What Does Rheumatoid Arthritis Progression Look Like?

Your experience with rheumatoid arthritis (RA) is different than anyone else who has the condition. In fact, everyone’s experience is different, and RA can be mild, moderate, or severe, and symptoms vary from person to person. There is no exact science or timeline when it comes to how your RA—or anyone’s—will progress.  What doctors and researchers know for sure is that RA will get worse without proper treatment.

Here is what you need to know RA progression and how doctors work to slow it down.

Rheumatoid arthritis affects about 1.5 million Americans, according to the Arthritis Foundation. Women are two to three times for likely to develop the condition than are men, as hormones play a part in preventing or triggering it. Most people are diagnosed between the ages 30 and 60, but the RA can strike anyone of any age, including small children.

RA is an autoimmune disease where the body’s immune system, which normally protects you by attacking bacteria, viruses, and other foreign invaders, suddenly attacks the joints.  This overreaction causes inflammation inside the joints, resulting in swelling and pain in and around the joints. 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. 

RA can also affect other body parts, including the heart, lungs, skin, and eyes. That is why is called a systemic disease. Systemic means it affects the whole body.

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
• 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.

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 in some cases, remission means there are no antibodies in the blood related to RA. 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 periods with few or no problems, and they also have flare-ups, periods where disease activity (pain, stiffness and other RA symptoms) is high.

Progressive RA: Most people with RA need long-term treatment and a comprehensive medical team to help manage their disease in order to slow it down or stop from getting worse, and causing joint damages, disability, and other RA complications.

There are four stages of RA and each is unique in the symptoms it causes and how it presents.

In this stage, most people will not have many symptoms. Early on, symptoms usually include stiffness upon waking and pain in the small joints—hands, fingers, and feet. Stiffness usually gets better with movement. While there is no damage to the bones, the joint lining—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 even present. Moreover, X-rays in this stage are usually normal, although more sensitive imaging, such as ultrasound, may show fluid or inflammation in affected joints. But even still, a definitive diagnosis of RA this early may be difficult because even ultrasounds may not show anything unusual.

In this stage, the inflammation of the synovium has caused damage to joint cartilage. When cartilage is damaged, you will start to experience pain, loss of mobility, limited range of motion. Limited range of motion means you will not be able to move a joint as far as you used to.

It is possible that RA may progress to stage 2 without a diagnosis. In this second stage, the body will start to make antibodies that can be seen in blood work and cause the joints to swell, with actual signs of inflammation with imaging. The disease may also cause inflammation to the lungs, eyes, skin, and/or the heart. Lumps on the elbows called rheumatoid nodules may develop.

Some people with RA have what is known as seronegative RA, where bloodwork does not reveal antibodies or an RF. This is where imaging can be helpful in confirming a diagnosis. X-rays, ultrasound imaging, and magnetic resonance imaging (MRI) may show inflammation and/or the start of some joint damage.

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 bone to rub together. There will be more pain and swelling, and some people may experience muscle weakness and problems with mobility. There may be eroded (damaged) bone and some deformity. 

In this stage, your doctor and you will be able to see the effects of the disease, such as joints that are visibility bent and deformed and fingers that are crooked. Misshapen joints can press on nerves and you may experience nerve pain. This type of damage is rare these days due to newer treatment options available for treating RA.

By stage 4, joints no longer work. There is significant pain, swelling, stiffness, mobility loss, even disability. Some joints may be become destroyed and fuse together—a condition called ankylosis. 

Progression to stage 4 takes years or decades. Some people never make through all four stages. In some cases, RA has gone into remission, and in others, it is well-managed.

Different factors affect the disease pace and progression for each person. Some are things you cannot control, such as family history or gender, but others are things that you can modify.

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 response and drug survival in people with RA taking anti-tumor necrosis factor (anti-TNF) therapy are poorer for heavy smokers. Further, smoking can lead to disease complications, including cardiovascular problems and joint damage and disability.

People who work in heavy manual occupations and those where 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 have at least two times the risk for RA than they would in other occupations. Further, nurses have a 30% higher risk for 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 if you find your job is making your symptoms worse.

Activity and a healthy weight are helpful in reducing joint stress. You should talk to your doctor before starting a new workout routine. He or she can send you to a physical therapist to determine what exercises are not harmful to your joints. In addition, make sure you are getting enough sleep and eating a healthy diet, which includes anti-inflammatory foods and does not include junk or processed foods.

RA progression from stage 2 onward cannot be missed. This is because joint pain will become worse and you will have more swelling.  In the early stages of RA, flare-ups tend to be short-lived and will resolve on their own. But as RA progresses, your flares will be more frequent, last longer, and you will have worse pain and symptoms. 

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.

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

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, including diet, exercise, and not smoking. Early aggressive treatment is vital for the best outcomes.

The biggest factor affecting disease progression is treatment with medications that can slow down the disease. Traditional disease-modifying anti-rheumatic drugs (DMARDs) and biologic DMARDs are the best medications for slowing down progression. Traditional DMARDs—especially methotrexate—are first line treatments for RA.

Methotrexate and other DMARDs restrict the immune system and block pathways inside immune cells. When traditional DMARDs don’t work, your doctor will add a biologic, an injectable or infusion therapy drug, that is produced with living cells that affect immune proteins called cytokines. These drugs are potent and quite expensive, so your doctor will want you to try traditional DMARDs first.

Janus kinase (JAK) inhibitors are the newest treatments available for treating RA. They can help to ease joint pain and swelling by tampering down a person’s overactive immune system. Two JAK inhibitors —Xeljanz (tofacitinib) and Olumiant (baricitinib) are approved by the Food and Drug Administration for the treatment of rheumatoid arthritis, and many more are are being tested.

Some of the most recent research on JAK inhibitors suggests that they can be more effective for treating RA than biologics. Other research shows these drugs are more effective than a placebo drug. Similar research has also yielded equally promising information.

In treating RA, rheumatologists will follow a treat-to-target (T2T) strategy to manage the disease and prevent RA progression. Research shows this approach to reducing disease activity to low levels or even remission is quite realistic and can significantly improve long-term outcomes and quality for life for the majority of people with RA.

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

Thanks to newer available treatments and many more on the horizon, having RA doesn’t mean disability and limited mobility are in your future. People with RA can have normal lives. But that means you have to follow your doctor’s recommendations and treatment plan. You should also see your rheumatologist routinely so he or she can perform joint exams and blood work to check for systemic inflammation, and to assess your overall function. All these things are helpful to ensure your RA is under control and not progressing, and for you live a good quality life with and despite RA.