Arthritis Rheumatoid Arthritis What Does Rheumatoid Arthritis Progression Look Like? By Lana Barhum facebook linkedin Lana Barhum has been a freelance medical writer for over 10 years. She shares advice on living well with chronic disease. Learn about our editorial process Lana Barhum Medically reviewed by Medically reviewed by Scott Zashin, MD on October 11, 2020 linkedin Scott J. Zashin, MD, specializes in the treatment of rheumatologic and musculoskeletal conditions using both traditional and alternative therapies. Learn about our Medical Review Board Scott Zashin, MD on October 11, 2020 Print Table of Contents View All Inflammation's Effects Disease Patterns Stages of Progression What Makes It Worse Signs to Look For Treatment Juvenile RA Rheumatoid arthritis (RA) is often a progressive disease, meaning that it will follow a more-or-less predictable course, especially if it's left untreated. While each case of RA and each progression is unique, and therefore hard to predict, four stages of progression have been defined. Doctors do know the disease will get worse and progress through these stages if it isn't properly treated. The goal of RA treatment is to slow down progression so you'll never see the more advanced stages of disease. © Verywell, 2018 Inflammation's Effects RA is an autoimmune disease in which the immune system, which normally protects you by attacking bacteria, viruses, and other foreign invaders, begins attacking your joints. This overreaction causes inflammation inside the joints, resulting in swelling and pain in and around them. Unchecked inflammation will eventually cause cartilage damage. Cartilage is the elastic tissue that covers the areas where the bones and joints meet. Over time, cartilage is lost and joint spacing becomes smaller. Joints start to become unstable and painful. They eventually lose mobility and joint deformity occurs. Joint damage is irreversible. Therefore, early diagnosis and treatment are important for controlling RA and halting the inflammation that leads to joint damage. RA can also affect other body parts, including the heart, lungs, skin, and eyes—why it's considered a systemic disease. Joint Involvement in RA Disease Patterns How you feel and how RA progresses is dependent on several factors, including: How advanced your RA was at the time of diagnosisHow old you when you were diagnosedHow active your disease is currentlyThe presence of antibodies in your blood: Two types of antibody molecules are present and elevated in people with RA—rheumatoid factor (RF) and anti-citrullinated protein antibody (ACPA). RF is detectable in up to 80% of people with RA and ACPAs are found in up to 90% of RA patients. Both are known for causing high disease activity. However, most people with RA will experience a gradual worsening of symptoms. RA progression is demonstrated in patterns over the years. Remission Periods Remission in people with RA means that disease activity stops, and that, in some cases, there are no RA-related antibodies in the blood. During RA remission, pain and stiffness go away or get much better but the disease is not cured. Most people have periods of remission that last for months, but there are people who are fortunate enough to go years without symptoms. According to the Johns Hopkins Arthritis Center, up 10% of people with RA fall into spontaneous remission within the first few months of the onset of their symptoms. Flare-Ups Most people with RA have symptoms that come and go. They have remissions and flare-ups—periods when disease activity (pain, stiffness and other RA symptoms) is high. Progressive RA Most cases of RA get steadily worse, especially without adequate management. People with this disease pattern need long-term treatment and a comprehensive medical team to help manage their disease in order to slow it down or stop it from getting worse and causing joint damage, disability, and other RA complications. Disease patterns can help your doctor to better understand how your condition is progressing and how to formulate a plan for treatment. It is important to note, however, that it is impossible to predict how exactly your RA will progress with time. Remember, too, that your disease course is different than anyone else’s—including family members who also have RA. Treating Rheumatoid Arthritis—Effectively Stages of RA Progression Doctors have identified four stages of RA. Each one is unique in the symptoms it causes and how it presents. Stage 1: Early RA In this stage, most people will not have many symptoms. Those that do experience stiffness when waking (which usually gets better with movement) and pain in the small joints of the hands, fingers, and feet. While there is no damage to the bones at this point, the joint lining—called the synovium—is inflamed. While it is a good idea to see a rheumatologist at this point, symptoms in early RA come and go and a diagnosis is hard to make. Antibodies might be present in the blood, but they may be there years before symptoms are noticeable. Moreover, X-rays in this stage are usually normal, although more sensitive imaging, such as ultrasound, may show fluid or inflammation in affected joints. Even so, a definitive diagnosis of RA this early is challenging. Stage 2: Moderate RA In this stage, the inflammation of the synovium has caused damage to joint cartilage. As a result, you will start to experience pain, loss of mobility, and limited range of motion. It's possible that RA may progress to stage 2 without a diagnosis. The body will start to make antibodies that can be seen in blood work and cause the joints to swell, with imaging showing actual signs of inflammation. The disease may also cause inflammation in the lungs, eyes, skin, and/or the heart at this point. Lumps on the elbows, called rheumatoid nodules, may develop as well. Some people with this disease have what is known as seronegative RA, where blood tests don't reveal antibodies or RF. This is where imaging can be helpful in confirming a diagnosis. X-rays, ultrasound imaging, and magnetic resonance imaging (MRI) may show signs of inflammation and/or the start of some joint damage. Stage 3: Severe RA Once RA has progressed to the severe stage, damage has started to extend to the joints. By this point, the cartilage between the bones has worn away, causing the bones to rub together. You'll have more pain and swelling and may experience muscle weakness and mobility problems. There may be eroded (damaged) bone. In this stage, you'll be able to see the effects of the disease, such as visibly bent, deformed joints and crooked fingers. Misshapen joints can press on nerves and cause nerve pain. However, this type of damage is rare these days due to newer treatment options. Hand Deformity in RA Stage 4: End Stage By stage 4, joints no longer work. There's significant pain, swelling, stiffness, mobility loss, and disability. Some joints may stop functioning and actually fuse together, which is called ankylosis. Progression to stage 4 takes years or decades, but some people never make it to this point because their RA is well-managed or has gone into remission. Treatment typically prevents RA from reaching stage 4, but those who don't respond well to treatment may very well reach this point in disease progression. What Makes RA Get Worse Different factors affect the disease pace and progression for each person. Some are beyond your control, such as family history or sex, but others are things that you can modify. Smoking Researchers know that smoking makes RA worse, decreases the effect of treatment, and can result in complications they may lead to death. One 2014 report in the International Journal of Molecular Sciences confirms that drug response and survival in people with RA taking anti-tumor necrosis factor (anti-TNF) therapy are poorer for heavy smokers. Furthermore, the researchers say smoking can lead to disease complications, including cardiovascular problems, joint damage, and disability. Occupation People who work in heavy manual occupations and those in which heavy toxins are used also have an increased risk for quicker disease progression. One 2017 Swedish study finds that airborne exposure to toxins increases the risk of RA. Bricklayers, concrete workers, and electricians had at least double the risk of RA compared to people in other jobs. Further, it found that nurses have a 30% higher risk of developing RA. The same occupational risk factors could also be applied to long-term management and disease activity over time. If your workplace can make accommodations for your disease, these things can help. Otherwise, it may make sense to look at other career options. Can You Keep Your Job or Career When You Have Arthritis? Lifestyle Staying active and maintaining a healthy weight are helpful in reducing joint stress, which can alleviate pain and inflammation. Less inflammation may mean a slower disease progression as well. Talk to your doctor before starting a new workout routine. They may refer you to a physical therapist to determine what exercises can keep you moving while protecting your joints. In addition, make sure you are getting enough sleep and eating a healthy diet including anti-inflammatory foods. Recognizing Progression RA progression from stage 2 onward cannot be missed because joint pain will become worse and you'll have more swelling. In the early stages of RA, flare-ups tend to be short-lived and will resolve on their own. However, as RA marches on, your flares will be more frequent, last longer, and be more painful. Other symptoms may become more intense as well. It is a good idea to pay attention to any non-joint symptoms you may have. This can include shortness of breath or dry, painful eyes—indicators that RA is affecting more than just your joints. You should also let your doctor know if your RA symptoms are changing in any way. Additional signs that your RA is getting worse are: Rheumatoid nodulesActive inflammation that shows up in joint fluid or blood workDamage that can be seen on X-rays and other imagingHigh levels of RF and ACPA in blood tests Treatment The main goals in treating RA are to control inflammation, relieve pain, and reduce the potential for joint damage and disability. Treatment usually involves medications, occupational or physical therapy, and a variety of lifestyle changes such as diet, exercise, and not smoking. Early, aggressive treatment is vital for the best outcomes. Treatment Prevents Progression Traditional disease-modifying anti-rheumatic drugs (DMARDs), especially methotrexate, and biologics are considered the best options for slowing down disease progression. They restrict the immune system and block pathways inside immune cells. Traditional DMARDs are first-line options. If they don't work, your doctor will likely add a biologic—an injectable or infusion therapy drug that affects immune proteins called cytokines. Biologics are potent and quite expensive, which is why doctors generally don't prescribe them right away. Janus kinase (JAK) inhibitors are the newest treatments available for RA. They can help ease joint pain and swelling by tamping down your overactive immune system. Two JAK inhibitors—Xeljanz (tofacitinib) and Olumiant (baricitinib)—are approved by the U.S. Food and Drug Administration (FDA) for the treatment of rheumatoid arthritis, and many other drugs in this class are being studied. Some of the most recent research on JAK inhibitors suggests that they can treat RA more effectively than biologics. How Do JAK Inhibitors Work? Treat-to-Target Approach In treating RA, most rheumatologists follow a treat-to-target (T2T) strategy to reduce disease activity to low levels or even remission. The concept of T2T involves: Setting specific testing goals of either remission or low disease activityTesting monthly to monitor progressSwitching out medications promptly when one treatment isn’t helping Experts believe the T2T approach is effective because it encourages medical professionals to test more often and be more aggressive in treatment. It is also helpful to have goals in mind, as this can help you feel more in control of your disease. Research shows this approach is quite realistic and can significantly improve long-term outcomes and quality for life for the majority of people with RA. Treat-to-Target Strategy for Rheumatoid Arthritis What About Juvenile RA? It's important to note that juvenile idiopathic arthritis (JIA), an umbrella diagnosis for several types of arthritis that affect kids and teens, is not the same as adult rheumatoid arthritis in most cases. In fact, JIA used to be called juvenile RA, but the name was changed to firmly make this distinction. Only one type of JIA, polyarticular arthritis positive for IgM rheumatoid factor, is believed to be the same disease as adult RA. Among the differences between JIA and RA is how they progress. And while RA is a lifelong, progressive condition without exception, some kids can "outgrow" some forms of JIA. Given this, information you read about adult RA cannot be considered applicable to all children with JIA. It's important that you speak with your child's doctors to learn more about what their JIA diagnosis could mean for them. A Word From Verywell Thanks to newer available treatments and many more on the horizon, having RA doesn’t mean eventual disability and limited mobility are a given. However, you do have to follow your doctor’s recommendations and treatment plan, as well as be vocal about your symptoms. See your rheumatologist routinely so they can perform joint exams and blood work to check for systemic inflammation, as well as assess your overall function. What Psoriatic Arthritis Progression Looks Like Was this page helpful? Thanks for your feedback! Dealing with chronic inflammation? An anti-inflammatory diet can help. Our free recipe guide shows you the best foods to fight inflammation. Get yours today! Sign Up You're in! Thank you, {{form.email}}, for signing up. There was an error. Please try again. What are your concerns? Other Inaccurate Hard to Understand Submit Article Sources Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy. Song YW and Kang EH. Autoantibodies in rheumatoid arthritis: rheumatoid factors and anticitrullinated protein antibodies. QJM. 2010 Mar; 103(3): 139–146. doi:10.1093/qjmed/hcp165 Ruffing V. and Bingham CO. Johns Hopkins Arthritis Center. Rheumatoid arthritis signs and symptoms. UpToDate. 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