If you’ve been living with rheumatoid arthritis, you know that the symptoms can be unpredictable. You may feel good one day and have a flare-up the next. It’s not possible to eliminate RA symptoms, but several treatment options are available that can help you manage them.
The first line of treatment for rheumatoid arthritis is usually medication. However, physical and occupational therapy can also be effective for symptom management and improving quality of life. Surgery can help reduce pain and improve functioning.
Non-steroidal Anti-inflammatory Drugs (NSAIDs)
Non-steroidal anti-inflammatory drugs are one of the most common treatment options for RA. They can help relieve RA pain, swelling, and inflammation. NSAIDs do not change the course of the disease or prevent joint destruction and are often used in conjunction with disease-modifying anti-rheumatic drugs (DMARDS).
NSAIDs work on a chemical level in the body. They block cyclooxygenase (COX), an enzyme the body uses to make naturally occurring fatty acids called prostaglandins that play a role in pain and inflammation. Most NSAIDs block COX-1 and COX-2 enzymes, while some only block COX-2. These are known as COX-2 inhibitors.
Common NSAIDs include aspirin, ibuprofen (Motrin, Advil), and naproxen (Aleve). Many NSAIDs are available over the counter and stronger ones are available as prescriptions.
Although NSAIDs are generally safe, they do have some side effects. These include:
- Stomach problems (pain, ulcers, gas)
- Kidney problems
- Swelling in the legs
- Increased blood pressure
People with rheumatoid arthritis are almost twice as likely to develop heart disease than those without the condition. Heart disease increases the risk of heart attack and stroke. Some prescription NSAIDs may also increase the risk for both events. Aspirin is the only NSAID that effectively prevents blood clots that cause heart attacks and strokes for those who have a high risk of those events.
It’s important to talk with your doctor about your choice of NSAIDs to make sure you are keeping your heart healthy and minimizing risk of cardiovascular diseases.
Corticosteroids are a group of drugs that help control inflammation. They closely resemble cortisol, a hormone that helps the body stay healthy. Cortisol aids in several processes, such as metabolism, stress, and immune response.
Corticosteroids are injected into a vein, joint, or muscle or taken in pill form by mouth. Some corticosteroids come in cream form, which can be applied directly to the skin.
Your doctor may prescribe corticosteroids using a “burst and taper” approach. This means you start with a high dose, followed by decreasing doses until you eventually stop the medication. The “burst” provides symptom relief quicker and reduces residual symptoms. However, patients’ symptoms may begin to worsen in some cases once the dose is tapered.
Your doctor may also use corticosteroids as a “bridge” therapy. This means you will use a low dose for a longer period until other medications start to control your RA. This is usually recommended for patients who are newly diagnosed. For example, a low dose of prednisolone may be prescribed for the first year after an RA diagnosis until a DMARD starts to take effect.
Corticosteroids are one of the most potent treatment options for RA, but they aren’t recommended for long-term use. They are usually prescribed only if the benefits outweigh the risks. Guidelines from the American College of Rheumatology advise doctors to use the lowest effective dose for the shortest duration possible.
Side effects of corticosteroids can include:
- Stomach ulcers
- High blood pressure
- High blood sugar
- Increased appetite
- Mood changes
- Withdrawal symptoms
Common corticosteroids for rheumatoid arthritis include:
- Prednisone—Prednisone is a short-acting oral corticosteroid that helps manage RA pain and inflammation. It is a synthetic version of glucocorticoid, a natural hormone produced by the adrenal glands. Glucocorticoids have anti-inflammatory properties and can reduce redness and swelling. They also suppress the immune system, which can help reduce symptoms.
- Dexamethasone—Dexamethasone is a synthetic glucocorticoid that suppresses the immune system to relieve inflammation.
- Betamethasone—Betamethasone activates natural substances in the skin to reduce itching, redness, and swelling.
- Hydrocortisone—Hydrocortisone relieves inflammation, swelling, heat, redness, and pain.
Disease-modifying Anti-rheumatic Drugs (DMARDs)
Disease-modifying anti-rheumatic drugs (DMARDs) are a group of medications that slow the progression of joint damage from RA. They target the actual disease rather than the symptoms. DMARDs aim to suppress the immune system to control inflammation. While it isn’t entirely clear how they work, they appear to block certain chemicals that are involved in the inflammatory process.
Although they are not painkillers, DMARDs can help reduce pain, swelling, and stiffness over several weeks or months. Because it takes time for DMARDs to become effective, your doctor may prescribe other medications, such as corticosteroids, to bridge the gap until DMARDs start to take effect.
It’s common to use two or three DMARDs together, known as combination therapy. This may be effective when a single DMARD is unsuccessful in modifying your RA. DMARDs are prescribed as soon as possible after an RA diagnosis. The earlier you start DMARDs, the more likely they are to prevent joint damage and slow the progression of RA.
Some common side effects of DMARDs include:
- Upset stomach
- Temporary hair loss
- Weight loss
- Abdominal pain
Methotrexate is one of the most common and effective DMARD prescribed to treat RA. About 90% of patients with RA will use methotrexate at some point. It helps relieve symptoms like joint pain, swelling, redness, and fatigue. It can also help prevent joint and organ damage.
Methotrexate interrupts the process that causes RA inflammation. It works by promoting cells to release a molecule that blocks chemicals that cause inflammation. Reducing inflammation helps reduce pain and joint damage.
The standard oral dosage for methotrexate is 7.5 to 10 milligrams once a week. Your doctor may increase the amount to 20 to 25 milligrams once per week if the lower doses do not work. The standard dose for an injection is either 25 mg/ml or 50 mg/2ml. It can be injected into a muscle or just under the skin.
Another common DMARD used for RA treatment is leflunomide. It works by blocking the formation of DNA that is essential for replicating cells, like those in the immune system. It also suppresses the immune system to reduce inflammation. You can take leflunomide as a 20mg tablet once a day. If you have severe RA or other health factors, you can take 10mg a day.
Your doctor may prescribe you a “loading” dose of leflunomide before switching you to a regular daily dose. A loading dose is sometimes used for medications that take a long time to build up in the body. It brings the amount of the drug in the body to an appropriate therapeutic level. It also helps the drug reach steady-state concentration quicker. Steady-state concentration is when the amount of a drug being absorbed is the same amount that is being cleared from the body when the drug is given continuously. This allows the patient to feel the effects sooner.
The loading dose is usually 100mg once weekly for three weeks or 100mg a day for the first three days after starting the medication. Whether you use a loading dose, or a daily dose will often depend on a balance between your ability to tolerate a higher dose and its ability to start working quickly.
Biologic drugs or biologic agents are genetically engineered proteins that target specific parts of the immune system that promote inflammatory processes. They are a special type of DMARD doctors usually prescribe to people who have moderate to severe RA that has not improved using conventional DMARDs. You can take biologics by themselves or with other RA medications.
Biologics do not cure RA, but they can slow the progression of the disease. They may also have fewer side effects than other treatment options for RA. However, they also suppress your immune system and weaken your ability to fight off germs. Because of this, you may get more infections while taking biologics compared to other medications.
There are several types of biologics and each has a specific inflammatory target.
B-cell inhibitors target B-lymphocytes, white blood cells that are responsible for inflammation. They are used when other treatment options for RA have not been effective. Depleting B cells has been shown to be effective in reducing signs and symptoms of rheumatoid arthritis.
B-cell inhibitors include belimumab (Benlysta) and rituximab (Rituxan). They are given by injection and the dosage is based on your weight. The effects can take a couple of months to appear after an infusion, but they can last from six months up to two years after a single infusion course.
The side effects of B cell inhibitors include itching, hives, swelling, difficulty breathing, fever, and chills.
T-cell inhibitors block communication between T cells, a type of white blood cell, to reduce inflammation. One type of T cell inhibitor is abatacept (Orencia). Doctors often prescribe abatacept if DMARDs are not effective. It may also be used as a first-line treatment for patients who have moderate to severe rheumatoid arthritis. You can take abatacept as a weekly shot or by IV once a month. People who take abatacept usually see a response within three months.
Common side effects include headache, sore throat, nausea, and a cold.
Tumor Necrosis Factor Inhibitors
Tumor necrosis factor (TNF) is a protein that causes inflammation. People with autoimmune or rheumatic conditions like RA have higher levels of TNF than people who do not have these conditions. These high levels can cause unnecessary inflammation that causes pain and swelling.
TNF inhibitors reduce inflammation and slow the progression of RA. They are lab-created antibodies that cause a reaction in the immune system that blocks inflammation. They may be used in combination with corticosteroids or DMARDs. TNF inhibitors include adalimumab (Humira), etanercept (Enbrel), golimumab (Simponi), infliximab (Remicade), and certolizumab pegol (Cimzia).
The most common side effect of TNF inhibitors is a reaction at the injection site that can last up to a week.
Interleukin inhibitors are immunosuppressive agents that stop the production of inflammatory chemicals your body makes. Interleukins are a group of cytokines that play a key role in regulating the immune system. Interleukin inhibitors target cytokines that act as chemical signals between white blood cells in response to an infection.
Interleukin inhibitors include anakinra (Kineret) and tocilizumab (Actemra). You can take anakinra as a shot once a day. You can take tocilizumab by IV once a month or by shots every week or every other week.
The most common side effects of interleukin inhibitors are headache, flu-like symptoms, nausea and vomiting, and diarrhea.
With RA, the body makes too many cytokines, which play a role in inflammation. Some cytokines attach to immune cell receptors, sending messages to the cell to make more cytokines. Janus kinase (JAK) inhibitors block this messaging pathway to keep your immune system in check.
The FDA has approved three JAK inhibitors as treatment options for RA: baricitinib (Olumiant), tofacitinib (Xeljanz), and upadacitinib (Rinvoq). Your doctor may prescribe a JAK inhibitor if DMARDs don’t work to control your RA.
JAK inhibitors come in pill form with dosages ranging from 2 mg to 25 mg. The side effects of JAK inhibitors include cough, headache, high blood pressure, and nausea. They may also cause upper respiratory infections like the common cold or sinus infections.
Physical therapy and occupational therapy can be beneficial for relieving some RA symptoms.
Physical therapy addresses mobility issues like walking, climbing stairs, or moving between positions. It can also help control pain and improve function. Strengthening the muscles that surround joints that are affected by RA can add support to the damaged areas and reduce symptoms. Exercise can help reduce excess weight, which can decrease the overall amount of inflammation in your body. Exercise can also lower your risk of cardiovascular disease. People with RA have twice the risk for cardiovascular disease than the general population.
Occupational therapy focuses on maximizing independence by making it easier to accomplish activities of daily living like bathing or dressing. An occupational therapist can help you adapt to any limitations you may have when it comes to completing different tasks. The therapist may assess you to see where you need help. Then they can customize a treatment plan based on your needs. A therapist can help you find ways to decrease pain and fatigue or provide you with assistive devices. For example aids like jar openers or adaptive utensils can assist with meal prep.
Most people with rheumatoid arthritis will not need surgery. However, some RA patients may choose to have surgery to reduce joint pain and improve daily functioning. Some surgeries may include joint replacements for large joints like shoulders, hips, or knees. Patients may also choose replacements for smaller joints in the fingers and toes.
During joint replacement surgery, a doctor removes either the entire joint or part of a damaged joint and replaces it with a synthetic joint. Joint replacement is a major surgery and you should consider the risks and benefits before undergoing the procedure.
Another type of surgery RA patients may elect to have is a synovectomy. During this procedure, a doctor removes the membrane, called the synovium, that lines the joints so it doesn’t damage cartilage and bone. Doctors usually perform this procedure on the knees, but they may perform it on the shoulders and elbows as well.
Get the Support You Need
Finding the right treatment options for your RA may take time, especially as your disease progresses. You and your doctor can work together to find the right medication or combination of medications and alternative therapies to help you manage your symptoms and improve your quality of life.
If you are struggling with your RA symptoms, you are not alone. At PatientsLikeMe, there are thousands of members living with rheumatoid arthritis and learning how to manage their condition. Join them today to find the support you need.