Ask the pharmacist: "I'm starting new arthritis medication, what do I need to know?"

From managing side effects to making sense of supplements, taking medicines can raise lots of questions for people living with arthritis. Professor Nick Barber, an internationally recognised expert in medicines and author of How to Take Drugs, answers some of the questions we hear most often.

Q. When starting a new arthritis medicine, what practical advice can help people use it safely and get the most benefit from treatment? 

A. Starting a new medicine can be a little like starting a new relationship. You need time to find out whether you get on well together, and both of you may have to make some changes for that to work. 

Start by reading the patient information leaflet and following the instructions from your healthcare team. Take your medicine at the recommended dose and at the right time. This gives it the best chance of working safely and effectively.

Try to establish a routine that fits your lifestyle. You could link taking your medicine with something you already do regularly, such as brushing your teeth, having breakfast or going to bed. Weekly medicines can be particularly easy to forget, so a phone reminder or calendar alert may help. 

Persevere, unless you quickly develop side effects that are difficult to manage. After a while, you may find that you can’t manage to take the medicine properly or that the side effects are too severe. In that case, go back to your healthcare team. Taking it at a different time, at a lower dose or in a different form may help. Or a different medicine may suit you better. There’s often an element of trial and error in finding a medicine that you can take regularly and that works well for you.

Q. Many people feel anxious about side effects after reading patient information leaflets, searching online or hearing about other people's experiences. How can people make sense of medicine risks without becoming overwhelmed? 

A. Before anyone takes a medicine, we don’t know for certain whether they will have side effects or, if they do, which ones, how severe they will be or how long they will last. Once we start a medicine, it’s natural to assume that if we feel different, it must be a side effect. However, that may not be the case. 

Drug information leaflets are not always easy to interpret. They are there to make sure you know about the medicine's possible side effects before you take it. They are also not particularly helpful because they describe the likelihood of side effects using words such as ‘common’ and ‘rare’. For example, a side effect described as ‘common’ may affect as few as one in 10 people.

Many side effects are relatively mild or tolerable because you feel the medicine is giving you enough relief for the benefits to outweigh them. So, it can be easy to overestimate the risk of side effects from the leaflet. The same is true of online sources and chatrooms. People who have been troubled by side effects are more likely to report them, while those who have no or acceptable side effects are less likely to do so.

When you start a medicine, you’re trying it out and finding out how it affects you. If the side effects are troublesome, there may well be ways to manage them. 

Q. People often worry that medicines such as methotrexate and biologics weaken the immune system too much, while others look for ways to ‘boost’ immunity. What’s helpful for people to understand about immune health and infection risk? 

A. Methotrexate and biologic medicines work by calming down an overactive immune system – which is exactly what drives the inflammation and joint damage in conditions like rheumatoid arthritis. This can mean the medicines make your immune system somewhat less reactive, which can slightly raise your risk of infections, particularly when combined with steroid medicines. 

Take what steps you can to reduce your chance of infections, and get any treated as soon as possible. Vaccination is important but a tricky subject, and you need to get good advice. Most live vaccines are not recommended while you’re taking these treatments.

If you need one of these vaccines, you may, under medical supervision, stop one of your medicines for a short while. You should take up other vaccines to protect you from infections such as COVID and flu. Always check with your GP or healthcare professional.

As for ‘boosting’ immunity, there’s no reliable evidence that supplements or special diets meaningfully strengthen immune defences, and for people on disease-modifying drugs or biologics with inflammatory arthritis, stimulating an already overactive immune system may not be helpful.

Q. For many people living with persistent pain, painkillers can gradually become a routine way of managing symptoms, whether bought over the counter or prescribed. What risks do people often underestimate with longer-term use? 

A. Long-term use of painkillers can adversely affect major systems in your body. It’s best to avoid long-term use if possible, so first look at the alternatives. Gentle exercise, stretching, weight loss, applying heat and cold, joint supports and household aids can all help. These may avoid the need for painkillers or reduce the dose required. Occupational therapists and physiotherapists can be really helpful with this. Now let’s look at the common painkillers.

Paracetamol is probably the safest of the painkillers, but it is not particularly effective for many people. It can be linked to liver problems, particularly if you have other factors that affect the liver.
NSAIDs (non-steroidal anti-inflammatory drugs), such as ibuprofen and diclofenac, can cause stomach problems and sometimes bleeding. They can also affect the kidneys, heart and blood vessels. You should not take aspirin for pain relief while taking methotrexate unless advised by your clinician.

Opioid painkillers, such as codeine, can cause nausea, constipation, dizziness and slow thinking, as well as dependence. Where possible, opioid painkillers are best avoided. 

Do try to get your regular pain medication from your doctor, so it’s on your medical record and you can be monitored for early signs of harm.

Q. People sometimes stop or reduce arthritis medicines without speaking to their healthcare team because they're worried about side effects or long-term harm. What risks can this create, and what would you encourage people to do instead? 

A. The main risk of stopping disease-modifying drugs is that the disease is more likely to progress and there may be a flare-up in the following few months. A short-term break, for example, so a live vaccine can be given, may be appropriate, but you need advice from your healthcare team.

Coming off these medicines completely needs to be carefully considered and monitored after a review of the potential risks and benefits. For people taking prednisolone, there are additional risks of stopping suddenly, which can be very severe. It is important to reduce the dose gradually over time with medical advice.

It’s understandable that you may be worried about long-term harm and side effects, but with these drugs, particularly if you are older or have other conditions, it is important to speak to your healthcare team before you stop taking them.

Q. The joint health market is booming, with products promising everything from pain relief and better mobility to protecting joints. How can people make sense of these claims, and what should they look for when deciding whether a supplement is worth trying?

A. This is a very lucrative marketplace, and influencers can be paid large amounts of money to promote products. Supplements cannot be advertised as proven treatments without being classified as medicines and going through the necessary clinical trials and licensing arrangements. Instead, adverts use language such as ‘supports the body’, ‘helps with’ or ‘is thought to be effective’. Look at trusted sources to find out how effective a product is likely to be.

Although supplements cannot be advertised as medicines, some of the same issues apply. If they do work, what is the right dose? And, of course, they can still have side effects.

Dose is important. Turmeric, for example, is very poorly absorbed by the body, so getting the sort of dose used in some clinical trials may mean taking large amounts for several months. If there is evidence that a supplement or herbal medicine works, check the dose used in the trials. You’ll often find this is higher than the dose in products available from your local health food store.

After a flare-up of my osteoarthritis, I found a trial which showed that glucosamine and chondroitin were effective and discovered two things: it was very expensive to buy them in the doses used, and the resulting constipation was far worse than the arthritis. I never pursued that line of therapy again.

Herbal medicines can have significant effects on the body and may interact with medicines you are taking, so do be careful to research them and get clinical advice.

If you wish to explore supplements, do so with one eye on the literature and the other on your wallet.

This advice is general. You should always check with your healthcare professional before making any decisions about your treatment or medicines.