Would you consider the use of doxycycline or minocycline in the management of RA?

When faced with an issue of a TNF side effect or an infectious complication, I have used minocycline for the management of RA. This is based on an observation of minocycline’s effectiveness in early RA. A patient of mine developed optic neuritis while administering adalimumab, and Opthalmology (appropriately) recommended stopping the anti-TNF monotherapy. His joint symptoms flared. We added minocycline to low-dose prednisone with control of disease. Another patient of mine developed an atypical mycobacterial infection while frightened the patient about using immunosuppressives; while on antibiotic therapy, we added minocycline, again with success.

An awareness of side effects is needed when using minocycline, as it can cause some odd effect...

Personally, I have been reluctant to use minocycline in RA as we have so many other options and I harbor serious doubts as to the ability of minocyline's effectiveness if other agents are not helpful. I have seen several cases of minocycline-induced lupus and drug-induced vasculitis. Particularly, I had a young man in his 20s who was taking minocycline for acne and developed SBP > 200's with severe transaminitis with mesenteric angiogram showing renal artery and hepatic artery narrowing and beading, positive ANCA. Resolved with blood pressure control, steroid, and cessation of minocycline. When I looked this up in the literature, several case reports documenting such presentations. Not saying minocycline cannot be used, especially in cases ...

I am glad to hear of Dr. @Dr. First Last's experience. One out of five of our RA patients has treatment-resistant RA (Messelink et al., PMID 34238346), even with so many miraculous biologics and targeted small molecule drugs. So, this is a valid question.

Like Dr. DeMarco, I also come from the days when the minocycline articles appeared, showing great promise for treating RA. I have used it in many patients over the years. Honestly, I cannot name one patient in whom I really thought it made a difference (even after giving it a year). However, I did cause many patients to have the minocycline hyperpigmentation side effect.

This is very different for all the other drugs (including using hydroxychloroquine, HCQ, for mild RA).

I'd say that around...

I have a small cohort of patients with RA who also had a total knee replacement with a subsequently infected prosthesis and a complicated revision/replacement course. Immunosuppressive agents are contraindicated due to the increased risk of recent prostheses infection. Minocycline has been effective in controlling RA activity in some but not all of them.