Rheumatoid Arthritis

	Overview
	Health Tools
	FAQs
	Cause
	Symptoms
	What Happens
	What Increases Your Risk
	When to Call a Doctor
	Exams and Tests
	Treatment Overview
	Prevention
	Living with Rheumatoid Arthritis
	Medications
	Surgery
	Other Treatment
	Other Places To Get Help
	Related Information
	References
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Is this topic for you?

There are many types of arthritis (disease of the joints). This topic is about rheumatoid arthritis. If you are looking for information about how juvenile rheumatoid arthritis affects young children, see the topic Juvenile Rheumatoid Arthritis. If you are looking for information on the most common form of arthritis in older adults, see the topic Osteoarthritis.

What is rheumatoid arthritis?

Rheumatoid arthritis (RA) causes tissues lining the joints to become swollen, stiff, and painful (inflamed).

Over time, this inflammation may destroy the joint tissues. This can limit your daily activities and make it hard for you to walk and use your hands.

Rheumatoid arthritis is 2 to 3 times more common in women than in men. It often begins between the ages of 40 and 60.

What causes rheumatoid arthritis?

The exact cause of rheumatoid arthritis is not known. But rheumatoid arthritis is an autoimmune disease. This means that the body's natural defense system attacks the joints. The disease also runs in some families.

What are the symptoms?

The main symptoms of rheumatoid arthritis are pain, stiffness, and swelling in the joints of the hands, wrists, elbows, feet, ankles, knees, or neck. The disease usually affects both sides of the body at the same time. In rare but severe cases, it may affect the eyes, lungs, heart, nerves, or blood vessels.

See a picture of the most commonly affected joints.

Sometimes rheumatoid arthritis can cause bumps called nodules to form over the elbows, knuckles, spine, and lower leg bones.

How is rheumatoid arthritis diagnosed?

There is no single test for rheumatoid arthritis. Your doctor will look at your joints for signs of swelling or tenderness. He or she will also ask about your symptoms and past health.

You may have blood tests, X-rays, and other tests to find out if another problem is causing your joint pain.

How is it treated?

There is no cure for rheumatoid arthritis, but treatment may help relieve symptoms and control the disease. Treatment continues throughout your life.

Treatment includes medicine, exercise, and lifestyle changes.

Experts recommend early treatment with medicines that may control rheumatoid arthritis or keep it from getting worse. Early treatment also may lower the chances that inflammation will destroy your joints and limit your daily activities.

Many of the medicines used to treat rheumatoid arthritis have side effects. So it is important to have regular checkups and talk with your doctor about any problems. This will help your doctor find a treatment that works for you.

At home, you can relieve your symptoms and help control your disease if you:

• Rest when you are tired.
• Protect your joints from injury by using special kitchen tools or doorknobs.
• Use splints, canes, or walkers to ease pain and take stress off your joints, if your symptoms are severe.
• Eat a balanced diet.
• Exercise regularly.
• Stay at a healthy weight.

If medicine, exercise, and lifestyle changes do not help enough, surgery may be an option. Total joint replacement can be done for many joints in the body.

It can be hard to live with a long-term illness that can limit your ability to do things. It is common for people with rheumatoid arthritis to have some depression. Be sure to seek the help and support you need from friends and family members. Professional counseling also can help you cope with long-term pain and depression.

Health tools help you make wise health decisions or take action to improve your health.

	Actionsets are designed to help people take an active role in managing a health condition.
	Arthritis: Managing rheumatoid arthritis

The cause of rheumatoid arthritis (RA) is not fully understood. Genes play a role in rheumatoid arthritis, but experts do not know exactly what that role is. For most people with RA, the disease does not run in their families and they do not pass it along to their children. One or more genes may make it more likely that the body's immune system will attack the tissues of the joints. This immune response may also be triggered by bacteria, a virus, or some other foreign substance.

The abnormal immune response causes ongoing inflammation of the tissues lining the joint, a breakdown of cartilage, and loosening of the ligaments and tendons supporting the joint. Ongoing inflammation also causes the membrane that lines the joint (synovium) to grow into a thick, abnormal tissue called pannus. These processes result in destruction of the cartilage, the underlying bone surrounding the joint, ligaments, and tendons and can eventually lead to deformed joints.

Joint pain can be an early symptom of many different diseases. In rheumatoid arthritis, symptoms often develop slowly over a period of weeks or months. Fatigue and stiffness are usually early symptoms of rheumatoid arthritis. Weight loss and a low-grade fever can also occur.

Joint symptoms of rheumatoid arthritis include:

• Painful, swollen, tender, stiff joints. The same joints on both sides of the body (symmetrical) are usually affected, especially the hands, wrists, elbows, feet, ankles, knees, or neck.
• Morning stiffness. Joint stiffness may develop after long periods of sleeping or sitting and lasts at least 60 minutes and often up to several hours.
• Bumps (nodules). Rheumatoid nodules ranging in size from a pea to a mothball develop in nearly one-third of people who have rheumatoid arthritis. Nodules usually form over pressure points in the body such as the elbows, knuckles, spine, and lower leg bones.

Rheumatoid arthritis can affect the hands, wrists, elbows, feet, ankles, knees, or neck. It usually affects both sides of the body at the same time, and more than three sets of joints are affected at one time.

In addition to specific joint symptoms, rheumatoid arthritis can cause symptoms throughout the body (systemic). These include:

• Fatigue.
• A loss of appetite.
• Weight loss.
• Mild fever.
• Numbness and tingling in the hands.

Some of the symptoms of rheumatoid arthritis may be similar to symptoms of other health conditions.

The course of rheumatoid arthritis is difficult to predict because it may progress slowly or quickly. If the disease progresses, joint pain can restrict simple movements, such as your ability to grip, and daily activities, such as climbing stairs. Rheumatoid arthritis is a common cause of permanent disability. But early treatment may significantly control the course of the disease.

In rare cases, you may get better on your own with no remaining signs or symptoms. This is called spontaneous remission. Partial remission is more common. It involves the relief of some, but not all, symptoms. Although a minority of people with rheumatoid arthritis will achieve a complete remission with treatment, the majority will have improvement in their symptoms.

Rheumatoid arthritis usually progresses gradually.

• Most rheumatoid arthritis cases begin slowly, over weeks to months.
• In a few rheumatoid arthritis cases, symptoms come on rapidly, within days.

Progression of the disease is more likely when:

• A rheumatoid factor blood test is positive.
• A blood test for the antibody CCP (cyclic citrullinated peptide) is positive.
• The disease fails to respond to therapy.
• Bumps (nodules) develop rapidly.
• Many joints are affected.
• X-rays show early loss of bone or cartilage.

In most cases, rheumatoid arthritis does not affect a woman's ability to become pregnant and have a healthy baby. Pregnancy often improves rheumatoid arthritis symptoms, especially from the end of the first trimester on. More than 75% of women have remission of disease activity during pregnancy; however, approximately 80% experience a flare of disease symptoms in the weeks after delivery.¹

Other organ involvement may occur later in the course of the disease. In a small number of severe cases, rheumatoid arthritis may cause damage to the heart, lungs, skin, blood vessels, nerves, and eyes. It is common for people with rheumatoid arthritis to have some degree of depression, which may be caused by pain and progressive disability.

Some people with rheumatoid arthritis cannot keep working because of the symptoms. But experts hope that the newer treatments for rheumatoid arthritis will help more people stay active and be able to work.

Studies have shown that damage to joints occurs in 60% of people with rheumatoid arthritis within 2 years. Because irreversible joint damage, chronic pain, and long-term disability can occur if rheumatoid arthritis is not diagnosed and treated early, it is now recommended that a person with rheumatoid arthritis see a specialist in joint disease (rheumatologist) within the first 3 months after symptoms appear.² As soon as rheumatoid arthritis is diagnosed, early treatment includes medicines known as disease-modifying antirheumatic drugs (DMARDs).

Joint destruction

The pain, stiffness, and whole-body (systemic) symptoms associated with rheumatoid arthritis can be disabling. Over time, rheumatoid arthritis can cause significant joint destruction, leading to deformity and difficulty with daily activities. Specific joint problems may also occur later in the course of the disease.

Hands and wrists are the most common location for deformities caused by rheumatoid arthritis.³

• Swan-neck and boutonniere deformities: Changes in the tissues around the finger joints cause abnormal bending or straightening.
• Swelling of the joints can push the supporting tendons and ligaments out of position, causing the fingers to bend toward the little finger (ulnar drift).
• The tendons may break (rupture), making it impossible to straighten or bend the finger, depending on which tendon ruptures. Tendon loosening is very common in rheumatoid arthritis, due to inflammation of the joints.
• Inflammation in the wrist can limit the ability to bend the wrist up or down.

The feet are a common site of rheumatoid-arthritis-caused deformities that affect more than one-third of people with this disease.⁴

• Hammer toes: Changes in the tissues around the toe joints cause abnormal bending (flexion).
• Hallux valgus/bunion: Changes in the tissues around the big toe joint cause it to bend toward the little toe and develop a bony enlargement.
• Movement of the joints between the toes and foot (metatarsophalangeal subluxation): The ball joints loosen, and the bones press down to the ground.
• Pes planus: The arch joint of the middle foot loosens, which causes a painful flat foot.
• Valgus hind foot: The joint below the ankle loosens, which causes the foot to bend outward.

Inflammation of the knees, if not controlled by treatment, can cause erosion of cartilage and can eventually lead to the need for knee replacement surgery.

X-rays of the neck joints show some damage in 15% of people with rheumatoid arthritis.⁵ This damage can limit how easily you can move your neck. In rare cases, the damage can pinch a nerve or affect the spinal cord and cause numbness, pain, or weakness in the arms or legs.

The only known risk factor for rheumatoid arthritis is a possible inherited factor in some families (genetic predisposition). A genetic factor may affect how the immune system functions, causing inflammation and eventual destruction of the membranes that line the joints.

Other factors that may influence your risk of developing rheumatoid arthritis include:

• Being female. Rheumatoid arthritis affects women 2 to 3 times as often as men.³
• Being between the ages of 40 and 60. Rheumatoid arthritis can begin at any age, but it most often begins in adulthood.⁴

Call your health professional immediately if you have:

• Sudden, unexplained swelling and pain in any joint or joints.
• Joint pain associated with a fever or rash.
• Pain that is so severe that you cannot use the joint.

Call your health professional within the next few days if you have:

• Mild to moderate joint pain that continues and has not improved for over 6 weeks.
• Side effects that occur with large doses of nonsteroidal anti-inflammatory drugs (NSAIDs) or other medicine used to treat your arthritis.

Watchful Waiting

It is reasonable to try home treatment for mild joint pain and stiffness. If there is no improvement after 6 weeks, or if any other symptoms are present, call your doctor.

Early treatment can slow and sometimes prevent significant joint damage. So if you have symptoms similar to rheumatoid arthritis, it is important to see your health professional to determine whether you have rheumatoid arthritis. Early diagnosis and treatment allows for possible reduction of joint pain, slows joint destruction, and reduces the chance of permanent disability.

Who to See

Early arthritis symptoms can be diagnosed by:

• A nurse practitioner.
• A physician assistant.
• A family medicine doctor.
• An internist.
• A rheumatologist.
• An orthopedic surgeon.

Rheumatoid arthritis can be treated by a:

• Family medicine doctor or internist in consultation with a rheumatologist.
• Specialist in inflammatory diseases of the joints (rheumatologist).
• Specialist in bone, muscle, and joint problems (orthopedic surgeon) if surgery is being considered to treat joint problems.

Supportive treatment can be provided by:

• A physical therapist, to assist with exercise and pain management (physical therapy).
• An occupational therapist, to assist with splinting or assistive devices (occupational therapy).
• A counselor, to help manage emotional issues that may occur in a long-term illness (counseling).

No single lab test can diagnose rheumatoid arthritis. Instead, rheumatoid arthritis is diagnosed by symptoms and physical signs and by eliminating other diseases that can cause similar symptoms. Physical signs include joint swelling or tenderness. Symptoms that help in diagnosis are stiffness and pain in the same joints on both sides of the body (symmetrical), morning stiffness, and development of rheumatoid nodules.

A medical history and physical examination are usually done to help determine the cause of joint pain. The pattern and nature of joint signs and symptoms are the most important clues to the diagnosis.

Diagnosis is based on a set of classification criteria for rheumatoid arthritis. The following tests may be done to evaluate your symptoms, to rule out other problems, or to monitor treatment:

• Complete blood count (CBC)
• Erythrocyte sedimentation rate (ESR) (may help to assess disease activity)
• C-reactive protein (may help to assess disease activity)
• Rheumatoid factor (RF)
• Antinuclear antibody assay (ANA)
• Anti-CCP (cyclic citrullinated peptide) antibody test (helps confirm diagnosis and may show your risk of having severe symptoms)
• Joint fluid analysis
• Tissue type (human leukocyte antigen) test
• X-rays (see X-ray images of rheumatoid arthritis in the feet and rheumatoid arthritis of the hands)

Other tests may be done to check for side effects of treatment. These tests may include:

• Kidney function tests.
• Liver and muscle enzyme tests.
• Bone density test, to check for bone loss (osteoporosis).
• Eye examination.

Because rheumatoid arthritis can lead to severe joint destruction and disability over time, regular evaluation by a health professional is important to determine whether current treatment is working or needs to be adjusted.

Rheumatoid arthritis is most often treated with medicine, exercise, and lifestyle changes. Treatment may help relieve symptoms and control the disease, but there is no cure. Treatment for rheumatoid arthritis usually continues throughout your life, but will vary depending on:

• The stage (active or in remission) and severity of your disease.
• Your treatment history.
• The benefits and risks of treatment options.
• Your preferences for treatment options, such as cost, side effects, and daily schedules.

The goal of treatment is to help you maintain your lifestyle, reduce joint pain, slow joint damage, and prevent disability.

Initial treatment

Treatment of rheumatoid arthritis should start with education about this disease, the possibility of joint damage and disability, and the risks and benefits of potential treatments. A long-term treatment plan should be developed by you and your health professional team.⁶

The purpose of early treatment is to:

• Relieve or reduce pain.
• Reduce joint inflammation.
• Improve daily function.
• Prevent or delay significant joint damage and deformity.
• Prevent permanent disability.
• Improve the quality of life.

Experts recommend early and aggressive treatment of rheumatoid arthritis with medicines called disease-modifying antirheumatic drugs (DMARDs) that can actually slow or sometimes prevent joint destruction.⁶ Examples of DMARDs include:

• Methotrexate.
• Etanercept.
• Adalimumab.
• Abatacept.
• Infliximab.
• Leflunomide.
• Sulfasalazine.
• Hydroxychloroquine sulfate.

One study suggested that advances in the treatment of rheumatoid arthritis, including DMARDs, has improved the health of people with the disease over the last 20 years.⁷ DMARD treatment, begun as soon as possible after diagnosis and continued for a prolonged period of time, may prevent damage to joints and other complications of rheumatoid arthritis.⁸

Joint pain, tenderness, and swelling are the most important means of measuring how the disease is progressing or responding to treatment. Nonsteroidal anti-inflammatory drugs (NSAIDs) and/or analgesics (pain relievers, such as acetaminophen, codeine, or hydrocodone) may be used to relieve these symptoms. NSAIDs relieve pain and lower inflammation. Analgesics relieve pain but do not affect inflammation. These medicines do not change the course of the disease or prevent joint destruction. Analgesics or NSAIDs are used as helpers in combination with DMARDs.

Corticosteroids may be used to treat your rheumatoid arthritis. They may be used as:

• Initial therapy until a DMARD has a chance to work (bridge therapy).
• A means of controlling flares of rheumatoid arthritis. When a single joint is inflamed, a corticosteroid injection can be effective in relieving symptoms.
• Disease management when DMARDS do not fully control the disease.

Because of the side effects of corticosteroids, your health professional will use the lowest possible dose and will try to reduce and eventually discontinue use of oral corticosteroids. But this is not always possible.

Exercise, physical therapy, and lifestyle changes can help you decrease joint pain. Many people with rheumatoid arthritis benefit from self-management plans that balance rest and activity. Steps you can take at home to relieve your symptoms and help control your disease include:

• Becoming involved in the day-to-day management of your disease. For more information, see:

  Managing rheumatoid arthritis.

• Staying active physically, mentally, and socially.
• Resting when you are tired.
• Protecting your joints from injury.
• Eating a balanced diet.
• Exercising regularly.
• Controlling your weight.

Ongoing treatment

Treatment for rheumatoid arthritis usually continues throughout your life. Your health professional will want to closely monitor your condition. A rheumatologist should evaluate you regularly. Depending on your symptoms and treatment, this could be done as often as every 2 to 3 months or as infrequently as every 6 to 12 months. Testing, such as blood tests, may be done more often.

During each follow-up visit, your health professional will assess how active your disease is. Markers of disease activity are:

• The amount of joint pain.
• How long morning stiffness lasts.
• The number of actively inflamed joints.
• How well you are functioning.
• Results of tests (erythrocyte sedimentation rate [ESR] or C-reactive protein)

Disease-modifying antirheumatic drugs (DMARDs), such as methotrexate, etanercept, adalimumab, infliximab, and leflunomide, will probably be used early in the course of your disease and for a prolonged period after treatment begins. DMARDs have been shown to slow the disease and may prevent joint destruction.

Corticosteroids may be used to treat your rheumatoid arthritis. They may be used as:

• Initial therapy until a DMARD has a chance to work (bridge therapy).
• A means of controlling flares of rheumatoid arthritis. When a single joint is inflamed, a corticosteroid injection can be effective in relieving symptoms.
• Disease management when DMARDS do not fully control the disease.

Because of the side effects of corticosteroids, your health professional will use the lowest possible dose and will try to reduce and eventually discontinue use of oral corticosteroids. But this is not always possible.

Nonsteroidal anti-inflammatory drugs (NSAIDs) and/or analgesics (pain relievers, such as acetaminophen) also may be used to relieve symptoms. NSAIDs can relieve pain and reduce inflammation in less severe cases of rheumatoid arthritis.

Exercise, physical therapy, and lifestyle changes can help you decrease joint pain. Many people with rheumatoid arthritis benefit from self-management plans that balance rest and activity. Steps you can take at home to relieve your symptoms and help control your disease include:

• Becoming involved in the day-to-day management of your disease. For more information, see:

  Managing rheumatoid arthritis.

• Staying active, physically, mentally, and socially.
• Resting when you are tired.
• Protecting your joints from injury.
• Eating a balanced diet.
• Exercising regularly.
• Controlling your weight.

Treatment if the condition gets worse

In some cases of rheumatoid arthritis, the disease does not respond to the first several treatments. Treatment-resistant rheumatoid arthritis may be treated with much higher doses of medicines or with different combinations of medicines. Surgery may be considered when the joints—especially the hips, knees, or feet—are severely damaged or deformed and are causing extreme pain. Surgery may include total joint replacement or other techniques to improve joint function.

What to Think About

Treatment to manage rheumatoid arthritis can be effective at slowing the progression of the disease, and you may have periods of time in which the disease is in remission. But if you have joint destruction from rheumatoid arthritis, you may need treatment such as pain relief, physical therapy, and/or surgery.

The course of rheumatoid arthritis is difficult to predict, and some people respond to treatment better than others. Scientists are studying the role that a person's genes may play in disease progression.⁹

There is no known way to prevent rheumatoid arthritis because the exact cause of the disease is not known.

It is important for people who worry that they may be at risk of rheumatoid arthritis to realize that at this time there are no medicines to take or lifestyle modifications to make that can prevent rheumatoid arthritis. Only after the disease is diagnosed can you take measures to control the disease. Until it is known for sure if certain bacteria or viruses trigger the disease, contact with people with the disease will not change your risk for developing it.

Researchers continue to study possible triggers of the disease. When researchers determine how the body's immune system becomes activated, we may be closer to knowing how to prevent rheumatoid arthritis.

Living with rheumatoid arthritis often means making changes to your lifestyle. You can do things at home, such as staying active and taking medicines, to help relieve your symptoms and prevent the disease from getting worse.

People who have rheumatoid arthritis also have an increased risk of heart disease. But healthy lifestyle changes, such as exercise and a healthy diet, may reduce your risk of heart disease.¹⁰ For more information, see the topics Healthy Eating and Fitness.

It is common to feel pain, fatigue, and joint stiffness with rheumatoid arthritis. Some activities may make your discomfort worse, while others might provide relief. Thousands of people with arthritis have benefited from developing and following plans to help them manage their symptoms. These plans often include education about the disease, exercise, diet changes, assistive devices, and other supports to help you stay as active as possible. For more information on managing your disease, see:

Managing rheumatoid arthritis.

You can also plan for those times when the disease symptoms may be more severe. It is important to work closely with your health professionals, who may include a physical therapist or counselor, to find ways to reduce pain.

People with rheumatoid arthritis have a high risk of developing osteoporosis because of the action of the disease itself, side effects from some treatments, and a decrease in physical activity as a result of disabling pain. It is recommended that people with rheumatoid arthritis take 1,000 mg to 1,500 mg of calcium and 800 IU of vitamin D daily. This calcium and vitamin D can come from dietary sources and supplements. If you do not consume significant amounts of milk and dairy products, you may need to take most of this requirement as supplements. Many health professionals also recommend that people with rheumatoid arthritis take bisphosphonates, such as alendronate (Fosamax) or risedronate (Actonel), which increase bone formation.³ For more information, see the topic Osteoporosis.

Rest when tired

Rheumatoid arthritis itself causes fatigue, and the strain of dealing with pain and limited activities also can make you tired. The amount of rest you need depends on how severe your symptoms are.

• With severe symptoms, you may need long periods of rest. You might need to rest a joint by lying down for 15 minutes several times a day to relax. Experiment until you find a good balance between daily activities that you must do or want to do and the amount of rest you need in be able to do those activities.
• Plan your day carefully, including rest periods, and pace your activities so that you don't get overtired.
• Don't feel guilty if you have to give up some tasks, such as making the bed or housework. Do the things you must do or really want to do, and find other ways to get less important things done.
• Don't rest too much. Prolonged joint inactivity can lead to more stiffness and, eventually, to weakness of underused muscles. Gently moving each joint through a comfortable range of motion each day will help prevent stiffness.

Protect your joints

You may need to change the way you do certain activities so that you are not overusing your joints. Try to find different ways to relieve your joint pain.

• Joint pain and stiffness may improve with heat therapy, which includes:
  • Taking warm showers or baths after long periods of sitting or sleeping.
  • Soaking hand joints in warm wax baths.
  • Sleeping under a warm electric blanket.
• Use assistive devices to reduce strain on your joints, such as special kitchen tools or door knobs.
• Use splints, canes, or walkers to reduce pain and improve function.

Exercise

Keep moving to maintain muscle strength, flexibility, and overall health.

• Physical therapy may be recommended by your health professional.
• Exercise can reduce pain and improve function in people with rheumatoid arthritis. Exercise for arthritis takes three forms—stretching, strengthening, and conditioning. Recent reviews of exercise studies report that both weight-bearing exercise and strength training improve or maintain the quality of life for people with rheumatoid arthritis.^{11, 12} Your specific joint problem may dictate what type of exercise will help the most. For example:
  • Swimming is a good conditioning exercise if you have joint problems in the lower extremities, such as the knees, ankles, or feet.
  • Bicycling and walking are good conditioning exercises if your joint problems are not in the lower extremities.

Eat a balanced diet

Some people with rheumatoid arthritis may not eat a healthy, balanced diet because symptoms may make it difficult to shop or cook.

The best diet for people with rheumatoid arthritis is a healthy, balanced diet that is low in saturated fat, cholesterol, and salt and high in fiber and complex carbohydrate (whole grains, beans, fruits, and vegetables).

• Although studies have been done to determine whether certain foods or special diets can improve the symptoms of rheumatoid arthritis, there is no consistent evidence that eating certain foods can help. The exception is fish. Fish oil (omega-3 fatty acids) has a modest effect in reducing inflammation and has been shown to slightly reduce swelling in rheumatoid arthritis. Although the doses of fish oil used in the studies were much higher than what a person can eat in an average serving of fish, eating fish may improve symptoms.
• Be sure to get enough calcium and vitamin D to protect your bones against osteoporosis. For more information, see the topic Osteoporosis.
• Lose weight, if you are overweight. For more information, see the topic Healthy Weight.

Medicines are the main treatment for rheumatoid arthritis. The types of medicines used depend on the severity of your disease, how fast it is progressing, and how it affects your daily life.

It is common for people with rheumatoid arthritis to have periods when the disease eases and then times when it gets worse. A long-range treatment plan that takes into account your lifestyle, medical history, and treatment options should be developed, followed, and regularly reviewed by all those involved in your health care—most importantly, you.

If your symptoms ease and you are in remission, you and your doctor will decide whether you can take less medicine or stop taking medicine. If your symptoms get worse, you will have to start taking medicine again.

Medicines to treat rheumatoid arthritis are used to:

• Relieve or reduce pain.
• Improve daily function.
• Reduce joint inflammation. Signs of joint inflammation include swelling, tenderness, and limited range of motion.
• Prevent or delay significant joint damage and deformity.
• Prevent permanent disability.
• Improve quality of life.

Medicines called disease-modifying antirheumatic drugs (DMARDs) that can slow or sometimes prevent joint destruction are now recommended early in the course of the disease. All people with rheumatoid arthritis are considered candidates for DMARD treatment. DMARDs can help prevent the significant joint damage that may occur in the early stages of rheumatoid arthritis. DMARDs are also called immunosuppressive drugs or slow-acting antirheumatic drugs (SAARDs).

Early treatment with DMARDs may significantly reduce disease severity. Experts recommend that DMARD treatment be continued for a prolonged period of time to sustain the benefit of disease control.⁸

DMARDS can be divided into two general categories based on how they work: oral DMARDs and biological DMARDs. Oral DMARDS are taken by mouth. They interfere with the making or working of immune cells that cause joint inflammation. Biological DMARDS are given by injection (infusion). They act in several different ways to affect how immune cells work. DMARDs decrease joint inflammation and damage.

Medicines may be given together. This is called combination therapy. Oral medicines are combined with each other or with biological DMARDs. But biological DMARDs are not used with each other because of a higher risk of infection.

Combination therapy may allow for lower doses of an individual drug to be used, which may reduce the risk of side effects that can occur with higher doses. Combination therapy may be an effective way to reduce symptoms of rheumatoid arthritis, control the disease, and prevent it from getting worse. And you may need fewer treatment adjustments with combination therapy than with treatment using individual medicines.¹³

Some medicines for rheumatoid arthritis may cause birth defects. If you are pregnant or are trying to become pregnant, talk with your health professional about your medicines.

Medication Choices

Medications to slow the progression of disease: Disease-modifying antirheumatic drugs (DMARDs) are usually started within 3 months of your diagnosis and are used to control the progression of rheumatoid arthritis and to try to prevent joint deterioration and disability. DMARDs are often given in combination with other DMARDs or with other medications, such as corticosteroids or nonsteroidal anti-inflammatory drugs (NSAIDs).

Commonly used oral DMARDs:

• Antimalarial medications such as hydroxychloroquine (Plaquenil) or chloroquine (Aralen)
• Leflunomide (Arava)
• Methotrexate such as Rheumatrex
• Sulfasalazine such as Azulfidine

Less commonly used oral DMARDs:

• Azathioprine such as Imuran
• Cyclophosphamide such as Cytoxan or Neosar
• Cyclosporine such as Neoral or Sandimmune
• Gold salts such as Ridaura or Aurolate
• Minocycline such as Dynacin or Minocin
• Penicillamine such as Cuprimine or Depen

Biological DMARDs:

• Abatacept (Orencia)
• Adalimumab (Humira)
• Anakinra (Kineret)
• Etanercept (Enbrel)
• Infliximab (Remicade)
• Rituximab (Rituxan)

Medications to relieve symptoms, such as pain, stiffness, and swelling, may also be used. These include:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, or naproxen. NSAIDs are used to control pain and may help reduce inflammation. They do not control the disease or stop it from getting worse. NSAIDs may be combined with disease-modifying antirheumatic drugs (DMARDs).
• Corticosteroids such as prednisone or Medrol. Corticosteroids are used to reduce disease activity and joint inflammation. But using corticosteroids as the only therapy for an extended time is not considered the best treatment. Corticosteroids are often used to control symptoms and flares of joint inflammation until DMARDs reach their full effectiveness, which can take up to 6 months.
• Analgesics (pain relievers). These do not reduce inflammation but may assist with pain control. Commonly used prescription analgesics include:
  • Acetaminophen with codeine (such as Tylenol with codeine).
  • Acetaminophen with hydrocodone (such as Vicodin).
  • Tramadol.
  • Propoxyphene (such as Darvon).
• Nonprescription acetaminophen, which may be used to reduce pain.

What to Think About

Some DMARDs can take up to 6 months to work. In some people, a certain DMARD may not work at all, and a different DMARD will be used. Rapid improvement should not be expected. Medications for rheumatoid arthritis are best managed by a doctor who specializes in inflammatory diseases of the joints (rheumatologist).

Many DMARDs have serious side effects. Regular blood and urine tests are usually needed when using a DMARD to monitor the drug's effects on blood-producing cells (bone marrow), the kidneys, and the liver.

Experts are studying many medicines that might be used for rheumatoid arthritis. Examples include:

• Tacrolimus (Prograf), an inhibitor of a protein called calcineurin. In one 6-month trial, people who had rheumatoid arthritis that had not responded to DMARD treatment experienced a reduction in disease activity and symptoms.¹⁴
• Tocilizumab, another biological DMARD that slows inflammation by inhibiting cytokine function. The results of research trials suggest that tocilizumab may reduce disease activity in rheumatoid arthritis.¹⁵

Surgical treatment in rheumatoid arthritis is used to relieve severe pain and improve function of severely deformed joints that do not respond to medication and physical therapy.

Total joint replacement (arthroplasty) can be done for many different joints in the body. Its success varies depending on which joint is replaced.

Surgery Choices

Surgeries considered for people who have severe rheumatoid arthritis include:

• Finger and hand surgeries, to correct joint problems in the hand.
• Arthroscopy, which removes debris or inflamed tissue in a joint through a small lighted instrument.
• Synovectomy, to remove inflamed joint tissue.
• Arthroplasty, to replace part or all of a joint in the hip or knee.
• Cervical spinal fusion, to treat severe neck pain and nerve problems.
• Resection of metatarsal heads, to remove deformed bone in the feet.

What to Think About

Joint surgery often restores near-normal movement in a person who has osteoarthritis in just one or two joints. But this is not the case in people affected by rheumatoid arthritis.

• Rheumatoid arthritis usually affects multiple joints, particularly smaller joints, such as finger joints, which are needed for many daily activities. Surgical treatment may not be an option for all of the affected joints.
• Joint surgery or replacement can relieve disabling pain and restore enough motion to allow you to complete daily activities, but it will seldom restore the joint to normal.
• The most successful procedures for rheumatoid arthritis are carpal tunnel release (in the wrist), resection of the metatarsal heads (in the foot), and total hip and total knee joint replacements.

A consultation with an orthopedic surgeon who is experienced in joint surgery for rheumatoid arthritis is important before making a decision to have surgery. For more information on questions before surgery, see:

Questions to consider about joint surgery.

Other types of treatment that may help you control some of the symptoms of rheumatoid arthritis include:

• Physical therapy, to improve joint function. Physical therapy includes exercise, hot and cold therapy, and massage.
• Occupational therapy, to learn how to maintain movement in the joints while carrying out the activities of daily living. Therapists can teach techniques to avoid excessive force being applied on non–weight-bearing joints and to avoid unnecessary impact on weight-bearing joints. A review of studies reported that instruction on joint protection and comprehensive occupational therapy can help people with rheumatoid arthritis overcome problems in performing daily activities.¹⁶
• Products that reduce stress on joints and aid with daily activities. This wide range of products includes foot supports, wrist or finger splints, assistive devices such as household aids (for example, specialized kitchen tools), or mobility aids (such as canes and walkers). For more information and a catalog, contact the Arthritis Foundation, listed in the Other Places to Get Help section of this topic.
• Behavioral modification techniques to reduce pain and stress, such as biofeedback and relaxation therapy, which may include breathing exercises and muscle relaxation.
• Counseling, to help you cope with long-term pain and disability.

Complementary and alternative medicine therapies

Although not proven in scientific studies, complementary therapies are used by many people to relieve symptoms caused by rheumatoid arthritis and improve their quality of life. These therapies include:

• Acupuncture. Acupuncture is used to relieve pain and treat certain health conditions. It is done by inserting very thin needles into the skin at specific points on the body.
• Massage. Massage can help relieve stress and reduce pain. But do not massage swollen or painful joints.
• Transcutaneous electrical nerve stimulation (TENS). TENS is a therapy that uses electrical current delivered through electrodes to the skin for pain relief. Electrical stimulation to the nerves may cause the body to produce natural painkillers called endorphins, which may block the perception of pain. Although TENS may help relieve pain caused by rheumatoid arthritis for some people, it has no effect on the disease itself and is not considered to be a long-term solution to pain.¹⁷
• Herbs and dietary supplements. If you decide to use herbs or dietary supplements, be sure to tell your health professional.
  • For some people, herbs (such as ginger or evening primrose) or essential fatty acids (such as fish oil) may provide some relief of symptoms caused by rheumatoid arthritis.¹⁸
  • The dietary supplement glucosamine is sometimes used to try to relieve joint pain. Studies do not show it is effective for rheumatoid arthritis.¹⁹

Organizations

• Juvenile Rheumatoid Arthritis
• Osteoarthritis
• Osteoporosis

Citations

1. Harrison MJ (2003). Young women with chronic disease: A female perspective on the impact and management of rheumatoid arthritis. Arthritis and Rheumatism, 49(6): 846–852.

2. O'Dell JR (2004). Therapeutic strategies for rheumatoid arthritis. New England Journal of Medicine, 350(25): 2591–2602.

3. O'Dell JR (2005). Rheumatoid arthritis: The clinical picture. In WJ Koopman, LW Moreland, eds., Arthritis and Allied Conditions: A Textbook of Rheumatology, 15th ed., vol. 1, pp. 1165-1194. Philadelphia: Lippincott Williams and Wilkins.

4. Harris ED Jr (2005). Clinical features of rheumatoid arthritis. In ED Harris Jr et al., eds., Kelley's Textbook of Rheumatology, 7th ed., vol. 2, pp. 1043–1078. Philadelphia: Elsevier Saunders.

5. Casey ATH, et al. (2002). Rheumatoid arthritis of the cervical spine: Current techniques for management. Orthopedic Clinics of North America, 33(2): 291–309.

6. Kwoh CK, et al. (2002). Guidelines for the management of rheumatoid arthritis. Arthritis and Rheumatism, 46(2): 328–346.

7. Ward MM (2004). Decreases in rates of hospitalizations for manifestations of severe rheumatoid arthritis, 1983–2001. Arthritis and Rheumatism, 50(4): 1122–1131.

8. Verstappen SMM, et al. (2003). Five-year follow-up of rheumatoid arthritis patients after early treatment with disease-modifying antirheumatic drugs versus treatment according to the pyramid approach in the first year. Arthritis and Rheumatism, 48(7): 1797–1807.

9. Goronzy JJ, et al. (2004). Prognostic markers of radiographic progression in early rheumatoid arthritis. Arthritis and Rheumatism, 50(1): 43–54.

10. Nicola PJ, et al. (2005). The risk of congestive heart failure in rheumatoid arthritis: A population-based study over 46 years. Arthritis and Rheumatism, 52(2): 412–420.

11. Häkkinsen A (2004). Effectiveness and safety of strength training in rheumatoid arthritis. Current Opinion in Rheumatology, 16(2): 132–137.

12. De Jong Z, et al. (2003). Is a long-term, high-intensity exercise program effective and safe in patients with rheumatoid arthritis? Arthritis and Rheumatism, 48(9): 2415–2424.

13. Goekoop-Ruiterman YPM, et al. (2007). Comparison of treatment strategies in early rheumatoid arthritis. Annals of Internal Medicine, 146(6): 406–415.

14. Yocum DE, et al. (2003). Efficacy and safety of tacrolimus in patients with rheumatoid arthritis. Arthritis and Rheumatism, 48(12): 3328–3337.

15. Nishimoto N, et al. (2004). Treatment of rheumatoid arthritis with humanized anti-interleukin-6 receptor antibody. Arthritis and Rheumatism, 50(6): 1761-1769.

16. Steultjens EMJ, et al. (2007). Occupational therapy for rheumatoid arthritis. Cochrane Database of Systematic Reviews (4).

17. Brosseau L, et al. (2007). Transcutaneous electrical nerve stimulation (TENS) for the treatment of rheumatoid arthritis in the hand. Cochrane Database of Systematic Reviews (4).

18. Murray MT, Pizzorno JE Jr (2006). Rheumatoid arthritis. In JE Pizzorno, MT Murray, eds., Textbook of Natural Medicine, 3rd ed., vol. 2, pp. 2089–2108. St. Louis: Churchill Livingstone Elsevier.

19. Firestein GS (2007). Rheumatoid arthritis. In DC Dale, DD Federman, eds., ACP Medicine, section 15, chap. 2. New York: WebMD.

Other Works Consulted

• Saag KG, et al. (2008). American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis and Rheumatism, 59(6): 762–784.