What Does Rheumatoid Arthritis Progression Look Like?

Rheumatoid arthritis (RA) is often a progressive disease, meaning that it will follow a more-or-less predictable course, especially if left untreated. While each case of RA and the associated rates of progression is unique, four stages of progression have been defined. Healthcare providers do know the disease will get worse and progress through these stages if it isn't properly treated.

Given there is no cure for RA, the goals of treatment are to slow progression, control disease and minimize its effects on quality of life.

Effects of Inflammation

RA is an autoimmune disease in which the immune system, which normally protects you from bacteria, viruses, and other foreign invaders, instead attacks healthy cell tissue. RA inflammation, which primarily affects the joints, causes swelling and pain. Untreated inflammation can ultimately damage cartilage, the tissue that protects joints.

Over time, cartilage damage can lead to long-lasting or chronic pain, unsteadiness (lack of balance), joint deformity, and loss of mobility.

Although joints tend to be the body structures most affected by RA, it is considered a systemic disease, meaning it can also affect other body parts, including the heart, lungs, skin, and eyes.

Disease Patterns

How you feel and how RA progresses is dependent on several factors, including:

• How advanced your RA was at the time of diagnosis
• How old you when you were diagnosed
• How active your disease is currently
• The 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.

Stages of RA Progression

Healthcare providers 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.

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.

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.

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 healthcare provider 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 healthcare provider know if your RA symptoms are changing in any way.

Additional signs that your RA is getting worse are:

• Rheumatoid nodules
• Active inflammation that shows up in joint fluid or blood work
• Damage that can be seen on X-rays and other imaging
• High 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, usually methotrexate or hydroxychloroquine, depending on disease severity. If they don't work, your healthcare provider 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 healthcare providers 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.

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 activity
• Testing monthly to monitor progress
• Switching 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.

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 healthcare providers 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 healthcare provider’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.