Why are there so many different treatment options for Still’s Disease?
If you have diabetes, your doctor gives you insulin. And if you have asthma, you are prescibed ventolin. Easy, right?
But why are there so many different types of medications that are used to treat Still’s Disease? Why isn’t everybody just on, say, Methotrexate or Plaquenil or Enbrel? Why is there so many treatment options available — and when should each be used?
The answer lies in the fact that the human immune system is incredibly complex and even doctors are only just coming to understand the intricacies of how auto-immune diseases like Still’s Disease actually function. Despite having many different options available to them, your rheumatologist will most likely approach the treating of your illness in a very systematic way.
The first treatment stage: Controlling the inflammation
If you have just been diagnosed with Still’s Disease, it is likely that your doctor will prescribe you both a prescription strength NSAID and a corticosteroid like prednisone. The aim of the game here is to control the inflammtion that causes pain, swelling and discomfort very quickly. Both NSAIDs and corticosteroids are very effective at offering rapid relief.
Although effective in the intial phases, steroids are not often used as a long term treatment option due to the severe side effects that are associated with these drugs and low long term tolerability. On the other hand, NSAIDs are useful tools, but most sufferers will not be able to control the disease with anti-inflammatory drugs alone.
The second treatment stage: Preventing long term damage.
Once the inflammation has been controlled, your doctor will want to get you on a DMARD (disease modifying anti-rheumatic drug).
It is here where it all gets complicated.
Still’s Disease for one is not necessarily Still’s Disease for the next. Different sufferers have different parts of the immune system that are disfunctional. To put this into perspective, the immune system contains over 40 different types of cytokines (a type of cell that allows the immune system to communicate with itself), B-Cells, T-Cells, Tumor Necrosis Factor cells, and macrophages… and any one of these could be causing your inflammation. And you guessed it: each is treated with a different drug.
The first line in treatment is usually either Methotrexate or Sulfasalazine. These drugs are considered generally effective when used correctly and are relatively well tolerated by most patients. For many sufferers, they will find that Methotrexate alone will be enough to control the illness indefinitely. Others, however, will find that their improvement is only modest and will need to explore the next stage in treatment options.
The third treatment stage: Doubling up
One of the peculiar attibutes of DMARDs is that they often work very well when combined together. Someone that does not initially respond well to Methotrexate alone will find that the efficacy of the treatment skyrockets as soon as another DMARD is added into the mix. At this stage, doctors will commonly prescribe sulphur based medication, malaria medication such as hydroxychloroquine (Plaquenil), gold salts or other more exotic medications such as the anti-transplant-rejection medication cyclosporin (Neoral) to increase the effectiveness of the Methotrexate.
These drugs suppress the general immune system, but many patients find that the treatment remains ineffective. In these cases, it is likely that your symptoms are controlled by one of the specialist parts of the immune system.
The fourth treatment stage: Bringing out the big guns - Biologics.
For ten years rheumatologists have been using a new class of medications known as anti-TNF biologics. These drugs, commonly referred by their brand names of Enbrel, Humira, Infliximab and Remicade provide relief to around 60-70% of Still’s Disease sufferers.
These drugs target a special immune system function known as Tumor Necrosis Factor and is responsible for cell death and the inflammatory response it encourages in the body. While these drugs are a godsend for some sufferers, others will find effective treatment continues to be ellusive.
The fifth treatment stage: Tap the T-Cells.
T Cells are one of the main enforcers of the immune system, and for a small amount of sufferers, the T-Cell delivery systems are faulty. After all other options have been exhausted, your doctor can use drugs like Aurentia to suppress T-Cell function - hopefully bringing relief.
The sixth treatment stage: Blast the B-Cells
B-Cells are the main causative agents in producing plasma - an important immune function that creates antibodies that can misfunction when a patient suffers from an autoimmune disease like Still’s Disease. Although rare, some patients’ disease function is dominated by B-Cell disfunction. Here drugs such as Rutuximab can offer relief.
The important thing to remember about Still’s Disease treatment is that it can takes weeks, months or even years to arrive at an effective treatment regime. Don’t be too dissapointed if a medication is proving to bein effective: it is likely that your doctor will have another treatment option available. Although patience is most certainly a virtue, it is very likely that there will be a drug that will work for you — sometimes it just takes a while to arrive at an effective option.
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