DMARDs, JAK inhibitors & steroids: a plain guide
Hydroxychloroquine, sulfasalazine, leflunomide, JAK inhibitors, steroids and painkillers — what each one does, what to watch for, and which are safe in pregnancy.
Treatment decisions in rheumatology are best made together with your treating rheumatologist, who knows your full history. These guides are here to help you understand the choices in plain language, so you can ask better questions and feel more settled about the plan you make with your doctor.
How the pieces fit together
Rheumatology medicines fall into a few groups, and understanding the groups makes every conversation with your doctor clearer:
- Conventional DMARDs (methotrexate, hydroxychloroquine, sulfasalazine, leflunomide) — the foundation. They slow the disease and protect joints. First choice for most people.
- Biologics and JAK inhibitors — targeted treatments used when conventional DMARDs aren't enough. Biologics guide →
- Steroids — a fast bridge or rescue, not a long-term plan.
- Painkillers / NSAIDs — for symptoms only; they don't change the disease.
Drug by drug
What it is: Originally an anti-malarial; a gentle immune modulator. First-line for lupus, and used in rheumatoid arthritis, often with methotrexate.
Good to know: One of the safest long-term drugs we have; it does not suppress immunity, reduces flares in lupus and protects against blood clots and organ damage. Takes 2–3 months to work.
Watch for: The eyes: a rare retinal effect after years of use, so a baseline eye check and then yearly checks after 5 years. Occasional nausea or skin darkening.
Pregnancy: Safe — continued through pregnancy and breastfeeding in lupus and RA.
What it is: A conventional DMARD used in rheumatoid arthritis and peripheral spondyloarthritis; often combined with methotrexate.
Good to know: Inexpensive and well-tolerated by most; safe in pregnancy. Turns urine and tears orange — harmless.
Watch for: Nausea early on (build the dose up slowly), rashes, and rarely a drop in blood counts — hence blood tests. Men: a reversible drop in sperm count while taking it.
Pregnancy: Safe in pregnancy and breastfeeding (with folic acid).
What it is: A conventional DMARD comparable to methotrexate in strength; used when methotrexate isn't suitable, or added to it.
Good to know: Effective, once-daily tablet.
Watch for: Liver enzyme rises and raised blood pressure (both monitored), diarrhoea, hair thinning, weight loss. Stays in the body for a very long time.
Pregnancy: Must be avoided. Because it lingers for months to years, a special 'washout' treatment (cholestyramine) is needed before conception — for women and, ideally, men. Plan well ahead.
What it is: Targeted synthetic tablets that block signalling inside immune cells; as effective as biologics, without injections.
Good to know: Fast — often within 2 weeks. Available as low-cost generics in India. Useful when biologics aren't practical.
Watch for: Shingles risk is higher (the recombinant shingles vaccine is worth planning). Regulators advise caution about blood clots, heart events and certain cancers, mainly in people over 65, smokers, or those with existing heart risk — the decision is individual. Blood tests for cholesterol and counts.
Pregnancy: Avoided. Stop before conception; not used in pregnancy or breastfeeding.
What it is: Powerful, fast anti-inflammatories. In rheumatology they're a bridge — to control disease quickly while slower DMARDs take hold — or a rescue for flares and serious organ involvement.
Good to know: Nothing settles inflammation faster. Low doses, used briefly and tapered, are safe and enormously useful.
Watch for: Long-term or high-dose use: weight gain, raised sugar and blood pressure, thinning bones, cataracts, infection risk, mood changes. This is why the goal is always the lowest dose for the shortest time. Never stop suddenly after weeks of use — taper. Ask about bone protection (calcium, vitamin D, sometimes more) if on them for months.
Pregnancy: Can be used when needed, at the lowest effective dose, with monitoring.
What it is: Ibuprofen, naproxen, etoricoxib and similar. They ease pain and stiffness but do not slow joint damage — they are not DMARDs.
Good to know: Helpful for symptoms, especially in spondyloarthritis where they are a core treatment.
Watch for: Stomach, kidney and heart risks with regular long-term use, particularly in older people or those with kidney disease or high blood pressure. Use the lowest dose that works; take with food; tell your doctor if you're using them daily.
Pregnancy: Generally avoided in the third trimester; discuss any regular use.
Rules that apply to all of them
- They take time. Conventional DMARDs need 2–3 months to show their effect; judge them fairly.
- Don't stop when you feel well. Feeling well is the medicine working. Changes are planned together.
- Blood tests are routine, not alarming. They're how we keep these drugs safe over years.
- Fever or infection — hold the immune-modulating drug and get seen. Restart once you're well.
- Tell every doctor what you take. Interactions matter, especially before surgery or with antibiotics.
- Planning a pregnancy changes the plan. Say so early. Several of these drugs are safe in pregnancy; others must be stopped months ahead.
Pregnancy at a glance
| Medicine | Pregnancy |
|---|---|
| Hydroxychloroquine | Safe — continue |
| Sulfasalazine | Safe — continue (with folic acid) |
| Low-dose steroids | Can be used when needed |
| Some anti-TNF biologics | Can be continued with planning |
| Methotrexate | Stop ≥3 months before conception |
| Leflunomide | Stop; needs washout — plan well ahead |
| JAK inhibitors | Stop before conception; avoid |
This is a guide, not a substitute for an individual plan. Tell your rheumatologist as soon as you're thinking about a family.
Questions about a medicine you've been prescribed?
Bring the prescription. I'll explain what it does and how it fits your plan. Walk-in, no appointment.
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