doctor and patient

Symptoms like fatigue, pain, and stiffness can be familiar companions when you have rheumatoid arthritis (RA). The good news? Not only are treatments these days better than ever, but “there are new treatments and discoveries occurring every year with RA,” says William F. Harvey, MD, clinical director of the Arthritis Treatment Center at Tufts Medical Center in Boston. We asked Harvey to answer some common questions about RA treatments.

Which medicines treat RA?

Pain medications like acetaminophen, ibuprofen, naproxen, tramadol, and opioids treat symptoms, but they don’t prevent ongoing joint damage. And while steroids like prednisone do treat inflammation, they have severe side effects if they’re overused, so we prefer to use them only short term.

Disease-modifying antirheumatic drugs (DMARDs) are the best treatments because they reduce inflammation and prevent ongoing joint damage. You can take DMARDs by mouth or get them as an injection under your skin or an infusion into a vein. In the midst of the COVID-19 pandemic, it’s important to know that these medications work by suppressing your immune system, which puts you at greater risk of infection. Your rheumatologist can help you understand the risks and benefits of treatment, but data suggests that in most cases, you should still take DMARDs if you have active RA.

Which medications are usually the first-line RA treatments?

The first-line RA treatments are oral DMARDs such as, hydroxychloroquine, leflunomide, methotrexate, and sulfasalazine, sometimes used in combination with each other. We choose these first because they have great treatment and safety profiles and they’re less expensive.

How well do RA drugs work?

DMARDs are highly effective for treating RA, and most people who are able to take these medications see substantial improvements in their disease and its symptoms. People who begin DMARDs early in the disease don’t develop the disability and joint disfigurement that were common years ago.

How soon should someone with RA start treatment?

People with RA should start taking DMARD therapy as soon as possible. Data shows that the faster treatment starts, the less pain, damage, and disability that occur. Not treating ongoing inflammation can lead to irreversible joint damage. The longer the inflammation goes unchecked, the more irreversible damage results, and the greater the risk of permanent disability and disfigurement. Even in the context of COVID-19, in most cases your doctor will recommend treatment. It’s important to talk with a rheumatologist about these risks and benefits.

How long will it take medications to get swelling and pain under control?

DMARDs start working in 2 to 4 weeks, but often take longer to reach their greatest effect. You might get additional treatments, too. We also use pain medications and steroids in the short term until the DMARDs kick in.

What do “tight control” and “treat to target” mean?

These terms both relate to the most important central concept in RA: Inflammation = joint damage. We want to keep the symptoms under the tightest possible control (ideally no or very few symptoms) because this is a sign the inflammation is under control and the damage to your joints will be minimized. There are several things a rheumatologist does to tell if inflammation is under control, including some lab tests, imaging tests like ultrasound and X-ray, a careful history of your symptoms, and a thorough physical examination. Often rheumatologists use this information to calculate a numerical score of how active your disease is. But regardless of whether they use a number or not, the goal is no or very low disease activity. Your doctor will recommend options to try and achieve this while taking into account your personal preferences regarding treatment.

Is remission possible?

Remission is the goal of treatment, where you’re able to do most everything you could before your illness, and you feel as normal as possible despite treatment. Most people get into remission, or low disease activity, when they follow their recommended treatment regimen. Sometimes this means taking more than one medication or switching to another treatment.

Is surgery ever necessary?

Treat-to-target approaches are designed to make joint damage less likely, but joint replacement surgery can help. Today knees, hips, ankles, shoulders, and even small finger joints can be replaced. In addition to joint replacements, surgeons can help repair torn tendons and ligaments.

What are some ways to manage fatigue?

Fatigue results from inflammation. It’s one of the most difficult RA symptoms to manage. It can also be a side effect of treatment, though treatment usually helps improve fatigue. Rheumatologists use a variety of adjunctive (add-on) treatments, including regular exercise, healthy diet, and support of healthy sleep patterns.

What type of exercise is good for people with RA?

Any exercise that doesn’t cause pain is good. Aerobic exercise that gets your heart rate up helps with fatigue, sleep, and heart health (people with RA are at higher risk of heart attack than the average person). Light weightlifting can build muscle, which helps support bones. But don’t overdo it. The expression “no pain, no gain” doesn’t really apply here. When you have RA, pain is a sign of inflammation. You shouldn’t ignore it. Many people with RA are unable to run even moderate distances due to pressure on the joints so swimming or walking in water can be helpful because the water relieves some pressure on your joints. Walking, bicycling, light yoga, and tai chi are also good options.

Are there other lifestyle changes that can help?

In addition to exercise, a healthy diet is important. It gives your body the nutrients it needs to help it heal and prevents side effects from medication. A heart-healthy diet is key because people with RA are at greater risk of heart disease.

Minimizing alcohol intake is important. Many of the medications used to treat RA can cause liver damage when they’re combined with alcohol. People with RA are often caught in a vicious cycle between fatigue, pain, poor sleep, and poor diet. Since these are all interlinked, improving even one of them will help the others, but the more you improve, the easier it is to break the cycle.

Do vitamins play a role in treating RA?

Some medications, like methotrexate, require vitamin supplements to prevent side effects. It’s better for the human body to get its nutrients, including vitamins, from healthy food rather than supplements. Very few have been proven in well-designed studies to be beneficial.

Can alternative therapies like yoga or acupuncture help with RA symptoms?

Many of the people I treat use alternative therapies. Most rheumatologists believe that these are actually very helpful. But since RA causes ongoing inflammation and joint damage, these treatments shouldn’t be the only ones you use. Talk to your rheumatologist before you try one. While most alternative therapies are safe and helpful, your doctor can give you advice in case they aren’t right for you. Light yoga that doesn’t put too much strain on your joints is helpful. Tai chi, qigong, prayer, and mindfulness meditation all can help not only the physical aspects of the disease, but also the significant mental strain caused by feeling pain.

What other health professionals might someone with RA need on their treatment team?

The best care comes from a multidisciplinary team. Your rheumatologist may refer you to a physical or occupational therapist. Many people with RA have trouble at work or home when their disease is active.  These professionals can help rheumatologists figure out ways to help you thrive at work. It’s rare, but medications and the disease itself can affect other organs. Your doctor may need to refer you to other specialists. If you already have significant damage, orthopedic surgeons can help repair your joints. And it’s critical to have a primary care physician who keeps an eye on your overall health. When you have other diseases like diabetes that aren’t well controlled, it makes it harder to get your RA under control.

What’s the most important thing people with RA can do to stay healthy?

The single most important thing is to have an open and close relationship with your rheumatologist. Most rheumatologists are extremely interested in hearing what your goals for treatment are so they can tailor their recommendations to include your preferences. Even if you hate medications, your rheumatologist can talk to you about the risks and benefits of various approaches.

Is there anything else you think people with RA should know about treatment?

There’s a common misconception that any type of arthritis is a normal part of aging and that you can’t avoid it. RA is a specific type of arthritis with highly effective treatments that can prevent pain, disability, and deformity. For more information or to find local support groups, consider visiting the Arthritis Foundation, Simple Tasks from the American College of Rheumatology, or Creaky Joints.

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William F. Harvey, MD, clinical director, Arthritis Treatment Center, Tufts Medical Center, Boston.