the joints and
can eventually damage or destroy the cartilage
and bone.
WHAT IS OSTEOARTHRITIS?
Inflammatory arthritis can affect any joint in the body.

The more common joints involved tend to be the small joints
of the hands and feet. Inflammatory arthritis can begin in a
number of different ways. The most common way is a slow
onset of joint pain and stiffness, starting in one joint and
spreading to more joints over a period of weeks to months.
Inflammatory arthritis can also start very dramatically (almost overnight) or
can start slowly with pain that seems to jump around from joint to joint.
Osteoarthritis (OA) occurs when cartilage (the tough elastic material that covers
and protects the ends of bones) begins to wear away. Cartilage is an essential
part of the joint; not only does it act as a shock absorber, it also enables the joint
to move smoothly. With osteoarthritis, the cartilage erodes, eventually
resulting in pain, stiffness, swelling and bone-on-bone movement in the
affected joint.
Inflammatory arthritis causes aching, pain, stiffness, warmth and swelling in the
joints that are affected. The most striking characteristic is feeling stiff in the joints
after rest. This is particularly apparent in the morning when the stiffness may take
hours before disappearing. In some people, the inflammation in the joints may
be accompanied by a loss of energy (fatigue). Other symptoms might include low
grade fevers, weight loss, muscle pain or numbness and tingling in the fingers.
This type of arthritis tends to affect the joint at the base of the
thumb, the end and/or middle joints of the fingers, the hips,
the knees and the joints at the base of the big toe. While
not a disease of the elderly, OA is more common as we age.
Most people have symptoms that continue steadily. Others have symptoms
that seem to wax and wane, with times of more severe joint pain and stiffness
alternating with better times. The severity of symptoms varies greatly from
person to person.
WHAT ARE THE TYPES OF ARTHRITIS?

There are over 100 different types of arthritis. To keep things simple, we will divide
arthritis into two categories osteoarthritis and inflammatory.
A person with OA may notice some stiffness of the affected

joint in the morning, lasting about 15-30 minutes. As the
day progresses and the joints are used, the pain and
discomfort usually gets worse. Resting the joints
tends to provide relief.
Once it is established, inflammatory arthritis

is a chronic condition that likely affects people
for the rest of their lives. As such, they will also
need some type of medication to control their
disease. It is usually a balancing act between
taking as much medication as needed to control
the arthritis and as little medication as necessary
to prevent side effects. Doctors will adjust doses
or change medications based on the latest
symptoms, findings on physical examinations
and laboratory tests.
www.arthritis.ca
A COMPARISION OF INFLAMMATORY ARTHRITIS

AND OSTEOARTHRITIS
Features
Inflammatory Arthritis
Osteoarthritis
What are
examples of
diseases?
Rheumatoid arthritis
Psoriatic arthritis
Ankylosing spondylitis
Systemic lupus erythematosus
Osteoarthritis
Usually starts in middle age

(30-60) and tends to get worse
over time. However, it can start
at any age
More common as we age,

tending to occur in joints that
have been subject to wear
and tear by excessive use
What is the
cause?
The bodys immune system

attacking the joints
Deterioration of cartilage
How quickly
does it start?
Fairly quickly, affecting joints over

a period of weeks to months
Usually slowly, with joints

getting worse over a period
of months to years
How many joints

does it affect?
Usually lots of joints and tends

to be symmetrical, involving joints
on both sides of the body
(i.e. both hands, both elbows, etc.)
Usually a few joints and

tends to be asymmetrical
(not matching), swelling
and pain in single joints
(i.e. one knee, one finger, etc.)
What joints can

be affected?
Small joints of the hands and feet

Wrists, elbows, shoulders, knees,
hips
Any joint
End joints of the fingers, neck,

lower back, knees and hips
What are
the usual
symptoms?
Joint pain, swelling, tenderness,

and redness of the joints
Prolonged morning stiffness and
less range of movement
Sometimes fever, weight loss,
fatigue and/or anemia
Stiff, painful and enlarged

joints
What amount of
morning stiffness
is experienced?
Morning stiffness lasting more

than 60 minutes
Morning stiffness lasting

about 15-30 minutes
What
medications
are available
Non-Steroidal Anti-Inflammatory Analgesics

NSAIDs
Drugs (NSAIDs)
Disease-Modifying Anti-Rheumatic Injections: steroids and
viscosupplementation
Drugs (DMARDs)
(hyaluronic acid)
Steroids
Biologics
Steroid injections
Who gets it?
LIVING WITH
ARTHRITIS
I HAVE BEEN DIAGNOSED
WITH ARTHRITIS
If you have been diagnosed with arthritis, youre
certainly not alone; there is hope. A famous
Canadian rheumatologist, Dr. Duncan Gordon,
is noted for saying, Everyone with arthritis can
be helped. The management of arthritis involves
a team, including doctors, surgeons, nurses,
physiotherapists, occupational therapists, social
workers, pharmacists, dietitians and YOU! Yes, you
are an active member of your health-care team.
TREATING YOUR ARTHRITIS

The treatment options for your arthritis will likely include non-medication
therapies, such as physiotherapy, occupational therapy, education, exercise and
relaxation techniques, as well as medications. Medications to treat arthritis can be
divided into two general categories those that only control symptoms and
those that control the symptoms and the disease.
Five Tips for Living with Arthritis
1 Get Educated: know the type of arthritis you have and the
treatments available.
2 Stay Involved: be an active participant in decisions
about your care.
3 Know Your Resources: know where to get the support and
resources you need.
4 Stay Healthy: exercise regularly, eat a balanced healthy diet and
maintain a healthy weight.
5 Know Your Medications: tell your health-care provider about all of the
prescription and non-prescription medications you are taking.
www.arthritis.ca
SYMPTOM CONTROL
MEDICATIONS FOR SYMPTOM CONTROL ONLY
PAIN MANAGEMENT
(analgesics) and anti-inflammatory medications (NSAIDs) fall into

Painkillers
this category.
usually take days to weeks to work.
They
they may make your feel better, they do not affect the course of the
Although
arthritis nor will they prevent the damage to bones and joints that can occur
Pain from arthritis can be so intense and constant that it dominates your every
waking moment (and can cause many sleepless nights). Due to the pain, you may
be unable to continue with your routine daily activities and you may become less
active in an attempt to keep your joints as comfortable as possible. Unfortunately,
this inactivity can then have negative effects on your muscles and joints. This can
then lead to a loss of strength, reduced flexibility and more pain. Therefore, good
pain control is essential in the treatment of arthritis.
Persistent, severe pain from arthritis requires a combination of therapies, as no
single pain management technique is powerful enough to provide non-stop
pain relief. You need to discover what works for you. This often means trying
many different therapies or combinations of therapies for prolonged pain relief.
These are medications used to control the pain, stiffness and swelling of your joints,
with the goal of improving your function. They are used for both inflammatory
arthritis and osteoarthritis.
with the disease.
NON-PRESCRIPTION MEDICATIONS FOR PAIN

Some pain-controlling medications can be bought over the counter without
a doctors prescription. You are probably familiar with many of these, such as
acetaminophen (e.g. Tylenol), ASA (e.g. Aspirin, Entrophen, Anacin, Novasen, etc),
and ibuprofen (e.g. Motrin or Advil ). There are also a number of topical nonprescription creams and rubs to help lessen the pain of arthritis.
NON-MEDICAL TECHNIQUES FOR PAIN CONTROL

Techniques
10
Physiotherapy
Ice/heat application to joints

Muscle strengthening
General conditioning programs and aqua therapy
Transcutaneous Electronic Nerve Stimulation (TENS)
Occupational
Therapy
Joint protection measures

Energy conservation techniques
Braces and splints to support painful joints
Adapting your home, vehicle or workplace for your arthritis
Special equipment (raised toilet seats, jar openers, reachers, etc)
Social Work
Support
Personal and family support

Anger control techniques
Community resources for financial management
Psychology
Relaxation techniques
Massage Therapy
Therapeutic massage
Dietitian Advice
Diet advice for weight loss
Self Management
The Arthritis Societys Arthritis Self-Management Program,

Toll-Free Arthritis Information Line (1.800.321.1433) and
website (www.arthritis.ca)
ACETAMINOPHEN
Acetaminophen is a very safe and effective medication for pain relief that can
be used for both short- and long-term pain control. If you have pain from
osteoarthritis that is present most of the time, your doctor may
recommend that you take acetaminophen regularly every 4-6 hours. When the
pain is there all of the time, there is no point in waiting for it to become unbearable
before taking your medication. Then, you have to wait for the effects of the
acetaminophen to catch up to the pain.
Although acetaminophen is safe, it does have its limits: you can take 2 regular
strength tablets (325 mg each) to a maximum of 12 tablets in a 24-hour
period, or 2 extra-strength tablets (500 mg each) every 6 hours to a maximum of
8 tablets in a 24-hour period, or 2 extended-release tablets (e.g. Tylenol-Arthritis,
650 mg each) every 8 hours to a maximum of 6 tablets in a 24-hour period.
Acetaminophen is found in other over-the-counter preparations, such as cough
and cold formulations. You must be careful to look at the ingredients of all of the
over-the-counter medications you are taking to ensure you are not taking too
much acetaminophen. The maximum daily recommended dose is 4 grams
(4000 mg). The suggested doses of acetaminophen are guidelines only and
should be discussed with your doctor or pharmacist.
www.arthritis.ca
11
IBUPROFEN AND ASA

Ibuprofen (e.g. Advil & Motrin) and acetylsalicylic acid (ASA) are non-steroidal
anti-inflammatory drugs that can be purchased over the counter. You can learn
more about NSAIDs in the chart on page 15. You must be careful to avoid taking
ibuprofen with other NSAIDs, as it increases your risk of developing a stomach
ulcer.
TOPICAL MEDICATIONS
There are a number of over-the-counter creams and rubs available to help with
the symptoms of arthritis. Some of these products contain salicylate as the active
ingredient, whereas others contain capsaicin or menthol. Salicylate is available,
for example, in Antiphlogistine Rub A535, Aspercreme, BenGay, Flexall and
Myoflex. Salicylates work by decreasing pain and inflammation. Capsaicin is
found naturally in hot peppers and sold under the brand names of Zostrix and
other drugs. Capsaicin works by blocking the transmission of a pain-relaying
substance called Substance P to the brain. Camphor, eucalyptus oil and menthol
are found in a variety of agents, such as ArthriCare, Deep Cold, Eucalyptamint
and Icy Hot, among others. These substances are able to relieve pain by tricking
the body to feel the coolness or heat of these agents.
PRESCRIPTION MEDICATIONS
FOR PAIN
Sometimes over-the-counter painkillers are not
strong enough for your pain. Your doctor can help
by prescribing stronger pain medications, such as
NSAIDs (more detailed information is available in the
table on page 15) or narcotics. Narcotics are a class
of pain medication that includes codeine and
morphine (see table on page 13). These medications
should be taken under the direct supervision of
your physician to monitor side effects. Common
side effects of narcotics include nausea, constipation,
drowsiness and dry mouth. Because these
medications slow down digestion and can cause
constipation, be sure to drink 6-8 tall glasses of
water throughout the day.
12
SOME COMMONLY PRESCRIBED NARCOTICS

Brand Names
Product
Tylenol #1, #2, #3, Codeine Contin
Codeine
Morphine, M-Eslon, MS-Contin
Morphine
Dilaudid, Hydromorph-Contin
Hydromorphone
Percocet, Percodan, Oxycontin
Oxycodone
Demerol
Meperidine
Duragesic Patches
Fentanyl
TRAMADOL
Tramadol is a unique type of opioid pain-relieving medication indicated for the
treatment of moderate pain. It is available in both long- and short-acting forms,
as outlined in the table below. Common side effects of tramadol may include
nausea, vomiting, constipation, headache, dizziness and sleepiness.
Brand Names
Product
Common Dose
Tramacet
Combination tablet of tramadol 37.5 mg

and acetaminophen 325 mg
1-2 tablets
every 4-6 hours
Tridural
Ralivia
Tramadol 100, 200 and 300 mg

tablets
100-300 mg once daily
Will I become addicted?

Clinical research shows that people who take a narcotic at an appropriate
dose for their level of pain are at low risk of becoming addicted. Why?
Drug dependency is fuelled by psychological cravings for the euphoric
effects of certain narcotics. When its used for pain relief, narcotics usually
dont produce the high that drug users seek. Still need convincing? Then
ask yourself these questions: If youre not in pain and you dont take the
narcotic, do you still feel a need for it? Do you require rapidly increasing
doses to control the same level of pain? Finally, do you get high when you
take the narcotic? Chances are you answered no to all these questions.
If so, relax. Youre not addicted.
www.arthritis.ca
13
NON-STEROIDAL ANTI-INFLAMMATORY
DRUGS (NSAIDs & COXIBs)

WHAT ARE NSAIDs?

Non-steroidal anti-inflammatory drugs (NSAIDs) are a class of medications used
to treat the pain and inflammation of arthritis. They do not contain steroids,
hence the name non-steroidal. NSAIDs are a very large category of medications,
some of which you can obtain without a prescription, such as ASA (Aspirin,
Entrophen, Novasen) and ibuprofen (Advil or Motrin). The list of NSAIDs is
long, with over 20 currently available today. COXIBs are NSAIDs that have been
custom-designed to minimize the risk of stomach problems.
WHAT TYPES OF ARTHRITIS ARE NSAIDs USED FOR?

NSAIDs are used for both inflammatory arthritis and osteoarthritis. It is important
to remember that these medications work to improve symptoms and have no
proven long-term benefits. As such, these medications can be taken on an
as-needed basis and do not need to be taken regularly. That being said, some patients
may find it helpful to take their NSAID on a regular basis to control their symptoms.
HOW LONG DO NSAIDs TAKE TO WORK?

Some patients will notice the effects of an NSAID within the first few hours of
taking a dose. In other patients, the effects may not be evident for a few days and
even up to a week or two after the medicine has been started. If it hasnt helped
within 2-3 weeks, it is unlikely to be of much benefit.
WHAT IS THE TYPICAL DOSE OF NSAIDs?

Every NSAID is different. Some are taken only once a day, while others are taken
up to 4 times a day. Your doctor will advise you of the correct dose to take.
WHICH NSAID IS RIGHT FOR YOU?

Your doctor might ask you to try a few different NSAIDs, as some may work better
for you than others; what works varies from person to person.
WHAT ARE COXIBs?

COXIBs are a new class of NSAIDs that have been developed to reduce the
risk of gastrointestinal ulcers and bleeding. Although COXIBs are safer on the
stomach, they have all of the other side effects of NSAIDs and may still cause
indigestion, nausea, stomach cramps and heartburn.
14
SOME COMMONLY PRESCRIBED NSAIDs

Brand Names
Product
Class
Common Dose
Voltaren,
Voltaren-SR
Diclofenac
Acetic Acid
50-75 mg, 2-3 times daily
Arthrotec-50,
Arthrotec-75
Diclofenac with
Misoprostol
50-75, 2-3 times daily
Ultradol
Etodolac
Toradol
Ketorolac
10 mg, 4-6 times daily
Celebrex
Celecoxib
COXIBs
100-200 mg, twice daily
Indocid
Indomethacin
Indoles
Clinoril
Sulindac
Relafen
Nabumetone
Naphthylalkanones 1000 mg, twice daily
Mobicox
Meloxicam
Oxicams
Mobiflex
Tenoxicam
10-20 mg, once a day
Feldene
Piroxicam
20 mg, once a day
Ansaid,Froben, Flurbiprofen
Froben-SR
Motrin, Advil
Propionic Acids
Ibuprofen
7.5-15 mg, once a day
100 mg, twice daily

Orudis, Oruvail, Ketoprofen

Rhodis
50 mg, 3-4 times daily
Naprosyn,
Naprosyn-SR
Naproxen
Daypro
Oxaprozin
1200 mg, once a day
Surgam,
Surgam-SR
Tiaprofenic Acid
200 mg, 3 times daily
Aspirin
Acetylsalicylic
Acid (ASA)
Dolobid
Diflunisal
Salicylates

www.arthritis.ca
15
IS THERE ANYBODY WHO SHOULD AVOID OR BE

CAREFUL TAKING NSAIDs AND COXIBs?
DO I NEED ANY MONITORING WHILE I AM

TAKING NSAIDs?
Even though you can purchase NSAIDs like Aspirin, Motrin and Advil without
a prescription, some people should avoid taking them. More detailed information
is available on pages 1718.
You dont normally need bloodwork while taking NSAIDs. However, if you take
NSAIDs regularly, your doctor will likely monitor your blood pressure and order
periodic blood tests to ensure the NSAIDs are causing no problems with stomach
bleeding or with your liver or kidneys.
WHAT ARE THE SIDE EFFECTS OF NSAIDs

AND COXIBs?
Indigestion, heartburn, stomach cramps and nausea are the most common side
effects of NSAIDs. NSAIDs can affect the protective lining of the stomach, making
you more susceptible to ulcers and bleeding. Ulcers usually cause stomach pain,
nausea and sometimes vomiting, but in some people ulcers produce no symptoms
whatsoever. Signs of stomach bleeding may include vomit that looks like it has
coffee grounds in it, vomiting blood or black, tarry bowel movements. See a
doctor immediately if you develop any of these symptoms.
NSAIDs can rarely irritate the liver or affect the kidneys. These problems usually
dont cause any symptoms. Fortunately, they are rare and will be monitored by
periodic blood tests if you are taking NSAIDs on a regular basis.
COMMON SIDE EFFECTS
16
Symptom
Frequency Call Doctor
Nausea / heartburn / stomach pain / cramps
Common
If severe or persistent
Constipation
Common
Vomiting or diarrhea
Rare
Skin rash
Rare
Yes
Ringing in the ears
Rare
Yes
Dizziness or lightheadedness
Rare
Yes
Increase in
blood pressure
Rare
Monitored periodically
by your doctor
Black or bloody stool
Rare
Yes
Wheezing or shortness of breath
Rare
Yes
Fluid retention
Rare
Yes
Chest pain or pressure
Rare
Yes
Kidney problems
Rare
Monitored by your
doctor through blood
and urine tests
HOW CAN I HELP TO MINIMIZE THE SIDE EFFECTS

OF NSAIDs?
Taking your NSAIDs with food may help to reduce stomach upset. Taking a
medication to protect the stomach or using a COXIB may be helpful in reducing
the risk of serious gastrointestinal side effects.
WHAT ARE THE RISKS OF HEART ATTACK AND

STROKE WITH NSAIDs AND COXIBs?
Health Canada and the U.S. Food and Drug Administration (FDA) have reviewed
all of the available studies on NSAIDs and COXIBs. Both groups have found that
NSAIDs and COXIBs are associated with an increased risk of cardiovascular events
(angina, heart attacks and strokes). The risk is greatest in those patients who use
these medications for long periods of time and have risk factors for, or a history of,
cardiovascular disease. Health Canadas recommendations are as follows:
not use NSAIDs or COXIBs directly before, during or after heart surgery
Do(bypass
surgery).
with a history of cardiovascular disease (angina, heart attack, TIA, stroke
Patients
or congestive heart failure) should be careful using NSAIDs or COXIBs.
with risk factors for cardiovascular disease (diabetes, smoking, elevated
Patients
cholesterol, obesity and family history) should also be careful using NSAIDs
and COXIBs. Safer alternative treatments should be used if available.
and COXIBs should be used in the lowest effective dose for the shortest
NSAIDs
possible duration of time.
PLEASE DISCUSS THIS ISSUE WITH YOUR DOCTOR.
WHAT TOPICAL NSAIDs ARE AVAILABLE?

In Canada, diclofenac (1.5 per cent) is available in a topical preparation sold
under the brand name of Pennsaid. When applied as directed to the skin over a
joint, very little of this medication is absorbed into the body, which significantly
reduces the usual side effects associated with NSAIDs. The common side effects
of Pennsaid include dry skin and rash at the site of application.
www.arthritis.ca
17
People who should probably avoid NSAIDs and COXIBs:

who is allergic to NSAIDs or is allergic to Aspirin.
Anyone
who has asthma, which is made worse while taking Aspirin.
Anyone
who has had a recent ulcer in the stomach or small intestine.
Anyone
with liver or kidney disease should discuss this with their doctor.
Anyone
with congestive heart failure.
Anyone
who has had a recent heart attack, stroke or experienced
Anyone
serious chest pain related to heart disease.
People who should be very careful taking NSAIDs and COXIBs:

over the age of 65.
Patients
who has had a previous stomach ulcer.
Anyone
taking blood thinners, such as warfarin (Coumadin) or Heparin.
Anyone
Anyone who has significant risk factors for heart attack or stroke.
PROTECTING YOUR STOMACH

WHY IS PROTECTING THE STOMACH IMPORTANT?

Some of the medications used to treat arthritis (NSAIDs, prednisone) can irritate
the lining of the stomach. If this irritation persists or is particularly aggressive, it may
result in the formation of ulcers in the stomach or the first part of the small intestine
(duodenum). Ulcers commonly cause pain, although sometimes they can be painless.
WHO SHOULD RECEIVE MEDICATION TO PROTECT

THE STOMACH?
Patients who experience stomach upset with NSAIDs or have risk factors for
stomach ulcers should discuss stomach protection with their doctor. Risk factors
include: ages 65+; a previous stomach ulcer or bleeding from the bowels; using
multiple NSAIDs, including ASA; taking anticoagulants, such as warfarin (Coumadin);
or taking corticosteroids.
WHAT MEDICATIONS ARE USED TO PROTECT

THE STOMACH?
There are currently two available types of stomach protection medications
Misoprostol and Proton Pump Inhibitors.
MISOPROSTOL
Brand Name: Cytotec
Supplied: 100 and 200 mcg tablets
What is misoprostol?
Misoprostol replaces a naturally occurring substance that helps maintain the
stomachs protective mucous lining.
What is the typical dose and when do I take it?
The usual dose of misoprostol is 200 mcg taken 2-3 times per day. The medication,
called Arthrotec, is actually a combination of an anti-inflammatory (diclofenac)
and misoprostol.
Is there anybody who should not take misoprostol?
Any woman who is pregnant or may become pregnant should not take misoprostol
since it can cause emergency complications, such as an incomplete miscarriage.
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What are the side effects of misoprostol?

Your body may take 2-3 days to adjust to misoprostol, during which time you
may experience nausea, cramps and diarrhea. These common side effects often
disappear completely, but if they persist, contact your doctor.
PROTON PUMP INHIBITORS
Brand Names: Esomeprazole (Nexium), Lansoprazole (Prevacid), Omeprazole
(Losec), Pantoprazole (Pantoloc), Rabeprazole (Pariet)
Supplied: Esomeprazole 20 and 40 mg tablets, Lansoprazole 15 and 30 mg
capsules, Omeprazole 20 mg tablets or capsules, Pantoprazole 40 mg tablets,
Rabeprazole 10 and 20 mg tablets
What are Proton Pump Inhibitors?
Proton Pump Inhibitors (PPIs) are a class of medications that work by stopping
your stomach from producing ulcer-causing acid. When taken with an NSAID,
PPIs reduce the risk of developing ulcers and promote ulcer healing. They also can
reduce symptoms of stomach upset, such as nausea, heartburn and indigestion.
The dose varies depending on which PPI your doctor has prescribed. They are
typically taken once or twice a day.
JOINT INJECTIONS

HYALURONAN INJECTIONS (VISCOSUPPLEMENTATION)

Viscosupplementation is the injection of a clear gel-like substance called hyaluronan
into the knee. Hyaluronan is a normal part of healthy cartilage. Injecting it into
the joint is thought to lubricate the cartilage (much like oil lubricates an engine),
reducing pain and allowing greater movement. Hyaluronan is only approved for
injection into the knee.
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There are a number of types of hyaluronan available. Most require you to have
an injection into the joint every week for 3 consecutive weeks. There is a new
preparation on the market that is given as a one-time single injection. The injections
may be repeated at a later date if they are felt to be helpful.
Although these medications can be purchased without a prescription, it is necessary
to see a physician for the injections. Speak to your doctor for more information on
viscosupplementation and which preparation might be best for you.
CORTICOSTEROIDS
See page 35 for extensive information.
MEDICATIONS FOR
SYMPTOMS AND
DISEASE CONTROL
These medications are only available for the treatment of inflammatory arthritis
because there are no known medications to slow down osteoarthritis. They work
to prevent joint damage and bone erosion in inflammatory arthritis. The goal is
to keep your joints healthy for years to come.
Anti-Rheumatic Drugs (DMARDs) and biologics fall into
Disease-Modifying
this category.
medications often take 6-12 weeks to begin to have an effect. They
These
work to address the root of the problem in inflammatory arthritis. Shutting
down the inflammatory processes can take a long time, but the result of
healthy joints will be worth it.
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DISEASE-MODIFYING ANTI-RHEUMATIC
DRUGS (DMARDs)

WHAT ARE DMARDs?

DMARDs are a class of medications used to treat inflammatory types of arthritis,
such as rheumatoid and psoriatic arthritis. Inflammation in the joint causes it to
be warm, swollen and sore. Once the joint is damaged, the damage cannot be
reversed.Rheumatologists know that early treatment is important to prevent
damage to the joint. This is where DMARDs come in. DMARDs are medications
that suppress inflammation and help to prevent joint damage.
HOW LONG DO DMARDs TAKE TO WORK?

DMARDs generally work well in most people; however, they do take some time to
work. Most DMARDs will start to work in about 6-12 weeks; however, some may
take longer up to 3-4 months. While you are waiting for the DMARD to work,
your doctor might prescribe an additional medication, such as prednisone or an
NSAID, to help control the symptoms.
SOME COMMONLY PRESCRIBED DMARDs
22
Brand Names
Product
Common Dose
Myochrisine
Gold
(sodium aurothiomalate)
50 mg once weekly injection
Plaquenil
Hydroxychloroquine
200-400 mg daily
1-2 tablets daily
Arava
Leflunomide
10-20 mg daily or every other day

1 tablet daily or every other day
Methotrexate
Methotrexate
7.5-25 mg once weekly

3-10 tablets once weekly or a
0.3-1.0 mL injection once weekly
Salazopyrin
Sulfasalazine
1000-1500 mg twice daily

2-3 tablets twice daily
Imuran
Azathioprine
50-150 mg per day

1-3 tablets daily
WHICH DMARD IS RIGHT FOR ME?

Although DMARDs can be used one at a time, many studies show that 2 or 3
DMARDs taken together are of greater benefit than one medication alone. Your
doctor will recommend a therapy that is best suited to your type of arthritis,
other medical problems and medications. Patients with mild arthritis may start
with a single DMARD, such as hydroxychloroquine or methotrexate. Patients with
more severe arthritis, on the other hand, need more aggressive treatment and
may receive 2 or 3 medications at the same time.
HOW LONG WILL I HAVE TO TAKE MY DMARD?

Once it is established, inflammatory arthritis is a chronic condition that will likely
affect you for the rest of your life. As such, you will need some type of medication
to control your disease. It is usually a balancing act between taking as much
medication as needed to control the arthritis and as little medication as necessary
to prevent side effects. Your doctor will adjust your dose or change your medication
based on the latest results from your symptoms, findings on physical examinations
and your laboratory tests.
WHAT ABOUT SIDE EFFECTS?

Unfortunately, taking DMARDs carries some risk, which must be balanced against
the potential benefits. In general, the risk of joint damage and permanent disability
is much greater than the risk of side effects from DMARDs used to control the
disease. When properly monitored, the vast majority of side effects are rare and
most are reversible by adjusting the dose or switching medications.
AZATHIOPRINE (AZA)
Brand Name: Imuran
Supplied: 50 mg tablets
What types of arthritis is azathioprine used for?
Azathioprine (AZA) is a DMARD used to treat inflammatory types of arthritis,
such as rheumatoid, psoriatic arthritis and other autoimmune diseases like lupus.
AZA is taken in tablet form every day. The usual starting dose is 50-100 mg per day
(1-2 tablets). Your doctor may further increase the dose to 100-200 mg per day
(2-4 tablets).
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WHAT ARE THE SIDE EFFECTS OF AZATHIOPRINE?

Symptom
Frequency
Call Doctor
Nausea and diarrhea
Common
If severe
Skin rash
Rare
Yes
Liver problems
Rare
Monitored by regular blood tests
4 Call your doctor if you develop a rash
Blood counts
Rare
Monitored by regular blood tests
5 See your doctor if you develop a fever
Infection
Rare
Yes call if you think you have an infection
Malignancy
Very rare
When used for long periods of time, AZA may

be associated with an increased risk of skin or
blood cancers; fortunately, this is very rare
1 Take once a day
How long will it take to work?

Like many of the DMARDs, you wont feel the effects of AZA right away.
Most people notice the effects about 6-8 weeks after they start taking it.
Is there anybody who should not take azathioprine?
It is generally advisable to avoid all medications, including AZA, during pregnancy
and breastfeeding. Occasionally this medication may need to be continued during
pregnancy and/or breastfeeding, but only after discussion between you and your
doctor. Please discuss all treatments with your doctor if you are planning a pregnancy
or if pregnancy is a possibility. People with active infections and liver, kidney or
blood diseases may not be able to use AZA and should discuss it with their doctor.
Is there anything I should avoid when taking azathioprine?
AZA has the potential to affect the liver (rarely), so your alcohol use must be limited.
Allopurinol, a medication used to treat gout, can have a severe interaction with AZA.
INFORM YOUR DOCTOR AND YOUR PHARMACIST IF YOU ARE

TAKING ALLOPURINOL.
Do I need any monitoring while taking azathioprine?

You will need regular blood tests to monitor your liver and blood counts
for side effects.
What helps to reduce side effects?
Take AZA as prescribed by your doctor. Reducing the dose may be helpful
in reducing side effects.
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AZATHIOPRINE I Key Points
2 Get regular blood tests

3 Discuss pregnancy concerns with your doctor
GOLD
Brand Name: Myochrisine
Supplied: Vials of 10, 25 and 50 mg
What types of arthritis is gold used for?
Gold is a DMARD used to treat inflammatory types of
arthritis, such as rheumatoid and psoriatic arthritis.
Gold is given as an injection usually once a week. A very small
test dose (10 mg ) is given on the first week to make sure you are not
overly sensitive. The second injection, a week later, builds up to 25 mg,
followed by 50 mg every week thereafter. If you respond very well to gold,
it may be possible to reduce the frequency of the injections to every 2 weeks
or every month.
Unfortunately, like many of the DMARDs, you wont feel the effects of gold right
away. Most people notice the effects about 12 weeks after they start taking it.
Is there anybody who should not take gold?
It is generally advisable to avoid all medications, including gold, during pregnancy
pregnancy and/or breastfeeding, but only after discussion between you and your
doctor. Please discuss all treatments with your doctor if you are planning a pregnancy
or if pregnancy is a possibility. Anyone who has had a prior allergic reaction to gold
should avoid it. People with certain kidney or blood diseases may not be able to
use gold and should discuss their situation with their doctor.
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WHAT ARE THE SIDE EFFECTS OF GOLD?

Symptom
Frequency
Call Doctor
Skin rash and itchiness
Common
Tell your doctor before the next injection

is given, as the gold may need to be
temporarily stopped. Call if symptoms
are severe
GOLD I Key Points

1 Given once a week
Mouth sores
Rare
Tell your doctor before the next injection

is given, as the gold may need to be
temporarily stopped. Call if symptoms
are severe
Metallic taste
Rare
No
Aching in muscles
and joints
Rare
No
Allergic reaction
Rare
Some patients experience weakness,

faintness, dizziness or nausea after
receiving a gold injection. These symptoms
usually go away if you lie down for a few
minutes
Blood counts
Rare
Monitored by monthly blood tests
Kidney problems
Rare
Monitored by monthly urine tests
Lung problems
Very rare
Yes call if you develop shortness of breath
Bowel problems
Very rare
Tell your doctor if you develop blood in

your stool
Is there anything I should avoid when taking gold?

Most medications can be given safely with gold.
Do I need any monitoring while taking gold?
At the beginning, you will need blood and urine tests every week. After a few
months, blood and urine can be tested every other week and, eventually, monthly
for side effects.
Inform your doctor of any rashes, itchiness or sores in the mouth prior to each
injection of gold. Get your urine and blood tests done regularly as directed by
your doctor.
2 Frequent blood and urine tests

3 Tell your doctor if you develop a rash, itchiness or mouth sores
HYDROXYCHLOROQUINE (HCQ)
Brand Name: Plaquenil
Supplied: 200 mg tablets
What types of arthritis is hydroxychloroquine used for?
HCQ is a DMARD used to treat inflammatory types of arthritis, such as rheumatoid
and psoriatic arthritis.
HCQ is taken as a tablet once or twice a day and the dose is based on your body
weight. Each tablet contains 200 mg of HCQ. The most common dose is 1-2 tablets
per day or 200-400 mg. If you require 300 mg per day, your doctor may ask you to
take 2 tablets one day and 1 the next. If you are taking 2 tablets a day, you can take
them both at once or divide them up one in the morning and one in the evening.
Like many of the DMARDs, you wont feel the effects of HCQ right away.
Most people start noticing the effects about 6-8 weeks after they start to take it,
but the benefit may not occur for 3 months.
Is there anybody who should not take hydroxychloroquine?
It is generally advisable to avoid all medications, including HCQ, during pregnancy and
breastfeeding. Occasionally this medication may need to be continued during pregnancy
and/or breastfeeding, but only after discussion between you and your doctor. Please
discuss all treatments with your doctor if you are planning a pregnancy or if pregnancy
is a possibility. Anybody who has had a previous reaction to HCQ or has had eye problems
as a result of hydroxychloroquine should avoid it. Anyone with problems in the retina
of the eye should discuss this treatment with their rheumatologist.
Is there anything I should avoid when taking hydroxychloroquine?
No, in general most things are very safe when taking HCQ.
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WHAT ARE THE SIDE EFFECTS OF

HYDROXYCHLOROQUINE?
HYDROXYCHLOROQUINE I Key Points
Symptom
Frequency
Call Doctor
Mild nausea, loss of appetite or diarrhea
Rare
If severe
Skin rash
Rare
Yes
Blurry vision
Rare
If severe
Headaches or dizziness
Rare
If severe
Nervousness, restless or sleeping difficulty
Rare
If severe
Ringing in the ears (tinnitus)
Rare
Yes
Eye problems (see above)
Rare
Yes
Do I need any monitoring while taking hydroxychloroquine?

Although you do not need regular blood tests while taking HCQ, your doctor
may order periodic tests to follow the activity of your arthritis. However, you do
need to have your eyes tested at least once a year while taking HCQ. Rarely,
HCQ can cause problems in the back of the eye (retina). If this rare event were
to occur, you might notice blurred vision or have a problem with reading or
seeing words, letters or parts of objects that would appear to be missing.
These problems seem to be related to the daily dose of medication. Fortunately,
this is very rare. Early eye problems are not usually serious and indicate sluggish
muscles involved in focusing the lens of
the eye. Damage to the retina almost never
occurs until a person has been on this
medication for over 2 years. However, once
damage occurs, it may be permanent.
Therefore, appropriate monitoring of the
eyes by a medical specialist familiar with
the side effects of chloroquine and
hydroxychloroquine is essential. The eye
examination includes regular tests, such as
vision and eye pressure. It also includes tests
that are not part of a regular eye check-up,
such as testing for colour vision and testing
your visual fields.
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1 Take once or twice daily

2 Have yearly eye tests
3 Call your doctor if you get a rash
LEFLUNOMIDE (LEF)
Brand Name: Arava
Supplied: 10 and 20 mg tablets
What types of arthritis is leflunomide used for?
Leflunomide (LEF) is a DMARD used to treat inflammatory types of arthritis,
such as rheumatoid and psoriatic arthritis.
LEF is taken as a tablet every day or every other day. The usual dose is 10-20 mg
per day. With this medication, taking 20 mg every other day is very similar to
taking 10 mg daily and is cheaper.
Like many of the DMARDs, you wont feel the effects of LEF right away. Most
people notice the effects about 6-8 weeks after they start taking it.
Is there anybody who should not take leflunomide?
Any woman who is pregnant or may become pregnant should not take LEF.
LEF taken during pregnancy can cause birth defects in the unborn child and
should be avoided at all cost. Any woman who is breastfeeding should also avoid
LEF. People with active infections or liver, kidney or blood diseases may not be
able to use LEF and should discuss this situation with their doctor.
Is there anything I should avoid when taking leflunomide?
Yes, avoid alcohol. LEF has the potential to affect the liver (rarely), so your alcohol
use must be severely restricted. Talk to your doctor.
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WHAT ARE THE SIDE EFFECTS OF LEFLUNOMIDE?

Symptom
Nausea and diarrhea
Common
If severe
Skin rash
Rare
Yes
Thinning hair
Rare
If severe
Increase in blood pressure
Rare
Have blood pressure monitored

by family doctor regularly
Lung problems: difficulty breathing,

dry cough, fever
Rare
Yes always
Liver problems
Rare
Monitored by regular
blood tests
Blood counts
Rare
blood tests
Infection
Rare
Yes call if you think you have

an infection
Do I need any monitoring while taking leflunomide?

You will need regular blood tests to monitor your liver and blood counts for side
effects.
Take LEF as prescribed by your doctor. Reducing the dose to 10 mg per day or
taking 20 mg every other day may be helpful in reducing side effects.
LEFLUNOMIDE I Key Points

1 Take once a day
2 Avoid alcohol
3 Have regular blood tests
4 Dont take during pregnancy or while breastfeeding
6 Stop LEF if you develop shortness of breath, dry cough or fever
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METHOTREXATE (MTX)
Brand Name: Methotrexate
Supplied: 2.5 mg tablets, 50 mg/2ml vials for injection
What types of arthritis is methotrexate used for?
MTX is a DMARD used to treat inflammatory types of arthritis, such as rheumatoid
MTX is given either as tablets or injection; the choice will be up to you and your
doctor.The most important thing to remember is that MTX is only taken once a
week. Choose a day that places the least demands on you, since some people feel
unwell (tired, sick to the stomach, loss of appetite or headache) for a day or two
after they take MTX. If you are taking the tablets, each tablet contains 2.5 mg of
MTX, with the most common dose ranging from 3-10 tablets per week or 7.5-25 mg.
If you are taking 6 or more tablets a week, the dose can be split to take half in the
morning and half at night (e.g. if you are taking 6 tablets a week, you take 3 with
breakfast and 3 with dinner). If you are taking the injection, MTX is supplied in 2 ml
vials containing a total of 50 mg. The most common dose with injections ranges
from 0.3-1.0 ml per week or 7.5-25 mg.
Like many of the DMARDs, you wont feel the effects of MTX right away. Most people
notice the effects about 6-8 weeks after they start taking it.
Is there anybody who should not take methotrexate?
Any woman who is pregnant or may become pregnant should not take MTX.
MTX taken during pregnancy can cause birth defects in the unborn child or even
a miscarriage, and should be avoided at all cost. Any woman who is breastfeeding
should also avoid MTX. People with active infections or liver, kidney or blood diseases
may not be able to use MTX and should discuss this situation with their doctor.
Is there anything I should avoid when taking methotrexate?
Yes, avoid alcohol. MTX has the potential to affect the liver, so your alcohol use
must be restricted. Talk to your doctor. The antibiotic trimethoprim should not be
used with MTX. Trimethoprim is often combined with sulfa antibiotics. If you need
an antibiotic for bladder, ear or chest infection, make sure that any doctor who
treats you is aware of this restriction.
Do I need any monitoring while taking methotrexate?
You will need regular blood tests to monitor your liver and blood counts for
side effects.
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WHAT ARE THE SIDE EFFECTS OF METHOTREXATE?

Symptom
Feel unwell for 24-48 hours
Common
If severe
Increased sun sensitivity
Rare
No wear a minimum of SPF 15

sunscreen
Headaches
Rare
If severe
Hair loss
Rare
No unless very severe
Mouth sores
Rare
Yes reduced with folic acid
Lung problems: difficulty breathing,

dry cough, fever
Rare
Yes always
Liver problems
Rare
blood tests
Blood counts
Rare
blood tests
Infection
Rare
Yes call if you think you have

an infection
How to help reduce side effects?

To reduce some of the side effects of methotrexate (such as nausea and mouth
sores), your doctor might suggest a supplement called folic acid to be taken daily
or a few times a week while you are on MTX. Taking MTX before going to bed can
sometimes help you sleep through any unpleasantness, such as nausea. Finally,
switching from tablets to injections can help to reduce nausea and feelings of
general unwellness.
SULFASALAZINE (SSZ)
Brand Name: Salazopyrin
Supplied: 500 mg tablets; 500 mg EC tablets
What types of arthritis is sulfasalazine used for?
SSZ is a DMARD used to treat inflammatory types of arthritis, such as rheumatoid
SSZ is taken as tablets, usually twice a day. Each tablet contains 500 mg of SSZ.
The most common dose is 2 tablets (1000 mg) twice a day; however, your doctor
may increase the dose to 3 tablets twice a day. As SSZ can upset the stomach,
it is important to start the medication gradually and build up as directed by
your doctor.
Like many of the DMARDs, you wont feel the effects of SSZ right away.
Most people notice the effects about 6-8 weeks after they start taking it.
Is there anybody who should not take sulfasalazine?
It is generally advisable to avoid all medications, including SSZ, during pregnancy
pregnancy and/or breastfeeding, but only after discussion between you and
your doctor. Please discuss all treatments with your doctor if you are planning a
pregnancy or if pregnancy is a possibility. Anyone who has had a prior allergic
reaction to medications containing sulfa should avoid SSZ. Patients who have
had an allergy to ASA (Aspirin) should also avoid SSZ.
METHOTREXATE I Key Points

1 Take only once a week
2 Avoid alcohol
4 Avoid sulfa antibiotics
5 Dont take during pregnancy or while breastfeeding
6 Stop MTX if you develop shortness of breath, dry cough or fever
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WHAT ARE THE SIDE EFFECTS OF SULFASALAZINE?
CORTICOSTEROIDS
Symptom
Nausea, diarrhea and

abdominal pain
Common
If severe
Headaches or slight dizziness
Common
If severe
WHAT ARE CORTICOSTEROIDS?
Rash
Common
Yes
Sensitivity to the sun
Common
No wear SPF 15 or higher

sunscreen
Blood counts
Rare
blood tests
Liver problems
Very rare
blood tests
Kidney problems
Very rare
blood tests
Cortisone is a hormone produced naturally by the bodys adrenal glands that

regulates routine inflammation from minor injuries. Major traumas, such as broken
bones or surgery, depend upon the adrenal gland to produce even more cortisone.
But the adrenal gland cannot produce enough cortisone to meet the challenge
of inflammatory arthritis. In the 1950s, physicians found that giving extra cortisone
to patients with rheumatoid arthritis dramatically improved their symptoms.
From this discovery, corticosteroids, also known as steroids, were developed and
are some of the oldest, most effective and fastest working medications for
inflammatory arthritis. Steroids can be given by mouth (prednisone), injected into
the joint, injected into a muscle or administered through an intravenous drip.
Infertility
Very rare
May temporarily reduce

sperm count in men
Is there anything I should avoid when taking sulfasalazine?

Most medications can be given safely with SSZ.
Do I need any monitoring while taking sulfasalazine?
You will need regular blood tests to monitor your blood counts for side effects.
To reduce some of the side effects of sulfasalazine, your doctor might suggest you start
with a low dose (1 tablet once or twice a day) and increase the dose slowly (adding a
tablet or two every week) until you reach the full dose. Taking SSZ with food may also help.
SULFASALAZINE I Key Points

1 Take twice a day

SOME COMMONLY USED STEROIDS

Brand Names Product
Common Dose Range
Route
Deltasone
Prednisone
Low Dose: 1-10 mg per day

Oral
Mod. Dose: 10-20 mg per day
High Dose: 20+ mg per day
Solumedrol
Methylprednisolone
100-1000 mg
Intravenous (IV)
Celestone
Soluspan
Betamethasone
1-12 mg
Intra-articular
(joint injection)
Kenalog
Triamcinolone Acetonide 10-80 mg
Aristospan
Triamcinolone
Hexacetonide
10-80 mg
Depomedrol
Methylprednisolone
40-120 mg
Intra-muscular
(muscle injection)
HOW LONG DO CORTICOSTEROIDS TAKE TO WORK?

Steroids work quickly (usually within a few days) and some patients start to feel
better within hours of taking the first dose.
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35
WHICH STEROID IS RIGHT FOR ME?

Only you and your doctor can make this decision since it depends on your
individual condition. To maximize benefits and minimize side effects, doctors
prescribe corticosteroids in doses as low as possible and for as short a time as
possible. Dosages vary widely and are based on your disease and the goals of
treatment. For example, low doses of prednisone (5-10 mg) may be sufficient for
the joint inflammation in rheumatoid arthritis, whereas much higher doses may
be needed to control lupus-related kidney inflammation.
HOW LONG WILL I HAVE TO TAKE CORTICOSTEROIDS?

Only your doctor can make this decision since it depends on your individual
condition. Steroids are often used as interim measures in inflammatory types of
arthritis, such as rheumatoid arthritis and lupus, to get control of inflammation
while waiting for the slower-acting DMARDs to take effect.
STEROID INJECTIONS
Brand Names: Depomedrol, Kenalog, Aristospan, Celestone Soluspan
What types of arthritis are steroid injections used for?
Steroid injections, also referred to as cortisone injections, are used to help relieve
the pain and swelling associated with many types of arthritic conditions, including
both inflammatory arthritis and osteoarthritis. Injecting a steroid in or around the
joint is an effective way to locally reduce pain and swelling.
How long will it take for the injection to work and how long will it last?
Most injections typically take 24-48 hours to take full effect. If local anesthetic
(freezing) is given with the injection, you may feel improvement quite quickly.
After the injection, it is normal to feel a temporary increase in discomfort in the joint
that should be resolved within 24 hours. You can treat this discomfort by applying
a cold pack or by using medications, such as acetaminophen or non-steroidal
anti-inflammatory drugs (check with your doctor). If possible, it is best to rest the
joint for 24-48 hours after an injection, as studies have shown this may improve
the effect of the injection. However, the length of time an injection will last is variable.
Some patients report months of relief while others find only a few days of relief.
Is there anybody who should not be given an injection?
For the most part, steroid injections are very safe and suitable for most people.
Anyone who has had a serious allergic reaction to steroids and those with an
infection in the joint or in the skin or soft tissues overlying the joint should not
be given injections.
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WHAT ARE THE SIDE EFFECTS OF STEROID INJECTIONS?

Symptom
Infection
Rare
If the injected joint becomes very

painful, red or swollen after an injection,
seek medical attention immediately,
as the joint may be infected;
the risks are very low (1 in 15,000)
Injury to the joint or tendon
Rare
Yes
Loss of fat layer below the skin Rare
No
Loss of pigment in the skin
Rare
No
Calcium buildup around

the joint
Rare
No
How often can I have repeat injections?

If a significant benefit is achieved after one injection, then an argument can
be made for repeat injections. There is some debate that too many injections
may weaken tendons and ligaments, and damage cartilage, but other studies
have found that injections can actually slow down the rate of damage and
help preserve the joint. As a general rule, a reasonable approach is to limit the
frequency of injections to 3-4 for a single joint per year.
STEROID INJECTIONS I Key Points

1 Rest the joint for 24-48 hours after the injection
2 If the joint becomes very painful, red or swollen after
the injection, seek medical attention
PREDNISONE
Brand Name: Prednisone
Supplied: 1, 5 and 50 mg tablets
What types of arthritis is prednisone used for?
Prednisone is a steroid used to treat inflammatory types of arthritis, such as
rheumatoid and psoriatic arthritis, lupus and polymyalgia rheumatica.
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37

Prednisone is given as tablets. The dose of prednisone varies widely and is based
on your disease and the goals of therapy. Therefore, there is really no standard dose.
Low-dose prednisone is between 1-10 mg per day; moderate doses are between
10-20 mg per day; and higher doses range from 20 mg per day and upwards.
Prednisone works very quickly usually within 1-4 days if the prescribed
dose is adequate to reduce your particular level of inflammation. Some people
notice the effects of prednisone hours after taking the first dose.
WHAT ARE THE SIDE EFFECTS OF PREDNISONE?

Short-Term Side Effects Of Prednisone
(Not all side effects occur in all patients. Most of these side effects will disappear with
the decrease and discontinuation of prednisone).
Symptom
Frequency
Call Doctor
Low Dose
High Dose
If Severe
Always
Increased appetite
Weight gain / moonface
Is there anybody who should not take prednisone?

Prednisone is very safe and can be given to almost everyone. If you have had a
previous severe allergic reaction to prednisone, you should not use it. Although
it is generally advisable to avoid all medications during pregnancy, prednisone
has been used safely and successfully to treat arthritis during pregnancy.
Please discuss all treatments with your doctor if pregnancy is a possibility.
Emotional sensitivity
Difficulty sleeping
Restlessness / tremor
Lower resistance to infection
Nausea or indigestion
Is there anything I should avoid when taking prednisone?

Most medications can be given safely with prednisone.
Blurry vision
Rise in blood pressure
Fluid retention
Rise in blood sugars
Irregular menstrual cycle
Acne
Hair growth
Do I need any monitoring while taking prednisone?

You do not need to have regular blood tests while taking prednisone. However,
if you are taking prednisone for longer periods of time (more than 3 months), your
doctor will likely arrange periodic bone mineral density (BMD) tests of your bones.
WHAT SHOULD YOU DO ABOUT THE SIDE EFFECTS

OF PREDNISONE?
Side effect
Frequency
Increased appetite
and weight gain
Follow a healthy diet and, if possible, exercise regularly
Infection
If you develop a fever, chills or other symptoms of infection,

see your doctor
Osteoporosis
Take calcium and vitamin D supplements. Your doctor may

also prescribe a bisphosphonate medication to reduce the risk
of osteoporosis (e.g. alendronate, risedronate, etidronate)
Avascular necrosis
38
Long-Term Side Effects Of Prednisone

(Not all side effects occur in all patients. Most of these side effects will disappear with
the decrease and discontinuation of prednisone).
Symptom
If you develop sudden severe pain in the groin,

contact your doctor immediately
Frequency
Call Doctor
Low Dose
High Dose
If Severe
Always
Easy bruising/thin skin
Muscle weakness
Cataracts or glaucoma
Monitored by MD
Osteoporosis
Monitored by MD
Avascular necrosis
www.arthritis.ca
39
How to help minimize the effects of prednisone?

If you will be taking prednisone for a prolonged period (more than 3 months),
obtain a MedicAlert bracelet (www.medicalert.ca or phone 1.800.668.1507).
How do I stop Prednisone?
DO NOT STOP YOUR PREDNISONE ABRUPTLY.
Prednisone needs to be gradually reduced. Stopping prednisone too quickly can

sometimes result in SERIOUS side effects. Discuss with your doctor before making
any changes in your dose.
proteins specially designed to block the action of TNF. Abatacept is a protein

designed to interfere with the ability of the bodys immune T-cells to talk to each
other. By blocking this interaction, the production of TNF is reduced. Rituximab is
a protein designed to attach to and destroy the bodys immune B-cells, which play
a part in the pain and swelling caused by arthritis. By blocking TNF, interfering
with T-cell communication and destroying B-cells, biologics work to suppress the
bodys immune system. Although this suppression can make it slightly harder to
fight off infections, it also helps to stabilize an overactive immune system.
SOME COMMONLY PRESCRIBED BIOLOGICS

PREDNISONE I Key Points
Brand Names Product
Common Dose Range
1 Take it as directed
Actemra
Tocilizumab
Intravenous infusion given every 4 weeks
2 Do not stop it abruptly
Cimzia
Certolizumab
Pegol
400 mg injection at weeks 0, 2 and 4, followed

by 200 mg injection once every 2 weeks
Enbrel
Etanercept
50 mg injection once weekly or 25 mg

injection twice weekly
5 Protect your bones
Humira
Adalimumab
40 mg injection every other week
6 Watch out for infection
Kineret
Anakinra
100 mg injection every day
Orencia
Abatacept
500-1000 mg intravenous infusion every

4 weeks
Remicade
Infliximab
Intravenous infusion at weeks 0, 2 and 6, and

then once every 4-8 weeks; dosage depends on
body weight
Rituxan
Rituximab
1000 mg intravenous infusion given twice

2 weeks apart
Simponi
Golimumab
50 mg injection every 4 weeks
3 Get a MedicAlert bracelet

4 If you develop sudden severe pain in the groin, seek medical attention
BIOLOGICS

WHAT ARE BIOLOGICS?

Biologics are a class of medications specially designed to treat inflammatory
types of arthritis, such as rheumatoid and psoriatic arthritis. There are a number
of biologics available that work by different mechanisms. Like DMARDs, biologics
are used to suppress inflammation and help prevent damage to the joint.
HOW LONG DO BIOLOGICS TAKE TO WORK?

Biologics are generally successful with most people; however, they can take
some time to work. Some people may notice the effects of the medication
quite quickly (within days to weeks), while others may take 3-6 months to
feel the effects. Biologics are often combined with DMARDs.
WHICH BIOLOGIC IS RIGHT FOR ME?

In some people with arthritis, a protein called tumour necrosis factor (TNF)
is present in the blood and joints in excessive amounts, thereby increasing
inflammation (pain and swelling). Adalimumab, etanercept and infliximab are
40
Your doctor will recommend a therapy that is best suited to your type of arthritis,
other medical problems and other medications. Your doctor will discuss the benefits
of each biologic, how the medication is given and its potential side effects.
www.arthritis.ca
41
HOW ARE BIOLOGICS ADMINISTERED?
HOW LONG WILL I HAVE TO TAKE MY BIOLOGIC?
Biologics are administered in two ways: infusion and injection. Your doctor
can provide you with information on the way in which different medications
are administered and help make the right choice for you.
Once it is established, inflammatory arthritis is a chronic condition that will

likely affect you for the rest of your life. As such, you will also need some type of
medication to control your disease. It is usually a balancing act between taking
as much medication as needed to control the arthritis and as little medication
as necessary to prevent side effects. Your doctor will adjust your dose or change
your medication based on the latest results from your symptoms, findings on
physical examination and your laboratory tests.
Infusion
This means the medicine will be given to you
through a needle placed in a vein in your arm.
Each infusion will be carried out by a health-care
professional. The length of the infusion will range
from 30 minutes to two hours, depending on the
specific medication that you are taking, the period
that your doctor feels is best for you and, in some
cases, the length of time that you have been
receiving the medication.
The infusion may take place in a number of settings. One product is infused
only in clinics specifically set up to administer this drug. Others are administered
in other clinical settings. All clinics are staffed by health-care professionals. Some
medications may be administered in your home with the assistance of a healthcare professional. You will be monitored throughout the infusion and, in some
cases, for a period of time after the infusion.
The frequency of administration will vary by product, the length of time you have
been taking the product and how you respond to the medication. Your infusion
will be pre-scheduled with the clinic or health-care professional in accordance
with the frequency decided by your doctor.
Injection
This means that the medication will be given by a needle under the skin of your
abdomen or thigh. The medication is dispensed by the pharmacist in a single-use
pre-filled syringe containing the dose decided by your physician. The pharmacist
will advise you on how to store the medication until it is injected.
You can administer the injection yourself or a family member or friend can
do this for you. Training will be provided by your doctor or another health
professional. Detailed instructions will be provided to you. If you prefer, you can
make arrangements for a health professional to administer the medication.
42
WHAT ABOUT SIDE EFFECTS?

In general, the risk of joint damage and permanent disability is much greater
than the risk of side effects of medications (biologics) used to control the disease.
When properly monitored, the vast majority of side effects are rare and most are
reversible by adjusting the dose or switching medications.
BIOLOGICS I Key Points

1 STOP if you develop a fever, think you have an infection
or have been prescribed antibiotics
2 Tell your doctor about any upcoming surgeries
ABATACEPT
Brand Name: Orencia
Supplied: An intravenous infusion given by a health-care professional once a month,
either at home or in an infusion clinic
What types of arthritis is abatacept used for?
Abatacept is a biologic used to treat inflammatory types of arthritis, such as
rheumatoid arthritis.
Abatacept infusion is given every month. The dose given depends on your
body weight, but typical doses range from 500-1000 mg.
www.arthritis.ca
43

Some people begin to feel the effects of abatacept within a few weeks;
however, it may take months to feel the full effect. Some people respond a
little slower, taking up to 6 months until the maximum benefit is felt.
WHEN SHOULD I NOT TAKE MY ABATACEPT

AND CALL MY DOCTOR?
Concern
Action
Fever
Stop abatacept and see your doctor
Think you have an infection
Prescribed an antibiotic
Become pregnant
Scheduled for surgery
Notify your doctor of the surgery date
Is there anybody who should not take abatacept?

Abatacept is known to increase the risk of infection. People with active infections
should not take abatacept. People who have had frequent infections in the past
or a history of tuberculosis should discuss the use of abatacept with their doctor.
Any woman who is pregnant or may become pregnant should not take
abatacept, as it has not been studied in pregnant women. Women taking
abatacept should use birth control, such as the oral contraceptive pill.
Any woman who is breastfeeding should also avoid abatacept.
Anyone with a history of cancer or emphysema should discuss the use of
abatacept with their doctor. You should discuss all vaccinations with your doctor
and notify your doctor of any scheduled surgeries.
Do I need any monitoring while taking abatacept?
Blood tests are not routinely required while you are taking abatacept. However,
your doctor will likely order periodic blood tests to check your blood count and
follow the activity of your arthritis.
44
WHAT ARE THE SIDE EFFECTS OF ABATACEPT?

Symptom
Infusion reaction
Rare
Monitored during the infusion
Nausea and diarrhea
Rare
If severe
Headaches and dizziness
Rare
If severe
Back pain or aching in the joints
Rare
If severe
Rash or flushing
Rare
If severe
Infection (fever/chills, urinary tract

infection, etc.)
Rare
Yes always
Emphysema (COPD): May increase

the risk of exacerbations and
pneumonia in patients with
emphysema/chronic bronchitis
Rare
Monitored by your doctor
Cancer: Abatacept may be associated

with a small increased risk of developing
certain types of cancer
Very rare
ADALIMUMAB
Brand Name: Humira
Supplied: 40 mg pre-filled syringes and 40 mg pre-filled pens
What types of arthritis is adalimumab used for?
Adalimumab is a biologic used to treat inflammatory types of arthritis, such as
rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis, as well as other
diseases, such as Crohns disease and psoriasis.
Adalimumab is given by an injection under the skin. The usual dose is 40 mg
given once every 2 weeks. In some cases, it may be given once a week.
Some people begin to feel the effects of adalimumab within a few weeks;
however, it may take months to feel the full effect. Some people respond a little
slower, taking up to 6 months until the maximum benefit is felt.
www.arthritis.ca
45
WHEN SHOULD I NOT TAKE MY ADALIMUMAB

AND CALL MY DOCTOR?
Concern
WHAT ARE THE SIDE EFFECTS OF ADALIMUMAB?

Symptom
Frequency
Call Doctor
Mild skin reaction at injection site
Common
If severe
Action
Fever
Stop adalimumab and see your doctor
Nausea, abdominal pain
Rare
If severe
Headaches
Rare
If severe
Infection (fever/chills, etc.)
Rare
Yes always
Become pregnant
Very rare
Monitored by doctor
Congestive heart failure: New shortness

of breath upon exertion or while lying
flat (i.e. in bed) that is improved by
propping yourself up on pillows, sitting
up or sleeping in a chair
Very rare
Monitored by doctor
Cancer: Adalimumab has been associated

Very rare
Monitored by doctor
Drop in blood counts: Adalimumab

can very rarely cause a drop in blood counts
Very rare
Monitored by doctor
Is there anybody who should not take adalimumab?

Adalimumab is known to increase the risk of infection. People with active
infections should not take adalimumab. People who have had frequent infections
in the past or a history of tuberculosis should discuss the use of adalimumab
with their doctor.
adalimumab, as it has not been studied in pregnant women. Women taking
adalimumab should use birth control, such as the oral contraceptive pill.
Any woman who is breastfeeding should also avoid adalimumab.
Anyone with a history of cancer, congestive heart failure or nervous system
problems (like multiple sclerosis) should discuss the use of adalimumab with
their doctor.
You should discuss all vaccinations with your doctor and notify your doctor of
any scheduled surgeries.
Do I need any monitoring while taking adalimumab?
Blood tests are not routinely required while you are taking adalimumab.
However, your doctor will likely order periodic blood tests to check your blood
counts and follow the activity of your arthritis.
Nervous system problems:

Persistent, unexplained vision problems
(double or blurred), balance problems or
numbness or tingling in the arms or legs
ANAKINRA
Brand Name: Kineret
Supplied: 100 mg pre-filled syringes
What types of arthritis is anakinra used for?
Anakinra is a biologic used to treat inflammatory types of arthritis,
such as rheumatoid arthritis.
Anakinra is given by an injection under the skin every day. The dose given
with each injection is 100 mg.
Most people begin to feel the effects of anakinra after 2-4 weeks; however, it
may take months to feel the full effect. Some people respond a little slower,
taking 3-6 months until the maximum benefit is felt.
46
www.arthritis.ca
47
WHEN SHOULD I NOT TAKE MY ANAKINRA

AND CALL MY DOCTOR?
Concern
Action
Fever
Stop anakinra and see your doctor
Become pregnant
Is there anybody who should not take anakinra?

anakinra, as it has not been studied in pregnant women. Women taking anakinra
should use birth control, such as the oral contraceptive pill. Any woman who is
breastfeeding should also avoid anakinra. Anyone with a past history of recurrent
infections should also discuss the use of anakinra with their doctor.
Is there anything I should avoid when taking anakinra?
WHAT ARE THE SIDE EFFECTS OF ANAKINRA?

Symptom
Common
If severe
Common
If severe
Headaches
Common
If severe
Rare
Yes - always
Blood Counts: Anakinra can very rarely

cause a drop in white blood cell counts
Rare
Monitored by MD
Do I need any monitoring while taking anakinra?

Blood tests are not routinely required while you are taking anakinra. However,
your doctor will likely order periodic blood tests to check your blood counts and
48
CERTOLIZUMAB PEGOL
Brand Name: Cimzia
Supplied: 200 mg pre-filled syringes
What types of arthritis is certolizumab used for?
Certolizumab is a biologic used to treat inflammatory types of arthritis,
Certolizumab is given by an injection under the skin. The starting dose is
400 mg given at week 0, 2 and 4. This is followed by a maintenance dose of
200 mg given once every 2 weeks. In some cases, a 400 mg dose may be
prescribed once a month.
Some people begin to feel the effects of certolizumab within a few weeks;
WHEN SHOULD I NOT TAKE MY CERTOLIZUMAB

AND CALL MY DOCTOR?
Concern
Action
Fever
Stop certolizumab and see your doctor
Become pregnant
Is there anybody who should not take certolizumab?

Certolizumab is known to increase the risk of infection. People with active
infections should not take certolizumab. People who have had frequent
infections in the past or a history of tuberculosis should discuss the use of
certolizumab with their doctor.
www.arthritis.ca
49
certolizumab, as it has not been studied in pregnant women. Women taking
certolizumab should use birth control, such as the oral contraceptive pill.
Any woman who is breastfeeding should also avoid certolizumab.
ETANERCEPT
Brand Name: Enbrel
Supplied: 50 mg pre-filled syringes & 25 mg vials of powder for reconstitution

problems (like multiple sclerosis) should discuss the use of certolizumab with
their doctor.
What types of arthritis is etanercept used for?

Etanercept is a biologic used to treat inflammatory types of arthritis, such as
rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis.

Etanercept is given by an injection under the skin once or twice a week.
The dose given is 50 mg per week or 25 mg twice a week. In some circumstances,
etanercept may be given in 50 mg doses twice a week.
WHAT ARE THE SIDE EFFECTS OF CERTOLIZUMAB?

Symptom
Frequency
Call Doctor
Common
If severe
Rare
If severe
Headaches
Rare
If severe
Rare
Yes always

Very rare
Monitored by doctor

Very rare
Cancer: Certolizumab has been associated

Very rare
Drop in blood counts: Certolizumab

can very rarely cause a drop in blood counts
Very rare
Monitored by doctor
Monitored by doctor
WHEN SHOULD I NOT TAKE MY ETANERCEPT

AND CALL MY DOCTOR?
Concern
Action
Fever
Stop etanercept and see your doctor
Become pregnant
Monitored by doctor
Do I need any monitoring while taking certolizumab?

Blood tests are not routinely required while you are taking certolizumab.
However, your doctor will likely order periodic blood tests to check your blood
counts and follow the activity of your arthritis.
50

Some people begin to feel the effects of etanercept within a few weeks;
Is there anybody who should not take etanercept?

Etanercept is known to increase the risk of infection. People with active infections
should not take etanercept. People who have had frequent infections in the past
or a history of tuberculosis should discuss the use of etanercept with their doctor.
www.arthritis.ca
51
etanercept, as it has not been studied in pregnant women. Women taking
etanercept should use birth control, such as the oral contraceptive pill.
Any woman who is breastfeeding should also avoid etanercept.
GOLIMUMAB
Brand Name: Simponi
Supplied: 50 mg pre-filled syringes and 50 mg pre-filled autoinjector
Anyone with a history of cancer, congestive heart failure or nervous system problems
(like multiple sclerosis) should discuss the use of etanercept with their doctor.
What types of arthritis is golimumab used for?

Golimumab is a biologic used to treat inflammatory types of arthritis, such as
rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis.
WHAT ARE THE SIDE EFFECTS OF ETANERCEPT?

Symptom
Frequency
Call Doctor
Common
If severe
Rare
If severe
Headaches
Rare
If severe
Rare
Yes always

Very rare
Monitored by doctor

Very rare
Cancer: Etanercept has been associated

Very rare
Drop in blood counts: Etanercept can very

rarely cause a drop in blood counts
Very rare
Monitored by doctor
Monitored by doctor

Some people begin to feel the effects of golimumab within a few weeks;
WHEN SHOULD I NOT TAKE MY GOLIMUMAB

AND CALL MY DOCTOR?
Concern
Action
Fever
Stop golimumab and see your doctor
Become pregnant
Monitored by doctor
Do I need any monitoring while taking etanercept?

Blood tests are not routinely required while you are taking etanercept. However,
52

Golimumab is given by an injection under the skin. The usual dose is 50 mg
given once every month.
Is there anybody who should not take golimumab?

Golimumab is known to increase the risk of infection. People with active
infections should not take golimumab. People who have had frequent infections
in the past or a history of tuberculosis should discuss the use of golimumab with
their doctor.
www.arthritis.ca
53
golimumab, as it has not been studied in pregnant women. Women taking
golimumab should use birth control, such as the oral contraceptive pill.
Any woman who is breastfeeding should also avoid golimumab.
INFLIXIMAB
Brand Name: Remicade
Supplied: Given by intravenous infusion

problems (like multiple sclerosis) should discuss the use of golimumab with
their doctor.
What types of arthritis is infliximab used for?

Infliximab is a biologic used to treat inflammatory types of arthritis, such as
rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis, as well as
other diseases, such as Crohns disease and psoriasis.
WHAT ARE THE SIDE EFFECTS OF GOLIMUMAB?

Symptom
Frequency
Call Doctor
Common
If severe
Abdominal pain
Rare
If severe
Headaches
Rare
If severe
Rare
Yes always

Very rare
Monitored by doctor

Very rare
Cancer: Golimumab has been associated

Very rare
Drop in blood counts: Golimumab can very

Very rare
Monitored by doctor
Monitored by doctor

Some people begin to feel the effects of infliximab after the first infusion;
WHEN SHOULD I NOT TAKE MY INFLIXIMAB

AND CALL MY DOCTOR?
Concern
Action
Fever
Stop infliximab and see your doctor
Become pregnant
Monitored by doctor
Do I need any monitoring while taking golimumab?

Blood tests are not routinely required while you are taking golimumab. However,
54

Infliximab is given by an intravenous infusion at weeks 0, 2 and 6, and then
every 4-8 weeks depending on the condition you are being treated for and
your response to treatment. The dose depends on your body weight.
Is there anybody who should not take infliximab?

Infliximab is known to increase the risk of infection. People with active infections
should not take infliximab. People who have had frequent infections in the past
or a history of tuberculosis should discuss the use of infliximab with their doctor.
Any woman who is pregnant or may become pregnant should not take infliximab,
as it has not been studied in pregnant women. Women taking infliximab should
use birth control, such as the oral contraceptive pill. Any woman who is breastfeeding should also avoid infliximab.
www.arthritis.ca
55

problems (like multiple sclerosis) should discuss the use of infliximab with
their doctor.
It is also important to discuss all vaccinations with your doctor and notify your
doctor of any scheduled surgeries.
WHAT ARE THE SIDE EFFECTS OF INFLIXIMAB?

Symptom
Frequency
Call Doctor
Infusion reaction
Common
If severe
Nausea, abdominal pain, diarrhea
Rare
If severe
Headaches
Rare
If severe
Back pain or aching in the joints
Rare
If severe
Rash or flushing
Rare
If severe
Rare
Yes always

Very rare
Monitored by doctor

Very rare
Cancer: Infliximab has been associated

Very rare
Drop in blood counts: Infliximab can very

Very rare
Liver problems: Rarely can infliximab cause

problems with the liver.
Very rare
What types of arthritis is rituximab used for?

Rituximab is a biologic used to treat inflammatory types of arthritis,
Rituximab requires only 2 intravenous infusions spaced 2 weeks apart.
The dose given is 1000 mg with each infusion. An intravenous steroid, such
as methylprednisolone (Solumedrol), is usually given 30 minutes before the
infusion to reduce side effects. Repeat infusions of rituximab can be given
every 6 months based on the response and how active the arthritis is.
Although some people will feel the effects of rituximab earlier, it can take
4-6 months for the maximum benefit.
WHEN SHOULD I NOT TAKE MY RITUXIMAB

AND CALL MY DOCTOR?
Monitored by doctor
Monitored by doctor
Monitored by doctor
Concern
Action
Fever
Stop rituximab and see your doctor
Become pregnant
Monitored by doctor
Do I need any monitoring while taking infliximab?

Your doctor will decide, based on your condition, when and what type of blood
tests are required.
56
RITUXIMAB
Brand Name: Rituxan
Is there anybody who should not take rituximab?

Rituximab is known to increase the risk of infection. People with active infections
should not take rituximab. People who have had frequent infections in the past
should discuss the use of rituximab with their doctor.
www.arthritis.ca
57
rituximab, as it has not been studied in pregnant women. Women taking
rituximab should use birth control, such as the oral contraceptive pill.
Any woman who is breastfeeding should also avoid rituximab.
TOCILIZUMAB
Brand Name: Actemra
What types of arthritis is tocilizumab used for?

Tocilizumab is a biologic used to treat inflammatory types of arthritis,
WHAT ARE THE SIDE EFFECTS OF RITUXIMAB?

Symptom
Infusion reaction
Common
Monitored during the infusion
Abdominal pain, nausea, vomiting,

diarrhea
Rare
If severe
Headaches and dizziness
Rare
If severe
Aching in the joints and muscles
Rare
If severe
Rash or flushing
Rare
If severe
Infection (fever/chills, urinary tract

infection, etc.)
Rare
Yes always
Drop in blood counts: Rituximab can

very rarely cause a drop in blood counts
Very rare
Monitored by doctor
Kidney, bowel, heart and lung

problems: Very rare with rituximab
Very rare
Monitored by doctor
Do I need any monitoring while

taking rituximab?
Blood tests are not routinely required while
you are taking rituximab. However, your doctor
will likely order periodic blood tests to check
your blood count and follow the activity of
your arthritis.

Tocilizumab is given intravenously to patients every 4 weeks. Dosage is
dependant on your weight and starts at 4mg/kg.
Some people begin to feel the effects of tocilizumab within a few weeks;
WHEN SHOULD I NOT TAKE MY TOCILIZUMAB

AND CALL MY DOCTOR?
Concern
Action
Fever
Stop tocilizumab and see your doctor
You have been in contact with

someone with tuberculosis
Become pregnant
Is there anybody who should not take tocilizumab?

If you are allergic to tocilizumab or any of its non-medicinal ingredients,
you should not take this medication.
Tocilizumab is known to increase the risk of infection. People with active
infections should not take tocilizumab. People who have had frequent infections
in the past or a history of tuberculosis should discuss the use of tocilizumab with
their doctor.
58
www.arthritis.ca
59
tocilizumab, as it has not been studied in pregnant women. Women taking
tocilizumab should use birth control, such as the oral contraceptive pill.
Any woman who is breastfeeding should also avoid tocilizumab.
Anyone with a history of cancer, congestive heart failure or nervous system problems
(like multiple sclerosis) should discuss the use of tocilizumab with their doctor.
INDEX
Abatacept pg 43-45
Celebrex pg 15
Acetaminophen pg 11, 13, 36
Celecoxib pg 14, 15
Acetic acids pg 15
Celestone Soluspan pg 35, 36
WHAT ARE THE SIDE EFFECTS OF TOCILIZUMAB?
Acetylsalicylic acid (ASA) pg 12, 15
Certolizumab Pegol pg 41, 49, 50
Actemra pg 59, 60
Cimzia pg 49, 50
Adalimumab pg 40, 41, 45-47
Clinoril pg 15
Advil pg 11, 12, 15, 16
Codeine pg 12, 13
Allopurinol pg 24
Corticosteroids pg 19, 35-40
Symptom
Rash and itching
Rare
If severe
Upper respiratory tract infection

(coughs and colds)
Rare
If severe
Cold sores, mouth ulceration
Rare
If severe
Anacin pg 11
COXIBs pg 14-18
Blisters, shingles
Rare
If severe
Anakinra pg 41, 47, 48
Cytotec pg 19
Skin infection sometimes with

fever and chills
Rare
Yes always
Ansaid pg 15
Daypro pg 15
Stomach pain
Rare
If severe
Antiphlogistine Rub A535 pg 12
Demerol pg 13
Headache, dizziness
Rare
If severe
Arava pg 22, 29, 30
Depomedrol pg 35, 36
High blood pressure
Rare
Aristospan pg 35, 36
Diflunisal pg 15
Low white blood cell counts
Rare
ArthriCare pg 12
Dilaudid pg 13
High blood fats (cholesterol levels)
Rare
Arthrotec-50 pg 15
DMARDs (Disease-Modifying
Abnormal liver function tests
Rare
Arthrotec-75 pg 15
Diverticulitis (fever, nausea, diarrhea,

constipation, stomach pain)
Very rare
If severe
Aspercreme pg 12
Dolobid pg 15
Red swollen areas in the mouth
Very rare
If severe
Aspirin pg 11, 14-16, 18, 33
Duragesic Patches pg 13
High triglyceride levels
Very rare
Azathioprine pg 23-25
Enbrel pg 41, 51, 52
Serious allergic reactions
Very rare
Yes always
BenGay pg 12
Entrophen pg 11, 14
Betamethasone pg 35
Esomeprazole pg 20
Biologics pg 8, 21, 40-60
Etanercept pg 41, 51, 52
Do I need any monitoring while taking tocilizumab?

Your doctor will likely order regular blood tests to monitor your liver and blood
counts, as well as your cholesterol levels, for side effects of tocilizumab.
60
Anti-Rheumatic Drugs) pg 8, 21-34
www.arthritis.ca
61
Etodolac pg 15
Methotrexate pg 31, 32
Oxycodone pg 13
Steroids pg 8, 35, 40
Eucalyptamint pg 12
Meloxicam pg 15
Oxicams pg 15
Stomach protection pg 19, 20
Feldene pg 15
M-Eslon pg 13
Oxycontin pg 13
Sulfasalazine pg 22, 33, 34
Fentanyl pg 13
Meperidine pg 13
Pantoloc pg 20
Sulindac pg 15
Flexall pg 12
Methylprednisolone pg 35, 36
Pantoprazole pg 20
Surgam pg 15
Flurbiprofen pg 15
Misoprostol pg 15, 19, 20
Pariet pg 20
Surgam-SR pg 15
Froben pg 15
Mobicox pg 15
Pennsaid pg 17
Tenoxicam pg 15
Froben-SR pg 15
Morphine pg 12, 13
Percocet pg 13
Tiaprofenic Acid pg 15
Gold (sodium aurothiomalate) pg 22, 25-27
Motrin pg 11, 12, 14-16
Percodan pg 13
Tocilizumab pg 41, 59, 60
Golimumab pg 41, 53, 54
MS-Contin pg 13
Prescription medications pg 12, 13
Topical Medications pg 12
Humira pg 41, 45-47
Myochrisine pg 22, 25-27
Piroxicam pg 15
Toradol pg 15
Hyaluronan injections pg 20, 21
Myoflex pg 12
Plaquenil pg 22
Tramadol pg 13
Hydromorph-Contin pg 13
Nabumetone pg 15
Prednisone pg 35, 37-40
Tramacet pg 13
Hydromorphone pg 13
Naphthylalkanones pg 15
Prevacid pg 20
Triamcinolone Acetonide pg 35
Hydroxychloroquine pg 22, 23, 27, 28
Naprosyn pg 15
Propionic Acids pg 15
Triamcinolone Hexacetonide pg 35
Ibuprofen pg 11, 12, 14, 15
Naprosyn-SR pg 15
Proton Pump Inhibitors pg 19, 20
Tridural pg 13
Imuran pg 22-25
Naproxen pg 15
Rabeprazole pg 20
Tylenol pg 11, 13
Indocid pg 15
Nexium pg 20
Ralivia pg 13
Ultradol pg 15
Inflammatory arthritis pg 7, 8
Non-Medical Techniques pg 10
Relafen pg 15
Viscosupplementation pg 8, 20, 21
Infliximab pg 40, 41, 55, 56
Non-Prescription Medications pg 11
Remicade pg 41, 55, 56
Voltaren pg 15
Kenalog pg 35, 36
Novasen pg 11, 14
Rhodis pg 15
Voltaren-SR pg 15
Ketoprofen pg 15
NSAIDs (Non-Steroidal
Rituxan pg 56, 57
Zostrix pg 12
Ketorolac pg 15
Anti-Inflammatory Drugs) pg 8, 14-18
Rituximab pg 57, 58
Kineret pg 41, 47, 48
Orencia pg 43-45
Salazopyrin pg 22, 33, 34
Lansoprazole pg 20
Orudis pg 15
Salicylates pg 12, 15
Leflunomide pg 22, 29, 30
Oruvail pg 15
Simponi pg 41, 53, 54
Losec pg 20
Oxaprozin pg 15
Solumedrol pg 35, 57
62
www.arthritis.ca
63
Ways you can Fight Arthritis

Call The Arthritis Society
Our toll-free number can connect you with trained volunteers to provide you
with support and information. 1.800.321.1433
Join the Free Arthritis Registry
You will receive specific information to manage your arthritis and improve
your quality of life. www.arthritis.ca/registry
Enrol in the Arthritis Self-Management Program (ASMP)
ASMP is a six-week program for people with arthritis, their family and friends.
Trained leaders with first-hand experience of arthritis lead the weekly, interactive
2-hour workshops. Program participants will gain self-confidence in their ability to
control symptoms, learn how to develop action plans to manage their arthritis
and make connections with others living with arthritis. www.arthritis.ca/asmp
Use Arthritis Friendly Products
The Arthritis Society is proud to recognize manufacturers that have designed
products that are easy to use for people with arthritis. For a complete list of
products that have been commended by The Arthritis Society and deemed
Arthritis Friendly, visit our website. www.arthritis.ca/arthritisfriendly
NOTES
Make a Donation
The Arthritis Society is fighting for a world without arthritis and helps people live their
lives to the fullest by combating the limitations arthritis can impose daily. We trust that
you found this information valuable and helpful as you battle arthritis. Please help us
continue funding arthritis research, educational programming and services, and make a
donation today. To donate, visit us online at www.arthritis.ca, call 1.800.321.1433 or cut
out the form below and mail it to: Attention: Data Services, The Arthritis Society,
393 University Avenue, Suite 1700, Toronto, ON M5G 1E6.
-- - - - - - - - - - -- - - - - - -- - - - - - -- - - - -- - - -- -- - - - -- -- - - - -- - -- - -- - - -- -- -- -- - - I would like to help FIGHT ARTHRITIS by making a donation to
The Arthritis Society.
Name: ___________________________________________________________________________
Address: _________________________________________________________________________
City: ___________________ Province: ___________ Postal Code: ____________________________
Tel: _________________________________ Email: __________________________________________
Here is my gift of: $25
$50
$100
Other $ ______________
Enclosed is my cheque, payable to The Arthritis Society. OR

Please charge my: Visa
MasterCard
American Express
Card Number: _________________________________________________________________________________ Expiry Date: _____________________

Signature: _____________________________________________________________________________________
64
MEDBROCH
www.arthritis.ca
65
NOTES
The Arthritis Society

can help change your
life for the better!
If you have been diagnosed with arthritis and want to
learn more, contact The Arthritis Society for our most popular
disease brochures, which are available for FREE.
Osteoarthritis KNOW YOUR OPTIONS

Rheumatoid Arthritis KNOW YOUR OPTIONS
Ankylosing Spondylitis KNOW YOUR OPTIONS
Psoriatic Arthritis KNOW YOUR OPTIONS
CONTACT US TODAY FOR YOUR FREE BROCHURES

1.800.321.1433 WWW.ARTHRITIS.CA
66
www.arthritis.ca
67
To get the best results, form close ties with

your health-care team and become a full partner
in your treatment.
Learning daily living strategies to manage your
arthritis gives you a greater feeling of control and a
more positive outlook.
To support arthritis research or to learn more,
contact The Arthritis Society:
1.800.321.1433
www.arthritis.ca
This publication is endorsed by the Canadian Rheumatology Association,

whose mission is to represent Canadian rheumatologists and promote their
pursuit of excellence in arthritis care, education and research.
The Arthritis Society

Printed January 2011

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ARTHRITIS

A word about medication safety

Living with Arthritis

I have been diagnosed with arthritis

Non-medical techniques for pain control

Non-prescription medications for pain

Prescription medications for pain

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs and COXIBs)

What are NSAIDs?

Protecting Your Stomach

Why is protecting the stomach important?

Hyaluronan injections (viscosupplementation)

Medications for Symptoms and Disease Control

What are DMARDs?

What are corticosteroids?

What are biologics?

A WORD ABOUT MEDICATION SAFETY

FOR THE MOST CURRENT INFORMATION ON ARTHRITIS MEDICATIONS,

Limitations of the Guide

WHAT IS INFLAMMATORY ARTHRITIS?

Inflammatory arthritis can affect any joint in the body.

WHAT ARE THE TYPES OF ARTHRITIS?

A person with OA may notice some stiffness of the affected

Once it is established, inflammatory arthritis

A COMPARISION OF INFLAMMATORY ARTHRITIS

Usually starts in middle age

More common as we age,

The bodys immune system

Fairly quickly, affecting joints over

Usually slowly, with joints

How many joints

Usually lots of joints and tends

Usually a few joints and

What joints can

Small joints of the hands and feet

End joints of the fingers, neck,

Joint pain, swelling, tenderness,

Stiff, painful and enlarged

Morning stiffness lasting more

Morning stiffness lasting

Non-Steroidal Anti-Inflammatory Analgesics

Who gets it?

TREATING YOUR ARTHRITIS

MEDICATIONS FOR SYMPTOM CONTROL ONLY

(analgesics) and anti-inflammatory medications (NSAIDs) fall into

with the disease.

NON-PRESCRIPTION MEDICATIONS FOR PAIN

NON-MEDICAL TECHNIQUES FOR PAIN CONTROL

Ice/heat application to joints

Joint protection measures

Personal and family support

Diet advice for weight loss

The Arthritis Societys Arthritis Self-Management Program,

IBUPROFEN AND ASA

SOME COMMONLY PRESCRIBED NARCOTICS

Tylenol #1, #2, #3, Codeine Contin

Morphine, M-Eslon, MS-Contin

Percocet, Percodan, Oxycontin

Combination tablet of tramadol 37.5 mg

Tramadol 100, 200 and 300 mg

100-300 mg once daily

Will I become addicted?

FOR THE MOST CURRENT INFORMATION ON ARTHRITIS MEDICATIONS,

WHAT ARE NSAIDs?