Pharmacological Treatments in Canada
There are several classes of medications prescribed to treat Spondyloarthritis (SpA). We’ve put together these resources to better help you understand the different types of pharmacological treatments available to people with SpA.
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What is a DIN?
Drug Identification Number. Once a drug has been assigned a DIN, it means that it has undergone a successful Health Canada review process and is currently authorized for sale in Canada. It is an 8 digit number that can be found on the packaging of your medication. You are typically required to enter your DIN in order to access the online patient support group information for biologics and biosimilars.
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
Non-steroidal anti-inflammatory drugs (NSAIDs) act by blocking the inflammation that occurs in the lining of your joints. They can be very effective in controlling pain and stiffness. Usually you’ll find your symptoms improve within hours of taking these drugs but the effect will only last for a few hours, so you have to take the tablets regularly. Some people find that NSAIDs work well at first but become less effective after a few weeks. In this situation, it sometimes helps to try a different NSAID. Like all drugs, NSAIDs can have side-effects, so your doctor will reduce the risk of these, by prescribing the lowest effective dose for the shortest possible period of time and selecting the best NSAID based on other health conditions you may have. NSAIDs can cause digestive problems (stomach upsets, indigestion or damage to the lining of the stomach) so in some cases NSAIDs will be prescribed along with a drug called a proton pump inhibitor (PPI) that will help to protect the stomach. NSAIDs also carry an increased risk of heart attack or stroke. Although the increased risk is small, your doctor will be cautious about prescribing NSAIDs if there are other factors that may increase your overall risk, for example, smoking, circulation problems, high blood pressure, high cholesterol or diabetes. The most common NSAIDs prescribed for AS include Naproxen
| Medication | Mechanism | Indications | Delivery | Dose and Frequency | Side Effects |
|---|---|---|---|---|---|
| NSAIDs such as: -diclofenac (Voltaren®️) -ibuprofen (Motrin®️, Advil®️) -naproxen (Naprosyn®️) | Inhibits both COX-1 and COX-2 | Inflammation and pain caused by RA, AS, PsA, OA. Does not treat the underlying disease process. | Pill | Dose varies based on drug | Most common: stomach upset, heartburn, indigestion. Most serious: peptic ulcer disease, kidney toxicity, increased risk of cardiovascular disease, modest worsening of high blood pressure, liver toxicity, asthma, low blood counts, increased risk of asthma, skin rash. Most side effects are dose dependent. |
| NSAIDs such as: -diclofenac (Voltaren®️ Emulgel) -diclofenac (Pennsaid®️ Topical Solution) | Inhibits both COX-1 and COX-2 | Inflammation and pain caused by muscle and joint injuries and associated symptoms from arthritis. | Topical | Dose varies on use. Should not be used in combination with other NSAIDs, such as oral NSAIDs. | Most common: skin irritation, increased sensitivity of the skin to sunlight. Rare side effects include: blistering at the application site, heartburn, stomach discomfort, bleeding in the stomach or intestines |
| COX-2 NSAIDs: -celecoxib (Celebrex®️) | Selectively inhibits COX-2 | COX-2 NSAIDs: -celecoxib (Celebrex®️) Selectively inhibits COX-2 Inflammation and pain caused by RA, AS, PsA, OA. Does not treat the underlying disease process. Pill Dose depends on condition. 100-200mg, twice per day or as needed. Most common: same as other NSAIDs with less incidence of indigestion and stomach upset. May also cause bloating, nausea, stomach pain, heartburn and constipation. Most serious: Same as other NSAIDs except the risk of peptic ulcer disease is reduced by half and there is a possible increased risk of cardiovascular disease at the higher dose (200mg twice daily). Rare side effects: allergic reactions such as skin rashes or wheezing, headaches, dizziness, unusual bruising or bleeding, kidney problems, GI problems. | Pill | Dose depends on condition. 100-200mg, twice per day or as needed. | Most common: same as other NSAIDs with less incidence of indigestion and stomach upset. May also cause bloating, nausea, stomach pain, heartburn and constipation. Most serious: Same as other NSAIDs except the risk of peptic ulcer disease is reduced by half and there is a possible increased risk of cardiovascular disease at the higher dose (200mg twice daily). Rare side effects: allergic reactions such as skin rashes or wheezing, headaches, dizziness, unusual bruising or bleeding, kidney problems, GI problems. |
Conventional synthetic disease modifying anti-rheumatic drugs (csDMARDs)
csDMARDs are the first line of management along with NSAIDs, although they have not been shown to be very effective. These drugs aim to prevent AS from getting worse, and can take up to six months before you may notice any significant change. For some DMARDs you’ll need to have regular blood tests, and in some cases a urine test at regular intervals. The tests allow your doctor to monitor the effects of the drug on your condition but also to check for possible side effects, including problems with your liver, kidneys or blood count. You can take NSAIDs along with DMARDs, and some people may need to take more than one DMARD at a time. There are many DMARDs available, the most commonly prescribed is Methotrexate (Metoject®, Rheumatrex®, Methotrexate Sodium®, generics) and Leflunomide (Arava®, Generics). A newer DMARD that has been approved is Tofacitinib (Xeljanz®) which targets an enzyme responsible for inflammation. Other DMARDs that may be used in certain situations includes sulfasalazine (Salazopyrin®, various generics), azathioprine (Imuran®, various generics) , hydroxychloroquine (Plaquenil®, various generics) and cyclosporin (Neoral®, various generics).
| Medication | Mechanism | Indications | Delivery | Dose and Frequency | Side Effects |
|---|---|---|---|---|---|
| azathiopurine (Imuran®️) | Inhibits purine synthesis. | Inflammation and pain caused by RA, SLE, CTDs, vasculitis Treats underlying disease process in SLE, vasculitis, CTDs | Pill | 50-100mg daily | Most common: stomach upset, fever, infection, unexpected bruising or bleeding, nausea Most serious: increased risk of infection, low blood counts, mouth ulcers, liver toxicity. Serious drug interactions with allopurinol. Remission maintaining treatment may be continued during pregnancy. Treatment is also compatible with breastfeeding. |
| hydroxychloroquine sulfate (Plaquenil®️) | Blocks toll-like receptors on plasmacytoid dendritic cells | Inflammation and pain caused by PsA, RA, SLE, OA | Pill | Adults dose ranges from 200 to 400mg per day. Can be a single dose of 2. | Most common: stomach upset, cramps, diarrhea and itchy skin rash. Long term use can cause skin pigmentation changes and other skin rashes, and ringing in the ears. Rare: irritability, nightmares, headaches, blurred vision, vision halo. Most serious: rarely it can cause visual changes or loss of vision. Rare reports of changes in heart rhythm have been reported. |
| leflunomide (Arava®️) | Inhibits mitochondrial enzyme dihydroorotate dehydrogenase | Inflammation and pain caused by RA. Treats underlying disease process in RA and PsA. | Pill | Daily dose ranged from 10-20mg | Most common: stomach upset, diarrhea, increased risk of infection, high blood pressure, headache, skin rash. Most serious: liver toxicity and damage, severe inflection, low blood counts, nerve damage. Teratogenic, should be avoided in pregnancy. Discontinue 2 years prior to conceiving. Breastfeeding is not recommended. |
| methotrexate (Rheumatrex®️) | Exact mechanism in rheumatic disease is unclear. Inhibition of enzymes involved in purine metabolism is thought to play a role. | Inflammation and pain caused by RA, AS, PsA, SLE Treats underlying disease process in RA, AS, SLE, PsA (peripheral arthritis only) | Pill or injection | 7.5-10mg/ week | Most common: mouth ulcers, stomach upset, nausea, diarrhea, headache, fatigue, mood symptoms. |
| sulfasalazine (Salazopyrin®️) | Exact mechanisms unclear. Inhibition of prostaglandins is thought to contribute to effect. | Inflammation and pain caused by RA, AS, PsA Effective at treating the underlying disease process in RA, AS (peripheral arthritis only) | Pill | Adult dose ranges from 500-2000 mg daily. | Most common: nausea, stomach upset, diarrhea, abdominal pain, skin rash. Most severe: liver toxicity, severe skin rash, drop in blood counts, temporary drop in sperm, kidney stones. |
Targeted Synthetic Molecules (tsDMARD)
* We have included in this section information on the Patient Support Programs (PSP) offered with each medication. These programs usually include financial support, often to offer a bridge until the patient’s insurance takes over reimbursement of the medication. Some PSP’s have other offerings to support patients. Each PSP is owned by the manufacturer of the medication and may vary from one company to the other.
| Medication | Mechanism | Indications | Delivery | Dose and Frequency | Side Effects | Patient Support Program* |
|---|---|---|---|---|---|---|
| tofacitinib citrate (Xeljanz®️) | Inhibits JAK1, JAK 2, and JAK3, and to a lesser extent TyK2 | Inflammation and pain caused by RA | Pill | 5mg, once in the morning and evening | Most common: nausea, indigestion, diarrhea, headaches, upper respiratory tract infection, may increase cholesterol levels. Most severe: increased risk of serious infection, drop in red and white blood cell counts, may irritate the liver, may increase risk of bowel perforation and may cause slight decrease in kidney function. Should be discontinued 6 weeks prior to planned pregnancy. Should not be used if breastfeeding. | https://www.xeljanz.com/sign-up |
| apremilast (Otezla®️) | Inhibits phosphodiesterase 4 | Inflammation and pain caused by PsA. Also decreases redness, thickness, and scaliness in plaque psoriasis. | Pill | 30mg twice per day | Most common: diarrhea, nausea, vomiting, headache, upper respiratory tract infections, tension headache and weight loss. Common side effects include depression, suicidal thoughts or behaviours and tachycardia. | https://www.otezla.com/supportplus |
| baricitinib (Olumiant®, tsDMARD) | Inhibits janus kinases (JAKs), reducing the phosphorylation and activation of STATs | For adults with moderately to severely active rheumatoid arthritis (RA) for whom a TNF inhibitor did not work well enough. | Pill | Recommended adult dose is 2 mg once daily in combination with methotrexate. | Most common: upper respiratory tract infections, such as a cold or sinus infections, nausea, cold sores, and shingles Most severe: increased risk of serious infections (i.e., tuberculosis), higher risk of developing shingles, possible increased risk of lymphoma and other cancers, and possible blood clots in the veins of the legs or lungs. | https://www.olumiant.com/olumiant-together |
| upadacitibib (Rinvoq®️) | Inhibits Janus kinases (JAK) with a high degree of selectivity against other kinases | Indicated for the treatment of adults with moderately to severely active RA who have had an inadequate response or intolerance to methotrexate. | Pill | Recommended adult dose is 15mg once daily. | Common side effects include: upper respiratory tract infections (common cold, sinus infections), nausea, cough, and fever. Most severe: increased risk of serious infections (i.e., tuberculosis), higher risk of developing shingles, possible increased risk of lymphoma and other cancers, possible blood clots in the veins of the legs or lungs and arteries, possible tears in the stomach or intestines, and possible changes in certain laboratory tests Should not be used in people who are pregnant, plan to become pregnant, are breastfeeding, or plan to breastfeed | https://www.abbvie.com/patients/patient-assistance.html?utm_source=myAbbVie-Assist-URL |
Biologic response modifiers (boDMARD)
Patients with AS may not be adequately controlled by NSAIDs and DMARDs but can be treated by a new class of medications called biologic response modifiers, or biologics. These are prescribed by rheumatologists and are injected under the skin or given intravenously and work to prevent inflammation that may result from an overactive immune system.
Biosimilars (bsDMARD): New types of biologics have been approved by Health Canada. These are called “biosimilars”. As the name suggests, they are similar (but not identical) versions of a previously approved biologic medication. Biosimilars are modelled after a previously approved biologic but because they are large, complex, and made in living cells introducing some level of natural variation they are not identical.
What is the difference between biologic and biosimilar? Biologics are a class of treatments derived from living cells (proteins) that target specific parts of the immune system, and are proven to effectively treat many diseases. Biosimilars are similar but not identical versions of an existing or original biologic medication. The exact conditions for making biologics are not made public, so while biosimilars are made by the same process as the original biologic, there may be small differences resulting in variances in the product. Differences in techniques may include the type of cells used to produce them, the temperature at which the cells are grown, the pH at which the cells are grown, and the types of nutrition provided to the cells. Unlike generics, where the active ingredient is identical to the brand name drug, biosimilars are the same protein as the originator biologic but may have some small structural changes due to differences in production. Biosimilars and biologics have the same mechanism of action, meaning that they target the same biological pathway, and should result in the same benefits and risks with treatment.
| Medication | Mechanism | Indications | Delivery | Dose and Frequency | Side Effects | Patient Support Program |
|---|---|---|---|---|---|---|
| abatacept (Orencia®️) | T-Cell co-stimulatory blockade, blocking the activation of T-cells | Inflammation, pain, joint damage caused by RA, JIA, PsA. Highly effective at treating symptoms and underlying disease processes in RA, JIA. | Intravenous infusion or subcutaneous injections | Depends on weight. Ranges from 500-1000mg IV/month and 125mg subcutaneous/week. | Most common: infusion reactions can occur, headache, runny nose, muscle or joint pain, sore throat, nausea, dizziness, heartburn. Most serious: increased risk of serious infections, possible increased risk of lymphoma, reactivation of hepatitis B or tuberculosis (TB) To be used consistent with methotrexate. Pregnancy and breastfeeding should be avoided due to lack of data. | Orencia OnCall |
| adalimumab (Humira®️, boDMARD) | TNF-alpha blocker | Inflammation, pain, joint damage caused by RA, AS, PsA, JIA, Crohn’s disease, ulcerative colitis, non-infectious uveitis, plaque psoriasis. Highly effective at treating symptoms and underlying disease processes in RA, AS, PsA, JIA, Crohn’s disease, ulcerative colitis, non-infectious uveitis, and plaque psoriasis. | Subcutaneous injections | 40mg injection every 2 weeks. Loading dose may be required based on condition. | Most common: heachache, skin rash, injection site reactions, increased risk of minor infections. Most serious: low blood counts, increased risk of serious infection, MS-like symptoms, possible increased risk in lymphoma, reactivation of hepatitis B or tuberculosis anti TNF-alpha antibody therapy is feasible throughout pregnancy. In stable remission, therapy may be discontinued at the end of the second trimester, though there is no evidence of increased risks of postpartum malformation or infection. Breastfeeding is compatible with this therapy. | AbbVie Care |
| adalimumab (Amgevita®, bsDMARD) | Binds and neutralizes TNF-alpha | Effective at treating RA, JIA, PsA, AS, adult and pediatric Crohn’s disease, ulcerative colitis, adult and adolescent hidradenitis suppurativa, psoriasis, and adult and pediatric uveitis | Subcutaneous injections | Recommended adult dosage is 40mg injection every 2 weeks. Loading dose may be required based on condition. Pediatric dosage varies by patient weight. | Most common: infections in the nose and throat, sinuses, and upper respiratory tract, injection site reactions (redness, itching, bleeding, pain or swelling), headache, and muscle and bone pain Most serious: increased risk of serious infections, failure of bone marrow to produce blood cells, disorder of the nerves, lupus and lupus-like conditions, and possible malignancies. | /EnLiven Services |
| adalimumab (Hadlima®, bsDMARD) | TNF-alpha blocker | Reducing the signs and symptoms of RA, JIA, PsA, AS, adult Crohn's disease, ulcerative colitis, hidradenitis suppurativa, plaque psoriasis, and adult and pediatric uveitis | Subcutaneous injection | Recommended adult dosage is 40mg injection every 2 weeks. Loading dose may be required based on condition. Pediatric dosage varies by patient weight. | Most common: injection site reactions and cough and cold symptoms | Harmony By Organon |
| adalimumab (Hulio®, bsDMARD) | TNF-alpha blocker | Effective at treating RA, JIA, PsA, AS, adult and pediatric Crohn’s disease, ulcerative colitis, adult and adolescent hidradenitis suppurativa, psoriasis, and adult and pediatric uveitis | Subcutaneous injection | Recommended adult dosage is 40mg injection every 2 weeks. Loading dose may be required based on condition. Pediatric dosage varies by patient weight. | Most common: injection site reaction, cough and cold symptoms (including sore throat), headache, rash, nausea, fever, and abdominal pain. Most serious: increased risk of serious infections, reactivation of tuberculosis, nerve disorder, appendicitis, risk of blood clots, bladder infection, and hepatitis | |
| adalimumab (Hyrimoz®, bsDMARD) | TNF-alpha blocker | Reducing the signs and symptoms of RA, JIA, PsA, AS, adult Crohn's disease, ulcerative colitis, hidradenitis suppurativa, psoriasis, and adult uveiti | Subcutaneous injection | Recommended adult dosage is 40mg injection every 2 weeks. Loading dose may be required based on condition. Pediatric dosage varies by patient weight. | Most common: mild injection site reaction (i.e., itching, pain, swelling), rash, nausea, abdominal pain, headache, and upper respiratory tract infections (i.e., sinusitis). Most severe: increased risk of serious infections (i.e., tuberculosis), neurologic events, and malignancies | Sandoz Continum |
| dalimumab (Idacio®, bsDMARD) | TNF-alpha blocker | Used in the treatment of RA, JIA, PsA, AS, adult and pediatric Crohn’s disease, ulcerative colitis, adult and adolescent hidradenitis suppurativa, psoriasis, and adult and pediatric uveitis | Subcutaneous injection | Recommended adult dosage is 40mg injection every 2 weeks. Loading dose may be required based on condition. Pediatric dosage varies by patient weight. | Most common: injection site reaction, cough and cold symptoms (including sore throat), headache, rash, nausea, fever, and abdominal pain. Most serious: increased risk of serious infections, reactivation of tuberculosis, nerve disorder, appendicitis, risk of blood clots, bladder infection, and hepatitis | Kabicare |
| anakinra (Kineret®️) | IL-1 inhibitor | Inflammation and pain caused by RA, adult Still’s disease. Rare auto-inflammatory disease. Also used in systemic JIA. | Subcutaneous injection | 100mg daily injection | Most common: injection site reactions, skin rash, headache, nausea, diarrhea, sinus infection, abdominal pain, increased risk of minor infections Most serious: increased risk of serious infection, reactivation of hepatitis B and tuberculosis May be used during pregnancy. Insufficient data to support the use during breastfeeding. | Kineret OnTrack |
| belimumab (Benlysta®️) | Inhibits B-cell activating factor | Effective at treating symptoms and underlying disease processes in SLE. Approved for skin and joint manifestations. | Intravenous infusion or subcutaneous injections | IV dose is based on weight and on initial or maintenance dose. SC dose is 200mg/ week. | Most common: nausea, diarrhea, fever, stuffy nose, cough, trouble sleeping, leg or arm pain, depression, headache, sore throat, UTI, decreased white blood cell count, vomiting, stomach pain, toothache, sudden high blood pressure Most serious: possible cancer, allergic and infusion reactions, serious reactions may occur on the day or day after receiving dose, and may cause death, infections, heart problems, mental health problems, suicidal thoughts, reactivation of hepatitis B and tuberculosis. Rare effect of progressive multifocal leukoencephalopathy. Should be avoided in pregnancy and breastfeeding due to insufficient data. | GSK ForYou |
| canakinumab (Ilaris®️) | Blocks IL-1 | Controls both systemic and joint inflammation caused by systemic JIA in patients aged 2 years older, helps maintain inactive disease. | Subcutaneous injection | 4mg/kg every 4 weeks | Most common: fever lasting longer than 3 days, cough, phlegm, chest pain, difficulty breathing, ear pain, prolonged headache, localized redness, warmth/swelling of skin, sudden bleeding or easy bruisin, sore throat, low levels of blood platelets, feeling dizzy, vertigo, ulcers due to infections, low levels of while blood cells Most serious: pneumonia, bronchitis, cellulitis, chronic tonsillitis, lower respiratory tract infection, sepsis and tonsillitis and other serious infections including of the skin, lungs, and blood. | Novartis Patient Assistance |
| certolizumab pegol (Cimzia®️) | TNF blocker | Inflammation, pain, joint damage caused by RA, AS, PsA, and plaque psoriasis, Crohn’s disease. Highly effective at treating symptoms and underlying disease processes in RA, AS, PsA, plaque psoriasis, Crohn’s disease. | Subcutaneous injection | Stater dose is 400mg every 2 weeks. Maintenance dose is either 200mg every 2 weeks or 400mg injections every 4 weeks. | Most common: upper respiratory tract infections, rash, UTI, lower respiratory tract and lung infections Most serious: infections including malignancies including possible increased risk of lymphoma, reactivation of hepatitis B and tuberculosis. Treatment is compatible with both pregnancy and breastfeeding. | Cimzia Solutions |
| denosumab (Prolia®️) | Binds RANKL, preventing it from activating RANK | Osteoporosis in postmenopausal women who have a high risk of bone fractures; or patients who have failed or are intolerant to other available osteoporosis therapy. | Injection | 60 mg, twice year | Most common: back pain, pain in arms and legs, high cholesterol, muscle pain and bladder infection. Most serious (rare): infections of the skin, abdomen, bladder or ear, endocarditis due to infection, osteonecrosis of the jaw, hypocalcemia, reactivation of hepatitis B or tuberculosis. | |
| etanercept (Enbrel®, boDMARD) | TNF inhibitor (soluble TNF receptor, binds to TNF alpha and beta) | Inflammation, pain, joint damage caused by RA, AS, JIA, PsA, plaque psoriasis. Highly effective at treating symptoms and underlying disease processes in RA, AS, JIA, PsA, plaque psoriasis. | Subcutaneous injection | 50mg injection every week | Most common: headache, skin rash, injection site reactions, rash, increased risk of minor infections, dizziness. Most serious: low blood counts, increased risk of serious infections, MS-like symptoms, possible increased risk of lymphoma, reactivation of hepatitis B and tuberculosis. | EnLiven Services |
| etanercept (Brenzys®, bsDMARD) | TNF blocker | Treating RA, PsA, and AS in adults, JIA, and psoriasis in adults and children | Subcutaneous injection | 50mg once per week | Most common: injection site reactions, upper respiratory infections, headaches. Most serious: nervous system diseases, blood problems, heart problems, allergic reactions, cancer, liver problems, hepatitis B, psoriasis, serious infections | Harmony By Organon |
| etanercept (Erelzi®, bsDMARD) | TNF blocker | Treatment of RA in adults. Reduces signs and symptoms of PsA, AS, and JIA. | Subcutaneous injection | 50mg once per week | Most common: injection site reactions, upper respiratory infections, headaches. Most serious: nervous system diseases, blood problems, heart problems, allergic reactions, cancer, liver problems, hepatitis B, psoriasis, serious infections | Sandoz Continum |
| golimumab (Simponi®️) | TNF-alpha blocker | Inflammation, pain, joint damage caused by RA, AS, PsA. Highly effective at treating symptoms and underlying disease processes in RA, AS, PsA, nrAxSpA. Also used to treat ulcerative colitis. | Subcutaneous injection | 50-100mg every month | Most common: upper respiratory tract infection, nausea, abnormal liver tests, redness at site of injection, high blood pressure, bronchitis, dizziness, sinus infection, flu, runny nose, fever, cold sores, numbness or tingling. Most serious: serious infection, increased risk of lymphoma, reactivation of hepatitis B and tuberculosis, heart failure, nervous system problems, liver problems, blood problems. Treatment is compatible with pregnancy and breastfeeding. | Janssen Carepath |
| infliximab (Remicade®️, boDMARD) | TNF-alpha blocker | Inflammation, pain, joint damage caused by RA, AS, JIA, PsA, plaque psoriasis, Crohn’s disease, ulcerative colitis. Highly effective at treating symptoms and underlying disease processes in RA, AS, JIA, PsA, plaque psoriasis, Crohn’s disease, ulcerative colitis. | Intravenous infusion | 5mg/kg. Frequency varies based on induction or maintenance. | Most common: headache, skin rash, infusion reactions, rash, increased risk of minor infections. Most serious: low blood counts, increased risk of serious infection, MS-like symptoms, possible increased risk of lymphoma, reactivation of hepatitis B or tuberculosis. Treatment is compatible with pregnancy and breastfeeding. | Janssen CarePath |
| infliximab (Avsola®, bsDMARD) | TNF-alpha blocker | Reduces signs and symptoms of RA, AS, PsA and treats plaque psoriasis. Also used to treat ulcerative colitis and Crohn’s disease in children and adults. | Intravenous infusion | 3-5mg/kg. Frequency varies based on induction or maintenance. | Most common: respiratory infections (that may include sinus infections and sore throat), headache, rash, coughing, and stomach pain. Most severe: reactivation of hepatitis B and tuberculosis, increased risk of serious infection, heart failure, liver injury, blood disorders, nervous system disorders, allergic reactions during or after the infusion, lupus-like syndrome, psoriasis, and increased risk of malignancy including lymphoma. | Amgen Assist |
| infliximab (Inflectra®, bsDMARD) | TNF-alpha blocker | Reduces signs and symptoms of RA, AS, PsA and treats plaque psoriasis. | Intravenous infusions | 3-5mg/kg. Frequency varies based on induction or maintenance. | Most common: abdominal pain, nausea, vomiting, diarrhea, back pain, aching joints, rash, flushing, headaches, upper respiratory tract infections. Most serious (rare): infusion reactions, increased risk of infection, nervous system disorders making heart failure worse, and malignancy. | Phizer EnCompass |
| infliximab (Renflexis®, bsDMARD) | TNF-alpha blocker | Reduces signs and symptoms of RA, AS, PsA and treats plaque psoriasis. Also used to treat ulcerative colitis and Crohn’s disease. | Intravenous infusion | Dose based on weight. 3 starting doses over the first 6 weeks followed by one dose every 6-8 weeks. | Most common: infusion reactions, respiratory infections such as sinus infections and sore throat, shortness of breath, joint pain, rash on the cheeks or arms that gets worse in the sun. Most severe: reactivation of hepatitis B and tuberculosis, increased risk of serious infection, heart failure, liver injury, blood disorders, nervous system disorders, allergic reactions during or after the infusion, lupus-like syndrome, psoriasis, and increased risk of malignancy including lymphoma. | Harmony By Organon |
| ixekizumab (Taltz®) | Binds to IL-17A, inhibiting the release of proinflammatory cytokines and chemokines. | Treatment of PsA, AS, non-radiographic axSpA in adults, and plaque psoriasis in adults and children. | Subcutaneous injection | Dose varies based on disease and weight. | Most common: injection site reactions, increased risk of upper respiratory tract infections, nausea, and fungal skin infections. Most serious: increased risk of serious infection, reactivation of tuberculosis, and may cause Crohn’s disease or ulcerative colitis to start or get worse. Insufficient information on the effects of Taltz on pregnancy or breastfeeding. | Talz Together |
| rituximab (Rituxan®️, boDMARD) | Targets B-cells | Inflammation, pain, joint damage caused by RA; used to treat ANCA vasculitis and can reduce or prevent organ damage. | Intravenous infusions | 1000mg IV every 6 months | Most common: infusion reactions (flushing, sweating, chest pains). These reactions are typically managed by slowing the rate of infusion and are less frequent after the first infusion. Most serious: sore throat, fever, chills, or other signs of infections, unusual bruising or bleeding, severe pain in the stomach area, vision changes, unusual eye movement, loss of balance, confusion, disorientation, difficulty walking, serious risk of infection, reactivation of hepatitis B or tuberculosis. Higher risk of reactivation of hepatitis B compared to other biologics. Rare side effect of multifocal leukoencephalopathy. Not recommended for pregnancy or breastfeeding. | OnCare |
| rituximab (Riabni®, bsDMARD) | Targets B-cells | RIABNI in combination with methotrexate is indicated in adult patients to reduce signs and symptoms in adult patients with moderately to severely active RA who have had an inadequate response or intolerance to one or more tumour necrosis factor (TNF) inhibitor therapies. Also used for the treatment of non-Hodgkin’s lymphoma, chronic lymphocytic leukemia, and ANCA vasculitis. | Intravenous infusions | The recommended dosage is 1000 mg by IV infusion followed two weeks later by a second 1000 mg IV infusion. | Most common: mild or moderate infusion-related reactions. These reactions are typically managed by slowing the rate of infusion and are less frequent after the first infusion. Most severe (rare): possibility of severe infusion-related reactions, severe skin reactions, reactivation of hepatitis B, progressive multifocal leukoencephalopathy (rare brain infection), higher risk of infections, cardiovascular reactions, renal toxicity, and bowel obstruction or perforation. | Amgen Assist360 |
| rituximab (Riximyo®, bsDMARD) | Targets B-cells | Riximyo in combination with methotrexate is indicated in adult patients to reduce signs and symptoms in adult patients with moderately to severely active RA who have had an inadequate response or intolerance to one or more tumour necrosis factor (TNF) inhibitor therapies. Also used to treat ANCA vasculitis. | Intravenous infusions | The recommended dosage is 1000 mg by IV infusion followed two weeks later by a second 1000 mg IV infusion. | Most common: infusion reactions. These reactions are typically managed by slowing the rate of infusion and are less frequent after the first infusion. Most severe: possibility of severe infusion-related reactions, severe skin reactions, reactivation of hepatitis B or TB, progressive multifocal leukoencephalopathy (rare brain infection), higher risk of infections, and cardiovascular reactions. | |
| rituximab (Ruxience®, bsDMARD) | Targets B-cells | RUXIENCE in combination with methotrexate is indicated in adult patients to reduce signs and symptoms in adult patients with moderately to severely active RA who have had an inadequate response or intolerance to one or more tumour necrosis factor (TNF) inhibitor therapies. Also used to treat ANCA vasculitis. | Intravenous infusions | The recommended dosage is 1000 mg by IV infusion followed two weeks later by a second 1000 mg IV infusion. | Most common: infusion-related reactions, higher risk of infections (may include fever, chills), body aches, tiredness, and nausea Most severe: serious infusion-related reactions, severe skin and mouth reactions (i.e., painful sores or ulcers on the skin, lips, or in mouth, blisters, peeling skin), hepatitis B virus reactivation, progressive multifocal leukoencephalopathy (rare brain infection), cardiovascular reactions, and higher risk of serious infections | Phizer EnCompass |
| rituximab (Truxima®, bsDMARD) | Targets B-cells | Truxima in combination with methotrexate is indicated in adult patients to reduce signs and symptoms in adult patients with moderately to severely active RA who have had an inadequate response or intolerance to one or more tumour necrosis factor (TNF) inhibitor therapies. Also used to treat ANCA vasculitis. | Intravenous infusions | The recommended dosage is 1000 mg by IV infusion followed two weeks later by a second 1000 mg IV infusion. | Most common: infusion-related reactions, higher risk of infections (may include fever, chills), body aches, tiredness, and nausea. Most severe: serious infusion-related reactions, severe skin and mouth reactions (i.e., painful sores or ulcers on the skin, lips, or in mouth, blisters, peeling skin), hepatitis B virus reactivation, progressive multifocal leukoencephalopathy (rare brain infection), cardiovascular reactions, kidney problems, stomach and serious bowel problems, and heightened risk of serious infections. | Teva Support Solutions |
| sarilumab (Kevzara®️) | IL-6 receptor blocker | Inflammation, pain, joint damage caused by RA | Subcutaneous injection | 200mg every 2 weeks | Most common: neutropenia, increased ALT, injection site reactions, upper respiratory tract infections. Most serious: serious infections leading to death or hospitalization (TB, hepatitis and other viral reactivation), liver abnormalities, gastrointestinal infection, diarrhea, headache, dizziness. | RxHelp, RenAssisst, Ontrack |
| secukinumab (Cosentyx®️) | IL-17A blocker | Inflammation, pain and joint damage caused by AS and PsA in adults, plaque psoriasis and children and adults | Subcutaneous injections | 150mg every 4 weeks | Most common: upper respiratory tract infection, gastrointestinal disorders, injection site reactions. Most serious: Increased risk of infection (TB), inflammatory bowel disease Should be avoided in pregnancy due to lack of data. | https://www.cosentyx.ca/ |
| tocilizumab (Actemra®️) | Inhibits IL-6 signalling | Inflammation, pain, joint damage caused by RA and JIA. Highly effective at treating symptoms and underlying disease processes in RA and JIA. | Intravenous infusions or subcutaneous injections | IV: 4mg/kg every 4 weeks SC: 162mg weekly | Most common: upper respiratory cold and sore throat, high blood pressure and elevated liver enzymes. Most serious: infections (in some cases fatal), gastrointestinal perforations, allergic reactions including anaphylaxis, reactivation of hepatitis B and tuberculosis. Should be avoided in pregnancy due to insufficient data. | RxHelp, RenAssisst, Ontrack |
| ustekinumab (Stelara®️) | Blocks IL-12 and IL-23. | Inflammation, pain, joint damage caused by PsA. Highly effective at treating symptoms and underlying disease processes on PsA, Crohn’s disease, ulcerative colitis, plaque psoriasis. | Intravenous infusions or subcutaneous injections | Dose varies based on disease and weight. Loading dose may be IV and maintenance dose SC. | Most common: upper respiratory infections, headache, fatigue. Most serious include: increased risk of infection, including reactivation of hepatitis and tuberculosis, increased risk of certain types of cancers. Should be avoided in pregnancy due to lack of data. | Jannesen CarePath |
Opioids
An opioid isn’t the first choice for treating chronic conditions such as arthritis. Aside from cancer pain, opioids more commonly are reserved for short-term pain relief, such as after injuries or surgeries. When other means of relieving arthritis pain haven’t helped, opioids may be prescribed. But safety and effectiveness are issues.
| Medication | Mechanism | Indications | Delivery | Dose and Frequency | Side Effects |
|---|---|---|---|---|---|
| Oral opioids: -codeine (Tylenol #2, Codeine Contin) -morphine (Morphine, M-Elson) -oxycodone (Percocet, Oxycontin) | Act on receptors located on cells of the nervous system. | Pain from knee and hip osteoarthritis and inflammatory arthritis. | Pill | Depends on condition and severity. | Most common: nausea, vomiting, constipation, sedation or drowsiness, confusion, urinary retention, dry mouth, allergic reactions. Most serious: risk of death or addiction. |
Corticosteroids
Corticosteroids are powerful anti-inflammatory drugs that relieve severe pain and swelling. You take them by mouth or in the form of injections into the joint. Corticosteroids are often used for rapid relief of symptoms in cases where only one or a few joints are affected. Steroid injections are often recommended for joints that are particularly troublesome or when ligaments and tendons become inflamed. Doctors typically prescribe only when really needed. If you use them for a long time, you could have serious side effects such as thinned skin, brittle bones, weight gain, and diabetes. The most common oral corticosteroids that may be prescribed is prednisone (various generics). For intra-articular injections, methylprednisolone (Depo Medrol®, various generics) is most commonly used.
| Medication | Mechanism | Indications | Delivery | Dose and Frequency | Side Effects |
|---|---|---|---|---|---|
| cortisone dexamethasone hydrocortisone methylprednisolone prednisone prednisolone | Differs based on the drug. | Inflammation caused by RA, AS, PsA, SLE, vasculitis. Sometimes injected into a joint of OA. Can be used as a bridge before DMARD therapy takes effect. | Glucocorticoids can be given by mouth, by IV infusion, by intramuscular injection, by injection directly into a joint or tendon sheath when there is local inflammation. | Dose depends on condition and method. | Side effects are usually dose and time dependent. They rarely occur with single injections or short courses, but are very frequent and sometimes irreversible with higher doses or long courses. Short term side effects include: sleep disturbance, mood swings or even psychosis, blurred vision. Below are side effects that are generally seem with long term use (a couple of months): Most common: stomach upset, thin skin, easy bruising, central weight gain, facial fullness, buffalo hump, increased hair growth, acne, thin extremities with muscle wasting and weakness, glaucoma, cataracts, increased cardiovascular risk, high cholesterol, high blood pressure, mood swings, depression, osteoporosis and increased risk of fracture, increased risk of infections, worsening of diabetes in known diabetics or induction of diabetes in people already prone to developing it. Rare but serious: psychosis, severe depression, stroke, heart attack, pancreatitis, peptic ulcer disease. Osteonecrosis (can occur over short term use) due to the interruption of blood supply to the end of a long bone (hip, knee, shoulder). This may cause complete destruction of the joint and is irreversible. Osteonecrosis risk is higher in SLE. Adrenal crisis can occur in long-term use as it usually suppresses adrenal gland function. |
Acetaminophen
Acetaminophen is used to treat pain associated with osteoarthritis and, sometimes, inflammatory forms of arthritis like Spondyloarthritis. It is taken orally in pill or liquid form.
| Medication | Mechanism | Indications | Delivery | Dose and Frequency | Side Effects |
|---|---|---|---|---|---|
| Tylenol | Pain caused by RA, AS, PsA, SLE, OA. Does not treat the underlying disease process. | Pill | 500mg every 4 hours as needed. Do not exceed 4000mg per day. | There are few common side effects. Rare side effects are rash, low blood counts, stomach upset. Most serious: sudden liver failure (large overdose) or chronic liver failure if used at higher than recommended doses, with alcohol or with other liver-toxic drugs. Possible kidney damage. |
Summary of Medications Available in Canada
We have include information on medications indicated for Psoriasis, Crohn’s and Colitis due to significant prevalence of these complications in Spondyloarthritis
| generic name (Brand Name) | AS | nr-AxSPA | Psoriatic Arthritis | Psoriasis* | Crohns & Colitis** | Juvenile Idiopathic Arthritis | Rheumatoid Arthritis |
|---|---|---|---|---|---|---|---|
| abatacept (Orencia®️) | N/A | N/A | ✓ | N/A | N/A | ✓ | ✓ |
| adalimumab (Humira®, boDMARD) | ✓ | N/A | ✓ | ✓ | ✓ | ✓ | ✓ |
| adalimumab (Amgevita®, bsDMARD) | ✓ | N/A | ✓ | ✓ | ✓ | ✓ | ✓ |
| adalimumab (Hadlima®, bsDMARD) | ✓ | N/A | ✓ | ✓ | ✓ | ✓ | ✓ |
| adalimumab (Hulio®, bsDMARD) | ✓ | N/A | ✓ | ✓ | ✓ | ✓ | ✓ |
| adalimumab (Hyrimoz®, bsDMARD) | ✓ | N/A | ✓ | ✓ | ✓ | ✓ | ✓ |
| adalimumab (Idacio®, bsDMARD) | ✓ | N/A | ✓ | ✓ | ✓ | ✓ | ✓ |
| anakinra (Kineret®) | N/A | N/A | N/A | N/A | N/A | ✓ | ✓ |
| belimumab (Benlysta®) | N/A | N/A | N/A | N/A | N/A | N/A | N/A |
| canakinumab (Ilaris®) | N/A | N/A | N/A | N/A | N/A | ✓ | N/A |
| certolizumab pegol (Cimzia®) | ✓ | N/A | ✓ | ✓ | N/A | N/A | ✓ |
| denosumab (Prolia®) | N/A | N/A | N/A | N/A | N/A | N/A | N/A |
| etanercept (Enbrel®, boDMARD) | ✓ | N/A | ✓ | ✓ | N/A | ✓ | ✓ |
| etanercept (Brenzys®, bsDMARD) | ✓ | N/A | ✓ | ✓ | N/A | ✓ | ✓ |
| etanercept (Brenzys®, bsDMARD) | ✓ | N/A | ✓ | ✓ | N/A | ✓ | ✓ |
| golimumab (Simponi®) | ✓ | ✓ | ✓ | N/A | ✓ | N/A | ✓ |
| infliximab (Remicade®, boDMARD) | ✓ | N/A | ✓ | ✓ | ✓ | ✓ | ✓ |
| infliximab (Avsola®, bsDMARD) | ✓ | N/A | ✓ | ✓ | ✓ | N/A | ✓ |
| infliximab (Inflectra®, bsDMARD) | ✓ | N/A | ✓ | ✓ | ✓ | N/A | ✓ |
| infliximab (Renflexis®, bsDMARD) | ✓ | N/A | ✓ | ✓ | ✓ | N/A | ✓ |
| ixekizumab (Taltz®) | ✓ | ✓ | ✓ | ✓ | N/A | N/A | N/A |
| rituximab (Rituxan®, boDMARD) | N/A | N/A | N/A | N/A | N/A | N/A | ✓ |
| rituximab (Riabni®, bsDMARD) | N/A | N/A | N/A | N/A | N/A | N/A | ✓ |
| rituximab (Riximyo®, bsDMARD) | N/A | N/A | N/A | N/A | N/A | N/A | ✓ |
| rituximab (Ruxience®, bsDMARD) | N/A | N/A | N/A | N/A | N/A | N/A | ✓ |
| rituximab (Truxima®, bsDMARD) | N/A | N/A | N/A | N/A | N/A | N/A | ✓ |
| sarilumab (Kevzara®) | N/A | N/A | N/A | N/A | N/A | N/A | ✓ |
| secukinumab (Cosentyx®) | ✓ | N/A | ✓ | ✓ | N/A | N/A | N/A |
| tocilizumab (Actemra®) | N/A | N/A | N/A | N/A | N/A | ✓ | ✓ |
| ustekinumab (Stelara®) | N/A | N/A | ✓ | ✓ | ✓ | N/A | N/A |
| apremilast (Otezla®, tsDMARD) | N/A | N/A | ✓ | ✓ | N/A | N/A | N/A |
| baricitinib (Olumiant®, tsDMARD) | N/A | N/A | N/A | N/A | N/A | N/A | ✓ |
| tofacitinib (Xeljanz®, tsDMARD) | N/A | N/A | ✓ | N/A | N/A | N/A | ✓ |
| upadacitinib (Rinvoq®, tsDMARD) | N/A | N/A | N/A | N/A | N/A | N/A | ✓ |
Note:
N/A (Not Applicable) = No Notice of Compliance (or NOC) has been issued for this medication for this form of arthritis.
✓= used to treat this inflammatory arthritic condition
Disclaimer: This information is for educational purposes only. Always refer to your physician when looking into starting a new medication. Doses are approximate and based on the recommended adult dose. Doses may vary based on disease severity and individual needs. All the medications listed are approved by Health Canada in Spondyloarthritic conditions.