Last updated: 5 / 01 / 20

Illustration: https://www.flickr.com/photos/emagineart/

This page contains a brief description that does not cover the medication. For more information read the review in Felleskatalogen.no for the respective drug.

Contents

1 Definition
2 Before any treatment is started
3 Four important questions one should patiently ask for treatment:
4 Follow-up
5 Medical treatment principles in rheumatic diseases
6 Monitoring of blood samples and follow-up
7 Pregnancy and medication
8 Treat against a goal (Treat to target)
9 Medicines (a selection): Alphabetical drug selection with links:
10 Current links
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Definition

Treatment of rheumatic connective tissue disorders and other rheumatic diseases with drugs may be crucial to the prognosis. However, drug use is associated with many uncertainties and objections. Studies have shown that 4% never starts treatment and 40% ends within one year, although continued treatment was planned (reference: Blascke TF, 2012). Good information about the purpose of the treatment, possible side effects and follow-up is therefore important (reference: Arians H, 2019)

Before any treatment is started

It is important to be clear about the disease, what the target is and the side effects that can occur.

Four important questions one should patiently ask for treatment:

Do I need this treatment?
What is the risk of side effects?
Is there an alternative?
What if I do not do anything?

Follow-up

When disease-inducing drugs, Biological drugs or cortisone (high doses) is started by the rheumatologist / rheumatology department and continues to be used, it is common for the specialist / department to follow up in collaboration with the GP until treatment can be terminated. This ensures proper treatment and good patient safety.

Please read more about the control plan here.

Medical treatment principles in rheumatic diseases

Against rheumatic pain is often paracetamol drugs first choice (Paracet, Pinex, Panodil, Paracetamol and more)
- Caution, among other things, in liver disease
Other choices are NSAIDs (Non-Steroidal Anti-Inflammatory Drugs). Examples are Ibux, Ibuprofen, Voltaren, Voltarol, Diclofenac and more
- Caution in the case of gastric ulcers or at the same time "blood thinning medication"
- Prolonged use may increase the risk of acute myocardial infarction (reference: Masclec GMC, 2018)
Some combine paracetamol and NSAIDs, but the Medicines Agency does not recommend this because of increased risk of side effects
Before stronger painkillers (Nobligan, Tramadol, Paralgin Forte with more), other treatments must first be considered. Prolonged use causes less impact and risk of addiction
In joint inflammation, joint puncture and cortisone injection can be a better solution.
If there is a lot of rheumatic inflammation, can Prednisone and / or other disease-inducing drugs (Methotrexate with more) be a better solution. However, if an infection is present, antibiotics (Penicillin with other) are essential
Biological drugs is a group of medicines that can be given if other treatment is not sufficient
In arthritis, data suggest that the need for hip replacement was 3 times higher and knee prostheses 14X times higher before more extensive use of antidepressant treatment began (1996 versus 2011 in Denmark, r: eference Cordtz RL, 2018)
Disease-suppressing / immunosuppressive drugs can be classified according to mechanisms of action
- B-cell inhibitors:
  - Azathioprine (Imurel)
  - Mycophenolate (CellCept)
- T-cell inhibitors
  - Ciclosporin A (Sandimmun Neoral)
  - Tacrolimus (Prograf, Advagraf)
- Folate inhibitor
  - Methotrexate (inhibiting actively dividing cells)

Monitoring of blood samples and follow-up

Please read here (Bindevevssykdommer.no)

Pregnancy and medication

In pregnancy or planning for pregnancy, proper use of drugs is particularly important: current information is on the separate page concerning pregnancy.

Treat against a goal (Treat to target)

Prior to starting treatment, a realistic treatment goal should be established.

The goal may be to achieve less disease activity as measured by symptoms and medical examinations, fewer swollen joints in arthritis, lesser signs of lungs, kidneys or other affected organs, less pain or less fatigue.
It is usually necessary to treat over 3-6 months before relevant evaluation can be done.

It is a goal to treat effectively, but with the least amount of drugs and the lowest possible drug doses. The risk of side effects is then reduced to a minimum. In order to succeed, good and regular contact between patient, GP and specialist is required.

Medicines (a selection): Alphabetical drug selection with links:

Aclasta (zoledronic acid)

Patient information in Norwegian here
Bisphosphonate against osteoporosis given intravenously once a year

Advagraf (Tacrolimus) See Prograf below

Alendronate

Patient information in Norwegian here
Bisphosphonate tablet for osteoporosis given once a week. Accurate correct intake is important for achieving drug effects

Apremilast (if Otezla)

Arava (Leflunomide)

Patient information in Norwegian here
Used against Rheumatoid arthritis (RA). Caution in Fertile Women; Must be stopped at least two years before pregnancy (or by washing out after cholestramine procedure)

Benepali (Etantercept)

Benlysta (Belimumab)

Patient information in Norwegian here
Word SLE, intravenous adjuvant. Initially three times at two week intervals, then monthly)
Biological treatment
Please read more about Benlysta here (Bindevevssykdommer.no)

Bio-equivalent drugs (biosimilars)

Various anti-doping drugs that are almost copies of original preparations
Please read more about bio-equivalent drugs here (Bindevevssykdommer.no)

Bosentan (Tracleer)

Tablets for Pulmonary Hypertension and Ulceration of Fingertips (Diagital Ulcers)
Please see separate page here

Calcigran Forte

Patient information in Norwegian here
Calcium and D Vitamin Supplements, Osteoporosis Prevention Chewable Tablets, Especially In Prednisolone Treatment

Calcort (Deflazocort)

A cortisone preparation that has many common features with prednisolone. Studies suggest that Calcort has the same side effects (and effects) as prednisolone when the dose is similar to prednisolone (reference: Badadjanova G, 1996). Deflazocort such as Calcort or other trade names is not available in Norway.
Information from Wikipedia (English) here

CellCept (Mycophenolate mofetil)

Patient information in Norwegian here
Disease modifiers, tablets, 1000-1.500 mg / day (dosing divided in morning and evening). Hemmer B lymphocytes
Blood test controls: Please see here
Please see more about CellCept here (Bindevevssykdommer.no)

Cimzia (Certulizumab)

Colrefuz (kolkisin)

Please see Kolkisin

Cosentyx (sekukinumab)

Enbrel (Etanercept)

Patient information in Norwegian here
Biological treatment, Inject 1-2 times a week (25-50mg)
Please read more about Enbrel here (Bindevevssykdommer.no)

Evoax (cevilemine) tablets

Alternatives to the Salagen (see below). Stimulates residual saliva production and can be used for dry mouth where one expects a residual function in salivary glands
Evoax is not marketed in Norway. One must apply The Norwegian Medicines Agency on a special form + write prescription
Side effects include sweating, chills, runny nose, headache and other cholinergic side effects. Side effects increase with increasing dose.
In heart or lung disease, Evoax may be contraindicated (not to be used)
The most commonly used dose is 30mg 3 daily
More information here (Drugs.com)

Folic acid

Patient information in Norwegian here
Tablets, 1mg. Used with Metotrexate treatment. Written on "blue prescription" in Norway
Folic acid 0,4mg / d is used for prevention of spinal cord in the first part of pregnancy

Humira (Adalimumab)

Patient information in Norwegian here
TNF inhibitor. Biological treatment
Injected each 14. day
Please read more about Humira here (Bindevevssykdommer.no)

Azathioprine (Azathioprine)

Patient information in Norwegian here
Inhibit B lymphocytes. Dose: 2,0-2,5mg / kg / d.
Allopurinol / Zyloric (against uric acid) increases Imurel effect and side effects
Measure whether genetic disposition for intolerance to Imurel is available (TPMT measurement)
Measure therapeutic area using 6-TGN (Therapeutic Area 3,5-5,0micromol / L). 6MMP <50micromol / L
Blood test controls: Please see here
Please read more about Imurel here (Bindevevssykdommer.no)

Inflectra (Inflix Simab)

Patient information in Norwegian here
Biosimilar to to Remicade and Remsima
Inflicsimab is described on separate page here

Kineret (Anakinra)

Patient information in Norwegian here
Biological treatment Effective against Adult stills disease and other autoinflammatory fever syndromes)
Please read more about Kineret here (Bindevevssykdommer.no)

Colchicine

Patient information in Norwegian here
Tablets against FMF (familial Mediterranean fever), pericarditis og gout, 0,5mg 1-3 times daily. Check leukocytes at the start
The drug is not listed in the "Directory", but in Norwegian Medicines Guide
Please read more here (Bindevevssykdommer.no)

LDN (Low dose naltrexone)

Uncertain if the drug has an effect on pain and fatigue
LDN is an opioid antagonist.
- thus, counteracts the effect of Pinex forte, Paralgin Forte and similar analgesic drugs containing opioid-like substances.
Apply for registration.
Delivery in Norway via Kragerø Apotek
Please read more about LDN here (Bindevessykdommer.no)

MabThera (Rituximab)

Patient information in Norwegian here
Rixathon er Bio-similar drug
B cell inhibitor. Measurement of CD19 + B cells indicates whether the drug still affects the cells
Biological medicine
Used against connective tissue disorders, Rheumatoid arthritis og Vasculitis
Increased infection risk
Please read more about MabThera here (Bindevevssykdommer.no)

Methotrexate / methotrexate

Patient information in Norwegian here
Disease-modifying. Doseres A day in the UK. Tablets or injection. Combined with Folic acid
May cause side effects from the liver (check liver enzymes in a blood test regularly). Generally, 3 alcoholic units per week can be tolerated (but not at all)
To be excreted by the kidneys (80-90%) (Note: Reduced dosing or discontinue treatment if renal failure is detected).
Treatment mustn't be ended before pregnancy
Blood test controls: Please see here
Please read more about Methotrexate here (Bindevevssykdommer.no)

Mycophenolate

Please see CellCept here
NB Myfortic has different pharmacogenetics from CellCept so that AUC cannot be calculated in the same way.

NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)

Nucala (mepolizumab)

Biological medication which inhibits interleukin-5 (IL-5).
The drug is indicated by severe asthma in adults but tested beyond approved indication against Eosinophil granulomatosis with polyangiitis (EGPA, Churg-Strauss vasculitis) (reference: Pagnoux C, 2016)
Prescription; H-prescription which is covered by the patient's health enterprise
Norwegian "Common Catalog" text here

Oluminant (baricitinib)

Patient information in Norwegian about Oluminant here
Tablets against Rheumatoid arthritis (RA) which does not have sufficient effect methotrexate or equivalent anti-rheumatic drug alone
Combined with methotrexate
Recommended dose for adults is tablets 4 mg once daily (2 mg / day for patients over 75 years of age)
Works by blocking Janus Kinase (JAK) signals in the cells. This reduces the development of rheumatic inflammation
Possible side effects include outbreaks of Herpes zoster infection ("Shingles"), Tuberculosis, others Opportunistic infections and increased general infection tendencies
Follow-up in collaboration with rheumatologist
Before starting treatment, it is recommended to Exclude signs of tuberculosis og hepatitis
Regular Blood tests are recommended
More information on separate page here
More information here (Norwegian Common Directory)

Opsumit (marcitentan)

Tablets used for Pulmonary Hypertension
Please read more about Ospumit on a separate page here

Orencia (abatacept)

Patient information in Norwegian here
Biological medication which is approved by Rheumatoid arthritis
Used outside approved indication against GPA / Wegeners granulomatosis. Studies in progress
Prescription: H-prescription which is covered by the patient's health enterprise

Otezla (apremilast)

Inhibits PDE4 (phosphodiesterase inhibitor) used against Psoriasis (Plaque psoriasis).
The drug has also shown an effect against Behcet's disease (on wounds in mucous membranes), Rheumatoid arthritis og Ankylosing spondylitis
Please read more about Otezla here (Bindevevssykdommer.no)

Plaquenil (Hydroxychloroquine)

Patient information in Norwegian here
"Antimalaria tablets", antiparasitic wood SLE and some other connective tissue disorders
Eye surgery is recommended annually, especially when the drug has been used for more than 5 years (reference: American Academy of ophthalmology, 2016)
Dose 1-2 Tablets (200-400mg / day)
Blood test controls: Please see here
Please read more about Plaquenil here (Bindevevssykdommer.no)

Prednisone

Patient information in Norwegian here
Cortisone-like tablets which have rapid disease-reducing effects in many autoimmune inflammatory rheumatic diseases. Combine with Calcigran Forte to prevent osteoporosis
Prednisolone leads to a risk of significant side effects, especially at high doses and for long periods of time
Please read more about Prednisolon here (Bindevevssykdommer.no)

Prograf (Tacrolimus)

T-cell inhibitor, calcineurin
I Studies on rheumatoid arthritis (RA) doses of 1-3 mg / d (tablets) divided into 2 doses / day are most appropriate
Sampling and measurement of concentration, please see here (anx.no/takrolimus)
Creatinine increase in blood occurs (NB! Kidney function).
Serum measurements indicate that C-0 values (the morning before the first dose) of 3-8 ng / ml may indicate adequate dose
Protection against strong sun is recommended because the medication can contribute to increased risk of skin cancer
Blood test controls: Please see here
Norwegian "Common Catalog" text here
Apply for individual refund in Norway on application to HELFO on §3 (a and b combined) more: HELFO
- Reference Zhang, 2016 (SLE NON-FREE)

Remicade (Infliximab)

Patient information in Norwegian here
Biological medication, TNF inhibitors: See also Remsima and Inflectra (bio-equivalent)
Please read more about Remicade, Remsima and Inflactra here (Bindevevssykdommer.no)

Remsima (Inflix Simab)

Patient information about Remsima here
Bio-similar drug (Like Remicade and Inflectra)
Please read more about Remsima here (Bindevevssykdommer.no)

Revatio (sildenafil)

Please see Orisild here

Rixathon (rituximab) is bioequivalent to MabThera

Please see information here

RoActemra (Tocilizumab)

Salagen (pilokarpin)

Information in English Wikipedia here
The most commonly used dose is 5mg 3 tablets daily
Stimulates residual saliva production and can be used for dry mouth if one expects a residual function in salivary glands
Salagen is not marketed in Norway and one must apply The Norwegian Medicines Agency on a special form + write prescription
Side effects include sweating, chills, headaches and other minor serious cholinergic side effects. The incidence of side effects increases with increasing dose
If one suffers from cardiovascular or eye disease, one may not use the Salagen

Sandimmun Neoral (Ciclosporin A)

Patient information in Norwegian here
About sampling and measurement of medication measurement, please see here (anx.no/ciclosporin)
- C0 level (morning blood test before first drug dose of 60-125 ng / ml may indicate proper dose
Beyond blood tests, also the blood pressure should be checked regularly
Protection against strong sun is recommended because the medication can contribute to increased risk of skin cancer
Blood test controls: Please see here
Please read more about Sandimmun Neoral here (Bindevevssykdommer.no)

Sendoxan (Cyclophosphamide)

Patient information in Norwegian here
Strong immunosuppressant drug given during a period of severe rheumatic disease, for example at lung involvement.
Most often intravenous infusion every 2-X NUMX months for 4-3 months, then transition to Imurel, Metotrexate or CellCept tablets
Combined most often with Prednisolon or Solu-Medrol
Blood test controls: Please see here
Please read more about Sendoxan here (Bindevevssykdommer.no)

Sildenafil

Please see Orisild here

Simponi (Golimumab)

Patient information in Norwegian here
Indications
Biological medication, TNF inhibitor (vs. Rheumatoid arthritis, Psoriatic arthritis, Ankylosing spondylitis, Ulcerative colitis)
Serum measurement and antibody, please see here (anx.no/golimumab) Bottom concentration (just before the next injection)
Prescription: H-prescription which is covered by the patient's health enterprise

Soliris (eculizumab)

Norwegian "Common Catalog" text here
Biological medication approved for use at
- Paroxysmal nocturnal hemoglobinuria
- Atypical hemolytic-uremic syndrome (atypical HUS)
Promising results when used outside approved indication against serious / catastrophic Antifosfolipid syndrome
Prescription: H-prescription which is covered by the patient's health enterprise

SoluMedrol (Methyl prednisolone)

Patient information in Norwegian here
Intravenous cortisone given for 1-3 days in severe rheumatic inflammation before transition to Prednisone tablets and any additional immunosuppressive treatment. Fast effect
Please read more about SoluMedrol here (Bindevevssykdommer.no)

Stellara (Ustekinumab)

Patient information in Norwegian here
Biological medication against Psoriasis (in Norway) which also has an effect on rheumatic disease. Often combined with methotrexate
Prescription: H-prescription which is covered by the patient's health enterprise

Tacrolimus

se Prograf og Advagraf above

Tracleer (bosentan)

Tablets against pulmonary hypertension and digital ulcers
Please see separate page here

Viatmin D

Please read about vitamin D here (Bindevevssykdommer.no)

Ambrisentan (ambrisentan)

Tablets for Pulmonary Hypertension
Please read about Volibris on separate page here

Volon A oral saliva 0,1%, (DERMAPHARM)

2-3 times / day v need.
Applyed in Norway via The Swedish Medicines Agency on exemption from registration + "white" prescription

Xeljanx (tofacitinib)

Basic information in Norwegian here
Tablets against Rheumatoid arthritis (RA) which does not have sufficient effect methotrexate or equivalent anti-rheumatic drug alone
Combined with methotrexate
The usual dose is 1mg (5mg) morning and evening but lower dose in some cases
Please read more about Xeljanz (tofcitinib) here (Bindevevssykdommer.no)

Current links

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