How Rheumatoid Arthritis Is Treated

From Self-Care to Surgery

While there is no cure for rheumatoid arthritis, there is an ever-increasing range of treatments able to alleviate the pain and swelling of this chronic inflammatory disorder. They include self-care remedies, diet, over-the-counter and prescription pain relievers, physical therapy, and newer generation disease-modifying drugs (DMARDs). Severe cases may require in-office procedures like arthrocentesis or surgeries to either repair or replace the damaged joint.

The goal of treatment is to achieve remission in order to halt the progression of joint damage, maintain mobility, minimize pain, and increase your overall quality of life.  

Home Remedies and Lifestyle

Rheumatoid arthritis (RA) is a chronic, progressive disease that needs to be managed as part of your life. Rather than just treating the disease with drugs, you need to take a holistic approach aimed at improving your overall health and mitigating the risk factors that place you in harm's way.

It's all about embracing healthy behaviors and changing how you respond to acute attacks.

Bed Rest

Bed rest is important if you are dealing with extreme and sudden pain that does not improve with movement. For these moments, "getting off your feet" may be just the remedy needed to reduce the acute inflammation triggered by an RA flare.

With that being said, bed rest is only intended as a short-term solution until ice and other forms of anti-inflammatory treatment can bring down the acute symptoms. Extended bed rest can have the opposite effect on your health, increasing stiffness, decreasing the range of motion, and leading to the loss of lean muscle (muscle atrophy).

Diet

Being overweight or obese triggers inflammation due to the release of inflammatory proteins (called cytokines) from fat cells. This only serves to aggravate the symptoms of rheumatoid arthritis anywhere in your body and add needless stress to the joints of the lower extremities.

While there is no specific diet for people with rheumatoid arthritis, many doctors endorse a Mediterranean diet, which provides a healthy balance of proteins, fats, and carbohydrates while encouraging an increased intake of fish (rich in anti-inflammatory omega-3 fatty acids), whole grains, vegetables, fruit, and healthy oils (like olive oil).

There is also limited evidence that a gluten-free diet may help alleviate symptoms, especially in those with an underlying (and often undiagnosed) gluten intolerance.

Finally, consider avoiding or reducing your intake of certain foods that can increase inflammation:

  • Alcohol should be avoided.
  • Omega-6 fatty acids (found in corn, safflower, sunflower, grapeseed, soy, peanut, and vegetable oils) should be cut back.
  • Saturated fat should account for no more than 10 percent of your total caloric intake.
  • Sugar should be reduced.
  • Trans fats should be entirely excluded from your diet.

Exercise

Rheumatoid arthritis is also characterized progressive damage to joint cartilage. By embarking on an informed workout plan, you can lose weight and sustain the range of motion of an affected joint.

Exercise can also ensure that your bones remain strong and fight the symptoms of osteoporosis common in people with rheumatoid arthritis.

Smoking

We all know that smoking is not good for us, but it can be especially bad if you have rheumatoid arthritis. Cigarette smoke does insidious things to your body, not only triggering inflammation but causing the constriction of blood vessels to a point where circulation can be altogether stopped in certain parts of the body.

This can promote the development of rheumatoid vasculitis, a common disease complication characterized by chronic fatigue, skin ulcers and rashes, fever, weight loss, and muscle and joint pain. Moreover, research has shown that smoking can even increase your risk of getting rheumatoid arthritis, in some cases by as much as 300 percent.

While quitting cigarette can be tough, the benefits to your joints and body as a whole can be enormous. Speak with your doctor about cessation aids. Drugs like Zyban (bupropion) and Chantix (varenicline) can be effective in some smokers and likely will not interfere with your rheumatoid arthritis drugs.

Over-the-Counter Remedies

As part of your first-line treatment plan, your doctor will typically recommend an over-the-counter (OTC) nonsteroidal anti-inflammatory drugs (NSAID), such as Aleve (naproxen) or Advil (ibuprofen), to alleviate mild to moderate pain and swelling.

In addition to having anti-inflammatory properties, NSAIDs are also analgesic and antipyretic, meaning that they can relieve pain and fever, respectively. These drugs have not been shown to slow the progression of the disease, however.

Side effects include stomach upset, high blood pressure, ringing in your ears, gastric ulcers, and liver toxicity.

Prescriptions

If you have been diagnosed with rheumatoid arthritis, your doctor will commonly prescribe a combination of medications, some of which treat the symptoms and others that address the underlying autoimmune disorder.

The urgency behind early treatment for rheumatoid arthritis has become more clear, as researchers continue to note a narrow "window of opportunity" in which rheumatoid arthritis treatment has the greatest impact on disease progression.

A single drug is typically prescribed in early treatment. If the response is inadequate, additional medications with different mechanisms of action may be added. In many cases, "triple therapy"—the use of three disease-modifying anti-rheumatic drugs (DMARDs) together—can provide greater control of chronic pain and inflammation. 

Anti-Inflammatories

Your doctor may start you on the OTC options listed above to help relieve pain and fever. If symptoms worsen, however, he or she may prescribe stronger NSAIDs such as Celebrex (celecoxib) or Voltaren (diclofenac)

Corticosteroids

Corticosteroids are highly-effective but potent drugs that can reduce inflammation and help moderate autoimmune activity. Corticosteroids work by mimicking cortisol, the adrenal hormone that helps regulate inflammation, metabolism, and blood sugar.

They are often prescribed as part of a multi-drug therapy and are delivered either orally (in pill form), by injection (into a muscle or joint space), or intravenously (into a vein). Prednisone is the drug most commonly used for rheumatoid arthritis.

Corticosteroids are only prescribed for short-term use due to the increased risk of side effects, including osteoporosis, weight gain, easy bruising, cataracts, glaucoma, and diabetes. When taken orally, they are prescribed in low doses and usually taken in the morning. Injections are reserved for acute attacks and used no more than three or four times a year.

DMARDs

Disease-modifying antirheumatic drugs (DMARDs) work by tempering the overall immune response. As an autoimmune disease, rheumatoid arthritis is caused by a malfunction of the immune system in which normal cell are targeted for attack. DMARDs work to suppress the immune system as a whole.

DMARDs are most effective when taken as soon as possible after the disease is diagnosed. There are many DMARDs approved for RA treatment, which include older generation drugs like Plaquenil (hydroxychloroquine) and newer ones like Arava (leflunomide). Most are taken orally.

By far, the most commonly prescribed DMARD is methotrexate. Methotrexate has been around for more than 50 years and continues to be the backbone of rheumatoid arthritis treatment. Among its many advantages, methotrexate can be taken safely for long periods of time, usually requires once-weekly dosing, and can even be used in children.

On the downside, methotrexate can cause liver toxicity and bone marrow suppression. Periodic blood tests are needed to monitor for these complications. Other side effects include fatigue, nausea, stomach upset, rash, diarrhea, mouth sores, and easy bruising. Taking a daily folic acid supplement may help reduce some of these drug-related side effects.

Avoid methotrexate if you are pregnant or trying to get pregnant, as it may cause birth defects.

Biologic Response Modifiers

Biologic response modifiers are a newer type of DMARD that targets specific parts of the immune system rather than the whole. They are considered biologic because they are produced by genetically engineered cells rather than synthesized in a chemistry laboratory.

While biological drugs used to treat rheumatoid arthritis have different mechanisms of action, they all work by blocking a specific immune target: e.g. tumor necrosis factor (TNF) (whose role it is to signal inflammation), interleukins (which do the same), T-cells or B-cells (which produce antibodies).

Biologic drugs are used to treat moderate to severe rheumatoid arthritis and can be used on their own or in combination therapy. The drugs are delivered either by injection or intravenously, and are only prescribed for people who have not responded to methotrexate or other DMARDs.

Commonly prescribed biologic drugs include:

Because biologics interfere with the immune processes, people on treatment are at greater risk of infection. Common side effects include injection site pain, respiratory infections, and flu-like symptoms.

JAK Inhibitors

Janus kinase (JAK) inhibitors are a newer class of non-biologic DMARD that work by blocking the inflammatory process inside of a cell. Jafaki (ruxolitinib) and Xeljanz (tofacitinib) are the first JAK inhibitors approved for use in the United States. Both are taken orally.

JAK inhibitors are used in people with moderate to severe rheumatoid arthritis who have not responded to methotrexate alone or who have failed on biologics.

JAK inhibitors are typically used in combination with methotrexate and taken twice daily. Side effects include a headache, fatigue, stomach irritation, flu-like symptoms, diarrhea, high cholesterol, low white blood cell counts, and an increased risk of infection.

Pipeline Drugs

You may hear of new drugs that are being developed for RA, such as ABP 501, BI 695500, CHS-0214, all biosimilars. While it can be exciting to hear of new potential treatments, especially if your treatment course has not adequately managed your symptoms, remember that these drugs must go through four major hoops before they can be approved. That said, it's worth learning about where they are in that process and if there's a chance that they could be appropriate for you if they come to market. You might also speak to your doctor about the appropriateness of joining a clinical trial. 

Therapies

In addition to medication, your doctor may refer you to a rehabilitative specialist who can work with you to restore joint function and mobility. This could be a physical and/or occupational therapist.

Physical therapy focuses on building strength and improving mobility. People with moderate to severe rheumatoid arthritis tend to work with a physical therapist on an ongoing basis and may be exposed different techniques based on their symptoms or limitations.

The therapies may include:

Occupational therapy aims to support your independence and improve your quality of life by helping you overcome physical limitations, often with the use of assistive tools and devices.

Examples include:

  • Installing larger doorknobs or handles that are easier to grip
  • Finding ergonomic chairs that allow you sit without discomfort
  • Choosing canes, walkers, or other mobility devices appropriate to your needs
  • Rearranging cabinets and shelves so items are easier to reach
  • Replacing light switches with sliders
  • Using voice-command controls

Massage therapy is also popularly embraced by people with rheumatoid arthritis. While the benefits of treatment have been largely under-researched, proponents of the practice believe that massage can induce relaxation and encourage gentle joint movement, both of which translate to less pain and improved mood.

Other specialists, including podiatrists and psychologists, may be sought to overcome other physical and emotional barriers.

Specialist-Driven Procedures

Surgery is always considered a last option if you have rheumatoid arthritis. Prior to even considering surgery, your doctor may want to explore minimally invasive, in-office techniques, especially if you are young and in otherwise good health.

Among the options is a procedure known as arthrocentesis in which fluid is extracted from a joint space with a needle to relieve pressure. It is often used as a means of diagnosis but can be just as effective in cases where fluid build-up is causing significant pain.

An arthrocentesis may be performed on its own or prior to administering a corticosteroid shot. Other intra-articular injections involve the use of hyaluronic acid to lubricate the joint space or platelet-rich plasma (PRP) derived from one's own blood to stimulate the production of cartilage in heavily damaged joints.

However, there will be times when arthrocentesis will not provide the expected relief, and surgery is the only option.

Surgery

If your joint pain has become unbearable, your doctor may recommend surgery to either repair the damaged joint or replace it. By and large, surgery is only considered if all other options have been exhausted and you are considered a reasonable candidate for the procedure.

Joint Repair

As rheumatoid arthritis progresses, the cartilage is damaged and the joint will lose its alignment and shape, resulting in joint deformity. Particularly in the smaller joints where replacement is not an option, surgeons will use different techniques to help restore motion and alleviate pain.

Among the repair options:

  • Arthrodesis, also known as a joint fusion, is used to relieve intractable joint pain by bonding bones together.
  • Arthroscopy is a procedure in which a lighted scope (called an arthroscope) is inserted into a joint space so that bits of bone and cartilage can be located and removed.
  • Carpal tunnel release, also called nerve release, is a surgery in which the carpal tunnel ligament of the hand is severed to make more space for nerves and tendons.
  • Synovectomy involves the removal of the joint lining, called the synovium when it becomes chronically inflamed and interferes with the articulation of a joint.

Joint Replacement

Joint replacement surgery, also known as arthroplasty, is increasingly common in people with rheumatoid arthritis. The decision to explore joint replacement is based on a review of physical symptoms, treatment history, and findings from imaging tests.

Moreover, your age plays a huge part in the decision, given that joint prostheses tend to last anywhere from 15 to 20 years. As such, most surgeons prefer to delay the procedure for as long as reasonably possible, typically until you are somewhere in your 50s. However, most people with rheumatoid arthritis are having replacements done in their early 60s or not at all due to the increased effectiveness of newer DMARDs.

Since some DMARDs work by suppressing the immune system, you need to ask your doctor about stopping them around the time of surgery.

Today, knee and hip replacements have become incredibly safe and effective with a greater than 90 percent success rate. Post-operative complications in people with rheumatoid arthritis are pretty much the same as in anyone else who has one of these procedures and may include nerve damage, infection, blood clots, and joint dislocation.

Complementary Medicine (CAM)

In dealing with a chronic, lifelong disorder, people with rheumatoid arthritis commonly embrace complementary therapies to support their traditional medical treatment. These include traditional medicines and mind-body therapies.

Traditional Medicines

While many traditional medicine offer benefits, both real and perceived, it is important to speak with your doctor about any supplement, herb, or, for that matter, traditional medicine you may be taking. This may prevent drug interactions that can undermine your therapy, as well as side effects and toxicities that can make you ill.

Among the remedies considered beneficial to rheumatoid arthritis treatment:

  • Fish oil supplements contain high amounts of two omega-3 fatty acids that the body uses to reduce inflammation. Many studies have shown that a three-gram daily supplement can provide modest relief of mild arthritis pain and stiffness. However, fish oil supplements may interact with blood thinners like warfarin.
  • Borage, evening primrose, and black currant oils, available in a gelcap and liquid formulations, are great sources omega-6 fatty acids, which also have anti-inflammatory properties. Overuse should be avoided as borage may cause liver damage at high doses, while evening primrose can interfere with phenothiazine drugs used in psychiatric therapies.
  • Boswellia (also known as frankincense) is gum resin from the bark of the Boswellia tree found in India, which contains an anti-inflammatory agent called boswellic acid. While considered safe when used as directed, the results have been mixed as to how effective it is in alleviating joint pain, stiffness, and swelling.  
  • Ginger is also commonly used to treat RA and works in a similar fashion as COX-2 anti-inflammatory drugs. While it is available as in powder, tincture, capsule, and oil formulations, an extract known as Eurovita Extract 77 is popularly used by people with rheumatoid arthritis and osteoarthritis.
  • Turmeric contains a chemical known as curcumin, which blocks two key inflammatory enzymes. Like ginger, the spice is considered safe and may help alleviate joint pain and swelling. It is unknown what dosing is needed to achieve a clinical benefit.

Other popularly used complementary remedies such as glucosamine, chondroitin, acupuncture, and magnetic therapy have not been shown to be particularly useful in treating rheumatoid arthritis.

Mind-Body Therapies

Mindfulness meditation and other mind-body therapies may provide you better pain control in combination with drug therapy. The goal of these options is to see beyond your emotions and focus on coping with pain and other aspects of the disease in the present moment. These need not be regarded as a spiritual practices, but ones that can help you control your emotions and your reaction to pain. 

Other forms of mind-therapy include:

  • Deep yoga breathing (pranayama), a meditative practice in which you focus on rhythmic, controlled inhalations and exhalations
  • Guided imagery, in which you conjure calming mental images
  • Tai chi, a practice focused on mindful movement
  • Hatha yoga, a gentler form of yoga
  • Progressive muscle relaxation (PMR), a technique in which you release your muscles one-by-one to achieve relaxation
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