What are disease modifying antirheumatic medicines (DMARDs)?

Disease modifying antirheumatic drugs are also known as DMARDs. They are a group of medicines that help treat arthritis caused by inflammation. These include:

• rheumatoid arthritis
• psoriatic arthritis
• ankylosing spondylitis
• juvenile arthritis

They are called 'disease modifying' because they slow or stop the disease process and help protect your joints.

They are the preferred treatment for rheumatoid arthritis. Your doctor may prescribe one medicine or a combination of medicines.

How do DMARDs work?

Many DMARDs reduce your body's immune system response. This is called immunosuppression.

This is helpful because rheumatoid arthritis is an autoimmune condition where your immune system damages your joints. Lowering this immune response helps reduce inflammation and damage to your joints.

It is important to start taking DMARDs as soon as possible after your doctor diagnoses rheumatoid arthritis. The earlier you start taking them, the better they will work.

How do I take DMARDs?

All DMARDs are prescription medicines and are usually prescribed by a specialist doctor, such as your rheumatologist. They come in different forms, including:

• tablets
• injections you can give yourself at home if you choose
• infusions that are given by a nurse into a vein

Different DMARD medicines are taken at different times. Some are taken daily or weekly. Injected medicines may be taken weekly, monthly or less often.

Talk to your doctor or pharmacist to make sure you know how and when to take your medicine.

Some DMARD medicines may take several weeks before they work best. Your doctor may prescribe other medicines to help manage pain and inflammation in the meantime. These may include anti-inflammatory medicines (NSAIDs) or prednisolone.

Read more about questions to ask before taking a medicine.

What types of DMARDs might I be prescribed?

There are 3 main types of DMARDs:

1. Conventional synthetic DMARDs — which affect your immune system in general. These include medicines such as methotrexate, sulfasalazine, hydroxychloroquine and leflunomide.
2. Targeted synthetic DMARDs — which target a specific protein in your immune system. They include medicines such as tofacitinib, baricitinib and upadacitinib.
3. Biological DMARDs — which also target a specific protein in your immune system but they are made from living cells. They include medicines such as infliximab, etanercept and adalimumab.

Biological DMARDs are usually prescribed if conventional DMARDs have not been working well enough.

Your doctor may suggest a DMARD for you based on:

• how long you have had arthritis
• what treatments you have already tried
• how severe your condition is
• whether you have other health conditions

They will also consider your preferences and personal needs, such as if you are planning a pregnancy.

What are the possible side effects or risks of DMARDs?

Every medicine has risks and possible side effects, including DMARDs. Talk with your doctor about the risks and benefits of your medicines.

Side effects of DMARDs

Methotrexate may cause side effects such as:

• nausea
• diarrhoea
• mouth ulcers
• liver and lung problems
• hair loss

Ask your doctor about taking a folic acid supplement to help lower your chance of some side effects.

Other conventional DMARDs may cause a rash. Hydroxychloroquine may lead to eye problems.

Targeted DMARDs may increase your chance of infections, such as upper respiratory tract infections or sinusitis.

Find out more about the DMARDs you are taking, including possible side effects.

Risks of DMARDs

DMARDs lower your body's immune system response. This makes you more likely to get infections, which may be serious.

• The chance is higher if you take more than one DMARD, especially if one is a biological DMARD.
• You may not always get a fever when you have an infection. This is because of how the medicine affects your immune system.
• Because of the risk of infection, it is important to have routine vaccinations, such as for pneumococcus and influenza (flu).
• You should not have 'live' vaccines when taking DMARDs. This means you may need to have these before starting treatment. Ask your doctor which vaccines you need.

You also have a higher chance of certain cancers, such as skin cancers. Sun protection and skin cancer checks are important. Ask your doctor which other cancer screening tests are right for you.

If you have had a tuberculosis infection in the past, some types of DMARDs can reactivate it. Your doctor will arrange for you to have a test to check for tuberculosis before you start treatment.

DMARDs may also raise your cholesterol levels or affect your levels of different types of blood cells. Regular blood tests will help check for these changes early.

When should I see my doctor?

It's a good idea to see your doctor or rheumatologist (specialist) regularly when taking DMARDs. These visits help make sure the medicine is working and remains safe for you.

See your doctor promptly if your symptoms aren't improving or if you have any side effects. Also see your doctor if you experience:

• unexplained weight loss
• pain that is different to your usual arthritis pain
• pain that wakes you from sleep
• muscle weakness

You should also see a doctor quickly if you think you may have an infection. Your symptoms may be different to what you may have experienced in the past with infections. See a doctor if you feel unwell or have:

• a fever
• a cough, cold, sore throat or shortness of breath
• sinus pain or headache
• pain, redness or swelling of your skin
• a painful rash
• feel more tired than usual

If you have an infection, you may need to take antibiotics or stop taking your DMARDs for a short time.

Are there any alternatives to this medicine?

There are many DMARDs available. If one doesn't work for you or causes side effects, your doctor may prescribe a different one or add another medicine.

Some medicines help relieve pain but do not stop joint damage. These include non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol.

Omega-3 fatty acids (fish oil) may help improve pain and lower your need for pain relief medicines. Some other herbal medicines may cause harm or interact with DMARDs. Tell your doctor about any supplements you use.

Self-management techniques

Self-management techniques may help support your treatment together with DMARDs. You could try:

• heat or cold packs
• relaxation techniques
• massage
• acupuncture
• transcutaneous electrical nerve stimulation (TENS)

It's also important that you:

• stop smoking
• do regular exercise
• eat a healthy diet
• look after your mental health

A physiotherapist or occupational therapist can give you advice on how to manage your symptoms.

Sometimes, your doctor may suggest surgery as an option if your arthritis is severe.

Resources and support

• The Australian Rheumatology Association has information sheets about each DMARD and other arthritis medicines.
• The Arthritis Australia MyRA Rheumatoid Arthritis Support Program has videos and fact sheets on DMARDs.

You can also call the healthdirect helpline on 1800 022 222 (known as NURSE-ON-CALL in Victoria). A registered nurse is available to speak with you 24 hours a day, 7 days a week.

Languages other than English

Arthritis Australia has information sheets about rheumatoid arthritis in many community languages.

Information for Aboriginal and/or Torres Strait Islander peoples

Staying Moving Staying Strong has resources for Aboriginal and/or Torres Strait Islander peoples living with arthritis.