October 12, 2020

Rheumatoid Arthritis Treatment

Biological medicines are a newer type of medicine, used to ease the symptoms of rheumatoid arthritis (RA) and reduce the damaging effect of the disease on the joints. They are usually prescribed when you have tried the older more traditional types of disease-modifying antirheumatic drugs (DMARDs) but they have not worked well. If a biological medicine will work, you will usually feel better within 12 weeks of starting it. Biological medicines make you more prone to infections and sometimes damage the blood-producing cells. You should carry a biological therapy alert card with you at all times to ensure that doctors or nurses treating you know that you are taking a biological medicine and so are at increased risk of developing a serious infection.

Overview of rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory condition. It can affect many different parts of the body but most commonly affects the joints, causing pain and stiffness. The cause of RA is unknown. It is different from osteoarthritis (OA), which is the most common form of arthritis; OA occurs when the cartilage protecting the joints wears down over time. See the separate articles, Osteoarthritis: Risk Factors, Symptoms, Diagnosis and Natural Course, and also Rheumatoid Arthritis: Risk Factors, Symptoms and Diagnosis.

Treatment plays a key role in controlling the inflammation of RA and in minimizing joint damage. Treatment usually involves a combination of medications and other non-drug therapies. In some cases, treatment may also involve surgery.

The treatment of RA must be tailored to each person's individual situation, including the severity of the condition, the effectiveness of specific therapies, and the presence of any side effects. Treatment choices may also be affected by the person's other health conditions, especially those affecting the liver or kidneys. If you have RA, it is important to work closely with your rheumatologist to discuss your options and form a plan for treatment.

This article discusses the treatment of RA. More information about RA is available separately. See the separate article, Rheumatoid Arthritis: Overview of Risk factors, Symptoms and Diagnosis, and also see Complementary and Alternative Therapies for Rheumatoid Arthritis.

General principles of rheumatoid arthritis treatment

The aim of rheumatoid arthritis (RA) treatment is to control symptoms, prevent joint damage, and maximize your quality of life and ability to function. Joint damage caused by inflammation due to RA generally occurs within the first two years of diagnosis, and it is difficult to predict which individuals will develop long-term complications. Therefore, the initial treatment of RA aims to eliminate or minimize inflammation. However, different treatments come with different possible side effects, and it's important to weigh the benefits and risks. In general, treatments with the potential to stop joint damage are recommended for everyone with RA.

A hand severely affected by rheumatoid arthritis. This degree of swelling and deformation does not typically occur with current treatment. Credit: James Heilman, MD / CC BY-SA
Long-term medical care with a healthcare provider you trust is essential for the successful management of RA. This involves regular visits and tests to assess how well your treatment is working and monitor you for side effects.

General measures to observe in treating rheumatoid arthritis

Almost everyone with established rheumatoid arthritis (RA) require some form of medication to control their disease. This does not diminish the importance of nonpharmacologic (non-drug) therapies, which can improve quality of life, help control symptoms, and minimize joint damage. Effective non-drug therapies include the following:

Education and counseling — Education and counseling can help you to better understand the nature of RA and cope with the challenges of your condition. You and your health care providers can work together to form a long-term treatment plan, define reasonable expectations, and discuss both standard and alternative treatment options.

Approaches such as biofeedback (a technique that teaches you to control certain body functions) and cognitive behavioral therapy or CBT (a form of therapy in which you learn to change how you react to your situation) may be helpful. These measures can reduce pain and disability and improve self-esteem. Programs on topics such as self-management skills, social support, biofeedback, and psychotherapy are offered by the Arthritis Foundation in the United States and by similar organizations worldwide. These services are also offered by many hospitals and clinics. You may want to ask your healthcare provider if they offer such, or if they know local organizations they can refer you to in your area which offer such. These programs have been shown to reduce pain, depression, and disability in people with RA and to allow them to gain some control over their illness.

Rest — Fatigue is a common symptom of RA. While it's important to rest inflamed and painful joints, physical fitness should be maintained as much as possible. Several studies have shown that staying physically active improves the quality of sleep, which in turn helps with fatigue.

Exercise — Pain and stiffness can make it difficult to exercise, leading many people with RA to limit physical activity. However, inactivity can lead to a loss of joint motion, contractions, and a loss of muscle strength. Weakness, in turn, decreases joint stability and further increases fatigue.

Regular exercise can help prevent and reverse these effects. Many different kinds of exercise can be beneficial, including range-of-motion exercises to preserve and restore joint motion, exercises to increase strength, and activities to increase endurance (walking, swimming, and cycling). Even gentle movement on a regular basis can help.

If your joint symptoms make it difficult for you to move or be active, a physical therapist, also called a physiotherapist, can help. They can work with you to identify forms of physical activity that are appropriate based on your symptoms and health. Exercise for people with arthritis is discussed in more detail separately. See the separate article, Arthritis and Exercise: How Exercise Benefits The Different Forms Of Arthritis, for more details.

Physical and occupational therapy — In addition to helping you design an individualized exercise program, a physical therapist or an occupational therapist can offer other approaches to help relieve pain, reduce inflammation, and help preserve joint structure and function.

Specific types of therapy are used to address specific effects of RA. For example:
  • The application of heat or cold can relieve pain or stiffness.
  • Ultrasound (the use of sound waves) may reduce inflammation of the sheaths surrounding tendons (called tenosynovitis).
  • Passive and active exercises can improve and maintain range of motion of the joints.
  • Splinting (to keep a joint from moving) during rest can reduce joint pain and improve function.
  • Finger splinting and other assistive devices can prevent deformities and improve hand function. See the separate article, Rehabilitative and Assistive Technology in Medicine, for more details.
  • Relaxation techniques can relieve muscle spasms associated with joint stiffness.
Physical therapy may also include a consultation with a podiatrist (foot specialist) who can help you with orthotics (devices that ensure correct positioning of the feet) and supportive footwear. Occupational therapists also focus on helping people with RA to be able to continue to actively participate in work and recreational activities, with special attention to maintaining good function of the hands and arms.

Nutrition and dietary therapy — People with active RA sometimes lose their appetite or are unable to eat enough food. If you have this problem, dietary therapy can help to ensure that you are getting enough calories and nutrients. If you are overweight or obese, your health care provider might recommend trying to lose weight in order to reduce stress on your joints. See the four different separate articles, The Sure Path to Weight Loss (Weight Reduction), How to Lose Weight in a Safe and Healthy Way, How to Loose Weight Fast...And Safely Too, and How to Loose Weight without Dieting, for more details on weight loss.

People with RA have a higher risk of developing coronary artery disease, which increases the risk of heart attack or stroke. High cholesterol is one risk factor for coronary disease that can respond to changes in diet. A nutritionist can recommend specific foods to eat or avoid to achieve a desirable cholesterol level.

Specific changes in diet have been studied as potential treatments for RA. The addition of fish oils and some plant oils, such as borage seed oil, have modestly improved arthritis pain and joint swelling. However, there is no particular diet that can cure RA. In addition, herbal or nutritional supplements, such as cartilage or collagen, can be dangerous and are not usually recommended. See the separate article, Complementary and alternative therapies for rheumatoid arthritis.

Smoking and alcohol — Several studies have shown that smoking is a risk factor for RA and that quitting smoking can improve symptoms. If you smoke, it's important to try to quit completely. This can be very difficult to do, but your health care provider can help.

Moderate alcohol consumption is not harmful to RA, although it may increase the risk of liver damage associated with certain drugs, such as methotrexate. If you drink alcohol, it's important to discuss this with your provider, as the risks will depend on what medications you take and whether you have other health conditions.

Measures to reduce bone loss — RA causes a decrease in bone density, which can lead to osteoporosis (weakness in bone strength causing it to fracture easily). Bone loss is more likely in people who are inactive. The use of steroid medications, such as prednisone, further increases the risk of bone loss, especially in women who have been through menopause.

Several measures can minimize the bone loss associated with steroid therapy:
  • Your healthcare provider will prescribe the lowest possible dose of steroids that is required for the shortest possible time needed to manage your condition.
  • You can make sure to consume an adequate amount of calcium and vitamin D, either through your diet or by taking supplements.
  • Your healthcare provider might prescribe medications that can reduce bone loss, including that caused by steroids.

Medications for rheumatoid arthritis

Medications are the cornerstone of treatment when rheumatoid arthritis (RA) symptoms become active. The goals of medication treatment are to achieve remission of symptoms and signs of RA and prevent further damage of the joints and loss of function, without causing permanent or unacceptable side effects.

The best medication(s) and dose(s) for you will depend upon individual factors as well as potential drug side effects. In most cases, the dose of a medication is increased until inflammation is suppressed or until drug side effects become unacceptable. This balance can pose a challenge, as the need to control inflammation must be weighed against the risk of side effects.

If you take medications for RA, you will need to see your health care provider regularly for examinations and blood tests to monitor for complications. If you do experience side effects, they can often be minimized or eliminated by reducing the dose or switching to a different drug.

Several types of drugs are used to treat RA. They include disease-modifying antirheumatic drugs (DMARDs), nonsteroidal antiinflammatory drugs (NSAIDs), steroids, and, if needed, pain medications.

DMARDs — Disease-modifying antirheumatic drugs (DMARDs) can substantially reduce the inflammation of RA, reduce or prevent joint damage, preserve joint structure and function, and enable a person to continue his or her daily activities. Although some DMARDs act slowly, they may allow you to take a lower dose of steroids to control pain and inflammation. There are several types of DMARDs:
  • Conventional synthetic DMARDs (sometimes called traditional DMARDs), such as methotrexate and sulfasalazine, are produced by traditional drug-manufacturing techniques.
  • Biologic DMARDs, sometimes called "targeted biologic agents," or "biologic medicines," or simply "biologics," are more recent and manufactured using molecular biology (recombinant DNA) techniques. Examples include etanercept, adalimumab, abatacept, and tocilizumab.
  • Other DMARDs, such as tofacitinib, are produced by traditional drug-manufacturing techniques; these are similar to the biologic DMARDs and are sometimes referred to as "targeted synthetic DMARDs."
More detailed information about DMARDs, including the potential side effects, is available separately. See the separate article, Disease-modifying antirheumatic drugs (DMARDs) in rheumatoid arthritis.

NSAIDs — Nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen and naproxen, may be recommended to relieve pain and reduce minor inflammation. Your healthcare provider will likely prescribe a dose that is higher than what people typically take to relieve headache or other minor aches and pains. However, NSAIDs do not reduce the long-term damaging effects of RA on the joints.

NSAIDs must be taken continuously and at a specific dose to optimize their antiinflammatory effect. Even at the correct doses, NSAIDs generally need to be used for several weeks before taking full effect. If the initial dose of NSAIDs does not improve symptoms, a clinician may recommend increasing the dose gradually or switching to another NSAID. You should not take two different NSAIDs at the same time.

Many NSAIDS have significant side effects, including gastrointestinal bleeding, fluid retention, and an increased risk of heart disease. The risks need to be weighed carefully against the benefits when taking these drugs.

More detailed information about NSAIDs is available separately. See the separate article, Nonsteroidal antiinflammatory drugs (NSAIDs).

Steroids — Steroids, also called glucocorticoids or corticosteroids, have strong antiinflammatory effects. Drugs in this class include prednisone and prednisolone. Steroids may be taken by mouth, injected into a vein, or injected directly into a joint. Steroids quickly improve RA symptoms such as pain and stiffness and decrease joint swelling and tenderness.

Steroids are generally used to treat RA that severely limits a person's ability to function normally. In this situation, steroid treatment may help control symptoms and preserve function until other slower-acting drugs with greater ability to prevent joint damage begin to work. Steroids may also be used to treat flares of disease while a person is receiving other treatments. Low doses of steroids are sometimes prescribed for long-term use along with DMARDs if necessary to control disease activity. (See 'Treatment of flares' below.)

Side effects — Steroids have many possible side effects, including weight gain, worsening diabetes, the development of cataracts in the eyes, bone loss (osteopenia and osteoporosis), and an increased risk of infection. Because of this, when steroids are used in the treatment of RA, the goal is to use the lowest possible dose for the shortest period of time.

Non-NSAID pain relievers — Pain relievers can help with pain, but they have no effect on inflammation. Examples include acetaminophen (sold as Paracetamol or Tylenol) and capsaicin cream or ointment.

Use of opioids (narcotics) like codeine, oxycodone, hydrocodone, and tramadol is generally discouraged because they also have no effect on inflammation. There is also risk of dependence and addiction because of the long-term nature of RA. However, treatment with a long-acting opioid may be considered for people with late-stage RA and severe joint damage who cannot undergo joint replacement surgery; this should only be done under the supervision of a rheumatologist or pain specialist.

Treatment of flares — Flares are periods in which symptoms temporarily worsen; these can occur in addition to the ongoing inflammation. Your rheumatologist or other healthcare provider may recommend treating flares by increasing the doses of the drugs you are already taking or adding additional drugs (such as injectable or oral steroids). Rest is often helpful during flares as well.

Which treatment will I get? — The type of drugs that your doctor recommends will depend on how severe your RA is and how well you respond to the medications. If you have early, mild arthritis, your treatment will likely be different from someone who has more severe arthritis or whose symptoms persist despite initial treatments.

In general, nearly everyone with RA will receive a DMARD as part of their treatment program. A different DMARD, whether one of the conventional DMARDs or a biologic agent, will be substituted for or added to the initial drug if treatment is not effective enough. See the separate article, Disease-modifying antirheumatic drugs (DMARDs) in rheumatoid arthritis.

Surgery for rheumatoid arthritis

Even with treatment, some people will progress to "end-stage" rheumatoid arthritis (RA), meaning that there is significant joint damage and loss of function even in the absence of ongoing inflammation. The goals of treatment in end-stage RA include pain relief, slowing or prevention of additional joint damage, maintenance of function, and relief of fatigue and weakness. Nonpharmacologic treatment such as physical and occupational therapy is particularly important. (See 'Physical and occupational therapy' above.)

In some cases, surgery is recommended to improve pain and function in people with end-stage RA. This may involve surgery to stabilize or replace a damaged joint. In such instances, surgical procedures like total hip replacement, or total knee replacement, may become necessary.

Pregnancy in rheumatoid arthritis

Some of the medications used to treat rheumatoid arthritis (RA) are not safe to take during pregnancy. It is important to visit your doctor, or other healthcare provider to talk things over if you get pregnant.

Where to get more information

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

1). Mayo Clinic Staff (2019): Rheumatoid arthritis. Available online: https://www.mayoclinic.org/diseases-conditions/rheumatoid-arthritis/diagnosis-treatment/drc-20353653
2). Centers for Disease Control: Factors that Increase Risk of Getting Arthritis. Available online: https://www.cdc.gov/arthritis/basics/risk-factors.htm
3). National Institutes of Health: Arthritis and Rheumatic Diseases. Available online: https://www.niams.nih.gov/health-topics/arthritis-rheumatic-diseases
4). UpToDate: Patient education: Rheumatoid arthritis treatment (Beyond the Basics). Available online: https://www.uptodate.com/contents/rheumatoid-arthritis-treatment-beyond-the-basics

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