JointHealth™ insight   July 2010

Arthritis medications in Canada
Time and time again, by email, telephone, and in person, people with arthritis tell ACE that medications are their most important weapon in their fight against disease.

New advances, along with a better understanding of combination medication therapy, are allowing people with arthritis to live healthier, more productive lives. Advances in the area of disease-modifying anti-rheumatic medications (or "DMARDs") and more specifically biologic response modifiers (or "biologics") have made an incredible difference in the lives of thousands of people living with inflammatory forms of arthritis.

While there are no cures for the over 100 types of arthritis, scientific advances and improved treatments are making a difference for many people living with arthritis today.

JH Med Card
Thousands of Canadians who depend on financial assistance from provincial medication benefit plans do not have access to new or improved medications. Through lengthy bureaucratic reviews or "do not list" decisions, provincial and territorial governments are denying reimbursement for arthritis medications proven safe, effective and cost-effective for people who need them the most.

In the two years since the publication of the first JointHealth™ report card on provincial formulary reimbursement for biologic response modifiers, people with arthritis have seen a marked improvement in the number of biologics covered in several provinces across the country. People in British Columbia, Saskatchewan, Newfoundland, Nova Scotia, and New Brunswick have seen significant improvements in access to reimbursement coverage for biologics. Sadly, people with arthritis in provinces like Manitoba, Prince Edward Island, and the Yukon are still being left behind.

The bottom line is this: medications are an important tool for treating crippling and debilitating forms of arthritis and across the country people with arthritis, who depend on financial assistance from their provincial medication benefit plan, are being routinely denied the medications arthritis specialists say are needed. It is for these reasons that ACE created the JointHealth™ Arthritis Medications Guide.

In this JointHealth™ Arthritis Medications Guide, you will find a chart listing important information about the medications used to treat arthritis in Canada. As well, the guide includes an updated copy of our Report Card on provincial formulary reimbursement listings for biologic response modifiers. The Report Card is a straightforward reference guide informing you about how your province compares to others in terms of review times and listing decisions (both the medications chart and Report Card are located on an easy-to-read pull-out sheet). We have also included an in-depth article on what to consider when making decisions about medications, and an article detailing medication treatment protocols for inflammatory arthritis and osteoarthritis.

Treating arthritis
Treating inflammatory arthritis: early and aggressive

What is inflammatory arthritis?
Inflammatory arthritis is a general term used to describe autoimmune forms of the disease. In inflammatory arthritis, the body's own immune system attacks healthy joints and tissues, causing inflammation and joint damage. Rheumatoid arthritis is the most common form of inflammatory arthritis. Other forms include ankylosing spondylitis, psoriatic arthritis, and juvenile idiopathic arthritis.

A diagnosis of any form of inflammatory arthritis often comes as a shock; because symptoms can appear very suddenly and with little warning, newly diagnosed patients are often left stunned and confused about what to do next.

Research has indicated that one of the most important components of any treatment plan for inflammatory arthritis is to begin early. Often, because of the shock of diagnosis and the suddenness of onset, patients would prefer to take a "wait and see" approach. Also, because of fears about side-effects and complications associated with drug treatment, newly diagnosed inflammatory arthritis patients often want to try "natural" treatments before progressing to pharmaceutical medications. While these fears and preferences are understandable, the research tells us that holding off on pharmaceutical treatments which have been proven effective can be very dangerous.

With some forms of inflammatory arthritis such as rheumatoid arthritis and ankylosing spondylitis, joint damage occurs because of the inflammation. To put it another way, attacking the inflammation that causes joint damage as early as possible can often limit the joint damage that causes long-term deformity and disability. Most importantly, it can also reduce the chances of premature death. For these reasons, it is important to work with your doctor to design and undertake a treatment plan that attacks your arthritis early, and effectively.

Treatment programs for more common and very serious forms of inflammatory arthritis, such as rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis, have several components.

The first course of treatment is often non-steroidal anti-inflammatory drugs (also called NSAIDs and COX-2s). Although they help to reduce inflammation, NSAIDs do not reverse or prevent joint damage. Commonly known NSAIDs include ibuprofen (for example Advil® or Motrin IB®), naproxen (or Naprosyn®), dicloflenac (or Voltaren® and Arthrotec®). Only one COX-2 NSAID, celecoxib (Celebrex®) is available in Canada. Some NSAIDs require a doctor's prescription. Different NSAIDs may work for different people, and some side effects may occur, so it is important to work with a doctor to determine the best course of NSAIDs to try.

Disease modifying anti-rheumatic drugs, or DMARDs, are sometimes called the second line of defense in treatment of more severe inflammatory arthritis. These medications work to relieve symptoms and prevent further joint damage, but cannot reverse joint damage which has already occurred. Examples of DMARDs are methotrexate, hydroxycholoriquine and sulfasalazine. Starting a DMARD early is the key to keeping disability at bay.

The most advanced drugs in the arsenal of treatments for inflammatory arthritis are called biologic response modifiers, or commonly, "biologics". Biologics are a type of DMARD that work to block specific immune responses. In clinical trials, biologics have proven to be very effective at treating the most common forms of inflammatory arthritis, including rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis.

Biologics are proven to radically alter or suppress disease activity making them the most exciting advance in treatment for inflammatory arthritis ever. The research costs to develop a biologic were approximately $1 billion, and because of their targeted mechanism of action they are very expensive to manufacture. For these reasons and others, a prescription for a biologic can cost approximately $20,000 per year. To date, many provincial drug plans offer very restricted reimbursement criteria for biologic prescriptions. It is very important to have an open dialogue with your doctor about which medications are covered under your provincial plans, as well as any private extended medical coverage you may have.

Treating osteoarthritis: a comprehensive approach
Osteoarthritis is the most common form of arthritis. It affects 3,000,000 Canadians. It is caused by the breakdown of cartilage in the joints, and most commonly affects the knees, hips, and hands. It usually starts after 40 years of age, but can strike earlier.

Pharmaceutical treatment options for osteoarthritis are more limited than for inflammatory forms of the disease, although new drugs are being developed which may help to treat the underlying disease as well as the symptoms.

A healthy diet and an exercise program can be the most important components of a treatment plan for osteoarthritis. Research shows that high risk for osteoarthritis can be clearly linked to high body weight. This may be because load-bearing joints are overstressed when they are supporting more weight. In any case, losing weight and/or maintaining a healthy body mass can help to prevent, or treat, osteoarthritis.

Usually, the first line of pharmaceutical treatment recommended is an analgesic (pain reliever), such as acetaminophen (Tylenol®, Panadol®). This is sometimes enough to treat the pain associated with mild osteoarthritis. These types of medications can help to relieve pain, but do not work to reduce inflammation.

If it is determined that a conventional pain reliever alone is not sufficient, traditional NSAIDs may be recommended. These NSAIDs are the same as those described earlier as part of treatment for inflammatory arthritis.

The newest type of NSAID, called a COX-2 inhibitor, has shown promise in treating osteoarthritis. COX-2 inhibitors work by blocking the COX-2 enzyme, and are thought to have a lower risk of causing gastrointestinal side-effects than traditional NSAIDs. They may, however, increase the possibility of cardiovascular side-effects in those at risk. The COX-2 available in Canada is called celecoxib (Celebrex®). As always, it is important to speak with your doctor about the potential benefits and risks of any prescribed treatment.

Sometimes, an injection of corticosteroid, or cortisone, into the joint can relieve inflammation and pain. While an injection can sometimes provide very quick relief to a painful, swollen joint, injections should only be used rarely, as the corticosteroid can weaken the cartilage in the joint and actually promote joint damage.

Making decisions about arthritis medications
Medications are often a critically important part of a successful arthritis treatment plan, and new advancements in medication treatments have expanded the options available to people living with arthritis. That said, decisions around medications can be very difficult to make. Getting all the facts about the medication choices available to you will help you to feel more comfortable and confident about your decision.

Once your doctor has made a medication recommendation, it is up to you to decide what is best for you, your family, and your life. You and your doctor should discuss the pros and cons of using the recommended medication, and you need to get all the information you can.

Here are some facts to get from your physician (along with other credible sources of information) before making a medication decision:
  • The generic and brand name of the medication(s) being recommended
  • The full list of medications in the "class" of the recommended medication
  • An explanation of why a particular medication or combination of medications is being recommended over another
  • A full list of the benefits and risks of the recommended medication
  • What the most common and most serious side effects are
  • What to do if you develop side effects
  • How often you will have to take the medication, and how it is administered
  • A full list of storage instructions for the medication
  • How long you will have to take the medication
  • A list of the benefits and risks of the other medications in the "class" of the recommended medication
  • What will happen if you do not take the recommended medication
  • A list of non-medication treatment options to try in addition to the recommended medication
Once you have this information, you will be better able to discuss with your physician the full range of choices available to you and make an informed decision.

It is important to remember that in the end, while it is great to have reliable information, advice and support, a good decision for yourself is one that comes free from pressure from others. Making a decision to start a medication is your personal choice and no one else's.

Your Responsibilities
Once you make an informed decision to start a medication, that decision comes with certain responsibilities. These include:
  • Agreeing to take the medication as prescribed
  • Getting side-effect monitoring tests done as ordered by your physician
  • Keeping track of health improvements while on the medication and reporting them to your physician at each follow-up visit
  • Reporting any uncommon or worrisome side effects you may experience to your physician right away
  • Storing the medication as instructed by your pharmacist, and paying careful attention to keeping the medication out of the reach of children.
Sticking with it
In terms of "sticking with" a medication, the research shows that the single most important step a person can take is to develop a good relationship with their physician. Contrary to popular belief, a person who asks questions of their physician is viewed more positively by that physician, not as someone who is challenging their medical expertise or authority. When you have a strong working relationship with your doctor, you will be more likely to follow the treatment plan you have designed together.

Reaching an agreement with your physician about your diagnosis is another important factor in sticking with a medication. Clearly, if a person does not agree with a physician's diagnosis, then they will not have the confidence they need to take the medication being recommended.

Also, understanding the risks associated with not treating your arthritis provides you with motivation to "follow doctor's orders". For example, in rheumatoid arthritis, the research is clear that the risk of suffering long-term disability and even death as a result of untreated (or under-treated) disease is substantially greater than the risk of serious side effects from medication therapy. Knowing what the "stakes" are in terms of health outcomes is critical when it comes to medications.

Lastly, clearly understanding the goals of the medication therapy will help you to assess whether it is working. This knowledge translates into feelings of power and control over your arthritis. In the end, only you - in close consultation with your physician - can make informed decisions about starting, tapering off, or stopping medications.

New biologics 'on the block'

Because no one person with inflammatory forms of arthritis responds to medication in the same way – many do not respond nearly well enough or at all – the need for more medications to treat this serious group of diseases is vitally important to those affected.

As we do in each issue of the JointHealth™ monthly medications guide, here are the most recent medications to be approved for sale and use in Canada

Golimumab (Simponi®): This medication is used to treat three of the most common forms of inflammatory arthritis: moderately to severely active rheumatoid arthritis, active ankylosing spondylitis and active psoriatic arthritis. Golimumab is taken by subcutaneous injection (like an insulin shot) every 4 weeks. On April 24, 2009 it was approved by the FDA and Health Canada approved it on April 14, 2009. The Common Drug Review recommended on March 17, 2010 that golimumab be listed on provincial and territorial reimbursement formularies for all three indications.

Certolizumab pegol (Cimzia®): This medication is used to treat adults with moderately to severely active rheumatoid arthritis. Certolizumab pegol, also an anti-TNF medication, is taken by subcutaneous injection (like an insulin shot) every two weeks. This medication was approved by Health Canada on August 12, 2009. It is currently under review by the Common Drug Review, but is covered by some private insurance plans.

Tocilizumab (Actemra®): This medication is used to treat rheumatoid arthritis. It is taken by intravenous infusion (or "IV") every 4 weeks. This medication was approved in the United States by the Arthritis Advisory Committee of the FDA on January 2010. Health Canada approved it for sale in Canada on April 30, 2010. It is currently under review by the Common Drug Review.

Listening to you

We hope you find this information of use. Please tell us what you think by writing to us or emailing us at Through your ongoing and active participation, ACE can make its work more relevant to all Canadians living with arthritis.

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Arthritis Consumer Experts (ACE)

Who We Are

Arthritis Consumer Experts (ACE) provides research-based education, advocacy training, advocacy leadership and information to Canadians with arthritis. We help empower people living with all forms of arthritis to take control of their disease and to take action in healthcare and research decision making. ACE activities are guided by its members and led by people with arthritis, leading medical professionals and the ACE Advisory Board. To learn more about ACE, visit:


Over the past 12 months, ACE received unrestricted grants-in-aid from: Abbott Laboratories Ltd., Amgen Canada, Arthritis Research Centre of Canada, Bristol-Myers Squibb Canada, Canadian Institutes of Health Research, GlaxoSmithKline, Hoffman-La Roche Canada Ltd., Merck & Co. Canada, Pfizer Canada, Sanofi-aventis Canada Inc., and UCB Canada Inc. ACE also receives unsolicited donations from its community members (people with arthritis) across Canada.

ACE thanks these private and public organizations and individuals.


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