How can rheumatoid arthritis be treated

We can only achieve these goals with your help. Strong, outspoken and engaged volunteers will help us conquer arthritis. By getting involved, you become a leader in our organization and help make a difference in the lives of millions.

Become a Volunteer More About Volunteering. By taking part in the Live Yes! And all it takes is just 10 minutes. Your shared experiences will help: - Lead to more effective treatments and outcomes - Develop programs to meet the needs of you and your community - Shape a powerful agenda that fights for you Now is the time to make your voice count, for yourself and the entire arthritis community.

Currently this program is for the adult arthritis community. Since the needs of the juvenile arthritis JA community are unique, we are currently working with experts to develop a customized experience for JA families. Get Started. As a partner, you will help the Arthritis Foundation provide life-changing resources, science, advocacy and community connections for people with arthritis, the nations leading cause of disability.

Join us today and help lead the way as a Champion of Yes. Our Trailblazers are committed partners ready to lead the way, take action and fight for everyday victories. Our Visionary partners help us plan for a future that includes a cure for arthritis. Our Pioneers are always ready to explore and find new weapons in the fight against arthritis.

Our Pacesetters ensure that we can chart the course for a cure for those who live with arthritis. Our Signature partners make their mark by helping us identify new and meaningful resources for people with arthritis. Our Supporting partners are active champions who provide encouragement and assistance to the arthritis community.

Rheumatoid Arthritis: Causes, Symptoms, Treatments and More This inflammatory form of arthritis causes joint pain, swelling and damage. Updated Oct, 15, Rheumatoid arthritis RA causes joint inflammation and pain.

These symptoms are clues to RA: Joint pain , tenderness, swelling or stiffness that lasts for six weeks or longer. Morning stiffness that lasts for 30 minutes or longer.

More than one joint is affected. Small joints wrists, certain joints in the hands and feet are typically affected first.

The same joints on both sides of the body are affected. Dryness, pain, inflammation, redness, sensitivity to light and trouble seeing properly. Dryness and gum inflammation, irritation or infection. Rheumatoid nodules — small lumps under the skin over bony areas. Inflammation and scarring that can lead to shortness of breath and lung disease. Blood vessels.

Inflammation of blood vessels that can lead to damage in the nerves, skin and other organs. A lower than normal number of red blood cells. Inflammation can damage the heart muscle and the surrounding areas. Painful joints also make it hard to exercise , leading to weight gain. Being overweight may make people with RA more likely to develop high cholesterol, diabetes, heart disease and high blood pressure.

Rheumatoid factor RF is an antibody found eventually in about 80 percent of people with RA. However, they are also found in people without RA. The goals of RA treatment are to: Stop inflammation or reduce it to the lowest possible level put disease in remission. Relieve symptoms. Prevent joint and organ damage. Improve function and overall well-being. Reduce long-term complications.

To meet these goals, the doctor will follow these strategies: Early, aggressive treatment to reduce or stop inflammation as quickly as possible.

Targeting remission or another goal called "treat-to-target" to work toward few or no signs or symptoms of active inflammation. Summary Read the full fact sheet. On this page. Your joints and rheumatoid arthritis What are the symptoms of rheumatoid arthritis?

What causes rheumatoid arthritis? What do I do if I think I have rheumatoid arthritis? What is the treatment for rheumatoid arthritis? How do I self-manage rheumatoid arthritis? Joint surgery for rheumatoid arthritis Where to get help. Your joints and rheumatoid arthritis Joints are places where bones meet. When you have rheumatoid arthritis: your immune system attacks your joints, which causes: a build-up of synovial fluid inflammation of the tissues that line the joint synovial membrane pain, heat and swelling cartilage becomes brittle and breaks down — because the cartilage no longer has a smooth surface, the joint becomes stiff and painful to move ligaments, tendons and muscles surrounding the joint can also be affected, causing joints to become unstable.

What are the symptoms of rheumatoid arthritis? The most common symptoms of rheumatoid arthritis include: swelling, pain and heat in the joints, usually starting in the smaller joints of the hands or feet stiffness in the joints, especially in the morning persistent mental and physical tiredness fatigue the same joints on both sides of the body being affected Less common symptoms may include weight loss, inflammation of other body parts such as the lungs or eyes or rheumatoid nodules fleshy lumps below the elbows or on hands or feet.

Medication for rheumatoid arthritis Some of the medications you may take include: pain relievers or analgesics , such as paracetamol, for temporary pain relief non-steroidal anti-inflammatory medications NSAIDs , such as ibuprofen, to control inflammation and provide pain relief corticosteroids, such as prednisolone, to quickly control or reduce inflammation disease-modifying anti-rheumatic drugs DMARDs , such as methotrexate, to control your overactive immune system biological and biosimilar medicines bDMARDs , such as infliximab — these are biological disease-modifying drugs that work to control your immune system, but in a much more targeted way.

There are other things you can do to manage your rheumatoid arthritis: learn about rheumatoid arthritis — knowing as much as possible about your condition means that you can make informed decisions about your healthcare and play an active role in the management of your condition exercise — this will help you maintain muscle strength and joint flexibility, build up stamina and help you manage your pain.

Appropriate low-impact aerobic activities include exercising in warm water, cycling and walking. Activities like strength training and tai chi are also beneficial. Seek advice from a physiotherapist or an accredited exercise physiologist before you begin an exercise program to make sure it is safe and suits your abilities see a physio — a physiotherapist can provide advice on ways you can modify your activities to minimise joint pain, show you pain relief techniques and design an individual exercise program for you talk to an OT — an occupational therapist can give advice on pacing yourself and managing fatigue, and modifying daily activities at both home and work to reduce strain and pain on affected joints try relaxation techniques — muscle relaxation, distraction, guided imagery and other techniques can help you manage pain and difficult emotions such as anxiety, and can help you get to sleep grab a gadget — supports such as walking aids and specialised cooking utensils, ergonomic computer equipment and long-handled shoe horns can reduce joint strain and can help you to manage pain and fatigue.

Talk with your doctor or rheumatologist before starting any treatment. Fish oil supplements may also be helpful as they contain omega-3 fats. Research suggests omega-3 fats can help reduce rheumatoid arthritis inflammation. Rheumatology , , Therapeutic Guidelines, Melbourne. Medicine information sheets , Australian Rheumatology Association. What is rheumatoid arthritis? Arthritis Research UK. However the dose required to achieve a response is variable in individual patients and may require weeks after a dose increase to determine if the drug is working.

A trial of 3 to 6 months at an increased dose e. In patients with partial responses to methotrexate, additional medications are usually added to rather than substituted for methotrexate to achieve combination therapies. Fortunately the most serious complications of methotrexate therapy: hepatic cirrhosis, interstitial pneumonitis, and severe myelosuppression are quite rare, especially with proper monitoring.

Stomatitis and oral ulcers, mild alopecia and hair thinning, and GI upset may occur and are related to folic acid antagonism. These side effects can be improved with folic acid supplementation. Folic acid given at a dose of 1mg daily does not diminish the efficacy of methotrexate and is routinely given with methotrexate to decrease these side effects. Some patients complain of GI upset nausea or diarrhea with oral methotrexate.

This may be lessened when methotrexate is taken at night. In most cases this is completely eliminated when methotrexate is given by subcutaneous administration. Before starting methotrexate, baseline studies should include complete blood count, liver chemistries, serum creatinine, hepatitis B and C serologies, and chest X-ray. Routine toxicity monitoring should include a CBC, liver profile, serum albumin and serum creatinine every weeks.

In all clinical trials combining methotrexate with one of these DMARDs, no unexpected toxicities or synergistic toxicities were observed with the exception of higher liver toxicity with leflunomide which is also metabolized by the liver. Hepatotoxicity liver injury has not been significant if patients with pre-existing liver disease, alcohol abuse, or hepatic dysfunction are excluded from treatment with methotrexate.

Patients are instructed to limit alcohol containing beverages to no more than one-two per week. Baseline or surveillance liver biopsies are not indicated unless pre-existing liver disease is suspected. Elevated liver enzymes do not directly correlate with toxicity but therapy should be stopped and doses of methotrexate reduced if transaminases are elevated to 2 times the upper limit of normal.

Liver biopsy should be done if elevated liver enzymes persist or if methotrexate therapy is to be continued. Methotrexate pneumonitis may occur at any time during therapy and is not dose related. A baseline chest x-ray is useful for comparison. Patients with poor pulmonary reserve from other causes may be excluded from therapy over concerns of increased morbidity if methotrexate pneumonitis occurs.

A more chronic form of interstitial lung disease and fibrosis is also seen in patients with rheumatoid arthritis. This may be increased with methotrexate.

Myelosuppression lowering of blood counts is also rare at the low doses of methotrexate utilized for rheumatoid arthritis. In the absence of leukopenia lowered white blood cell counts , there has not been conclusive information to link methotrexate use in rheumatoid arthritis with increased risk of infection.

The exception is a slight increased risk of localized herpes zoster infection shingles. Cancer risk with methotrexate. Although there are case reports of lymphoma associated with methotrexate therapy including cases where the lymphoma resolved after cessation of therapy, increased occurrence of malignancy has not been found in large population-based studies.

It is important to recognize that patient with rheumatoid arthritis have an increased risk of developing lymphoma as a consequence of their autoimmune disease, independently from any potential medication effects. Pregnancy and Conception with methotrexate. There have not been any notable effects on sperm production or ovarian function after the prolonged administration of methotrexate. However, methotrexate is considered a teratogen ; therefore, women of childbearing potential or men with partners of childbearing potential must practice effective birth control.

Women should discontinue methotrexate for at least one ovulatory cycle prior to attempting conception, while men should wait 3 months. Hydroxychloroquine is an antimalarial drug which is relatively safe and well-tolerated agent for the treatment of rheumatoid arthritis. Chloroquine is another antimalarial agent that is also sometimes used.

Because these drugs have limited ability to prevent joint damage on their own, their use should probably be limited to patients with very mild, seronegative, and nonerosive disease.

The mechanism of action of antimalarials in the treatment of patients with rheumatoid arthritis is unknown but is thought to involve changes in antigen presentation or effects on the innate immune system. Chloroquine is not commonly used because of greater toxicity on the eye. It may be prescribed as a single daily dose or in divided doses twice per day. A period of 2 to 4 months is usual. Most agree that if a patient shows no response after months that this should be considered a drug failure.

The most important toxicities are on the eyes: corneal deposits, extraocular muscular weakness, loss of accommodation and sensitivity to light , and a retinopathy that may progress to irreversible visual loss. Ocular toxicity is exceedingly rare, occurring in only 1 out of 40, patients treated at the doses recommended.

Patients with underlying retinopathies or risks may not be good candidates for antimalarial drugs. Baseline ophthalmologic examination and a follow-up examination every 12 months are recommended during the period of treatment. Its effectiveness overall is somewhat less than that methotrexate, but it has been shown to reduce signs and symptoms and slow radiographic damage.

Sulfasalazine is also used in the treatment of inflammatory bowel disease and spondyloarthropathies. Its mechanism of action in RA is unknown. Some of its effects may be due to folate depletion. The usual dose is grams per day in a twice daily dosing regimen. The dose may be initiated at 1 gram per day and increased as tolerated. Sulfasalazine may cause hypersensitivity and allergic reactions in patients who have experienced reactions to sulfa medications.

Mild gastrointestinal complaints are commonly seen and these can be decreased by using enteric coated formulations or administration of the medication with meals. Occasionally, mild cytopenias are seen. Patients may be screened before the use of sulfasalazine for a deficiency of the enzyme glucosephosphate dehydrogenase G6PD which may predispose patients to red blood cell hemolysis and anemia.

Blood monitoring is typically every months depending on dose. Though sulfasalazine may cause increases in liver function tests, it is generally considered a preferable agent to methotrexate in patients with liver disease or in patients who have hepatitis B or C. Its efficacy is similar to methotrexate in terms of signs and symptoms, and is a viable alternative to patients who have failed or are intolerant to methotrexate.

Leflunomide has been demonstrated to slow radiographic progression. Studies have demonstrated that it can also be carefully combined with methotrexate in patients with no preexisting liver disease, as long as the liver function tests are carefully monitored. Leflunomide has also been studied in psoriatic arthritis with some efficacy demonstrated. The mechanism of action of leflunomide is not fully understood but may be related to its ability to inhibit de novo pyrimidine biosynthesis through the inhibition of the enzyme dihydroorotate dehydrogenase.

Laboratory studies have demonstrated that it also has effects on stimulated T cells. The half-life of the active metabolite of leflunomide is very long. Leflunomide and its metabolites are extensively protein bound and undergo further metabolism before excretion.

When initially approved, the medication was given using a loading dose of mg daily for three days then followed by 20 mg daily. The dose may be reduced to 10mg daily if not tolerated at the 20 mg dose. The onset of action is relatively rapid within weeks. The onset of action of Arava may be seen earlier than methotrexate when using a loading dose. Leflunomide has been associated with liver transaminase elevations that reversed with cessation of the drug in clinical trials.

Routine monitoring should include complete blood count and hepatic panel more frequently at the beginning of therapy then on a regular basis at least every 2 months. Other toxicities that are common include mild diarrhea, GI upset and alopecia and hair thinning sometimes of sufficient severity to cause cessation of the drug. Because leflunomide and its metabolites are a teratogen , extreme care must be taken for treatment of women of child bearing potential.

Women must be warned about the possible risk to the fetus and cautioned to use adequate birth control. Women wishing to become pregnant must take cholestyramine 8gm 3 times daily for 11 days and then have two leflunomide metabolite levels drawn 14 days apart to document serum concentration less than 0.

Leflunomide treatment does not appear to be associated with an increased risk for infection. Tumor necrosis factor alpha TNF is a pro-inflammatory cytokine produced by macrophages and lymphocytes. It is found in large quantities in the rheumatoid joint and is produced locally in the joint by synovial macrophages and lymphocytes infiltrating the joint synovium. TNF is one of the critical cytokines that mediate joint damage and destruction due to its activities on many cells in the joint as well as effects on other organs and body systems.

These drugs began to enter the market for rheumatoid arthritis in and are now considered a part the ACR recommendations for treatment of RA. Etanercept is a soluble TNF receptor-Fc immunoglobulin fusion construct; infliximab, adalimumab, and golimumab are monoclonal antibodies; and certolizumab pegol is an anti-TNF antigen binding domain-polyethylene glycol construct.

While differing in structure, the efficacy and safety of the drugs is similar across the class in reducing the signs and symptoms of RA, as well as in slowing or halting radiographic damage, when used either as monotherapy or in combination with methotrexate. Usual Time to Effect : TNF inhibitors have a rapid onset of action sometimes with improvements seen within 2 to 4 weeks. However, additional improvements can be seen over months. Side Effects : With all TNF antagonists, there is an increased risk of infection both mild and severe.

The most common are upper respiratory infections, pneumonia, urinary tract infections, and skin infections. Studies are currently ongoing regarding the practice of temporarily holding the administration of any biologic DMARD in the presence of infection and use of antibiotics. However, many rheumatology practices are following that practice. In addition to routine infections, opportunistic infections have been seen.

Disseminated tuberculosis due to reactivation of latent disease has been seen with all TNF inhibitors; therefore, screening for latent TB is prudent before treatment with any TNF inhibitor.

Invasive fungal infections, including histoplasmosis, coccidioidomycosis, candidiasis, aspergillosis, blastomycosis, and pneumocystosis have all been seen in patients receiving TNF inhibitors. Patients with histoplasmosis or other invasive fungal infections may present with disseminated, rather than localized, disease.

Antigen and antibody testing for histoplasmosis may be negative in some patients with active infection. Empiric anti-fungal therapy should be considered in patients at risk for invasive fungal infections who develop severe systemic illness.

In some clinical trials of TNF antagonists, lymphomas were more commonly observed in patients treated with TNF inhibitors compared to placebo controls but the incidence rates do not appear, at this time, to exceed those reported in the RA population prior to the availability of TNF inhibitors.

It is important to note that RA itself is a risk factor for Non-Hodgkins lymphomas. Other malignancies have been seen in patients taking TNF inhibitors. There does appear to be an increase in nonmelanoma skin cancer basal and squamous cell in patients receiving these agents. Regular dermatologic assessment is recommended with any suspicious lesions promptly evaluated. The administration of TNF inhibitors in patients with a prior malignancy should be discussed with the patient and their oncologist to assess potential risk and benefit.

TNF inhibitors are not recommended in patients with demyelinating disease or with congestive heart failure. Transient neutropenia lowering of white blood cell counts or other blood dyscrasias have been reported with TNF inhibitors. Some patients develop positive antinuclear antibodies ANA , and cases of clinical lupus are reported but rare. The new onset of psoriasis has also been seen. Abatacept is the first of a class of agents known as T-cell costimulatory blockers. These agent interfere with the interactions between antigen-presenting cells and T lymphocytes and affect early stages in the pathogenic cascade of events in rheumatoid arthritis.