When you work on the Verrazano-Narrows, one of the biggest suspension bridges in the world, the cold temperatures and heavy lifting can really take a toll on your body. Construction worker John Melendez thought the pain and swelling he was experiencing in his hands, arms, and legs were just side effects of his job. Eventually, the pain became so severe that the 52-year-old Staten Island resident was unable to work at all. “My fingers were so swollen that I couldn’t bend them,” Melendez recalls. “I couldn’t even walk.”
When he finally went to see Jonathan Samuels, MD, an attending rheumatologist at New York University’s Langone Medical Center, Melendez was in so much pain that he had to be practically carried into the office. Tests revealed that he had rheumatoid arthritis or RA. RA is a degenerative autoimmune disease that attacks the joints. Melendez immediately thought of his mother, who also has RA and now lives in a nursing home. He worried that he would share her fate.
Had he been diagnosed 20 or 30 years ago, that might have been the case. People with severe rheumatoid arthritis once had to look forward to a lifetime of chronic pain and disability. But today’s treatments have dramatically improved the outlook. “With the new medications, we’re able to stop the disease process,” Samuels says.
Disease-Modifying Medications for Severe RA
In the past, most patients with rheumatoid arthritis took pain relievers to alleviate their symptoms. But the drugs did nothing to slow the progressive joint damage that occurs with chronic RA. Today, patients are diagnosed earlier and treated more aggressively. And the medications used can actually change the course of their disease and reverse joint damage. “The earlier you catch somebody and the earlier you start effective therapy, the more likely you are to get them into remission,” says Eric Ruderman, MD. Ruderman is associate professor of medicine at the Northwestern University Feinberg School of Medicine. He’s also an attending physician at Northwestern Memorial Hospital. “We are becoming more and more aggressive in the way we treat people,” he says. “So the goal really is remission.”
Aggressive treatment for chronic rheumatoid arthritis typically begins with disease-modifying antirheumatic drugs, or DMARDs. These drugs do more than just reduce symptoms, Ruderman tells WebMD. They address some of the root causes of rheumatoid arthritis.
The gold standard DMARD is methotrexate. “We’re going to try to start with methotrexate if we can,” Samuels says, “because it has the longest track record of doing very well.” Methotrexate has a number of distinct advantages:
- It is relatively inexpensive.
- It works quickly.
- It can slow RA damage to the joints.
- It is generally well tolerated.
Methotrexate and the other DMARDs are very effective. But they don’t provide instant relief. In fact, they may not start working for weeks or even months. DMARDs aren’t right for every patient. If these drugs don’t relieve symptoms, other drugs are available that also target the processes behind chronic RA.
Other Treatment Options for Chronic Rheumatoid Arthritis: Biologic DMARDs
People with severe rheumatoid arthritis who have a lot of joint damage or who aren’t responding well to the traditional DMARDs may be started on a biologic DMARD. Rheumatoid arthritis is caused by an overactive immune response, Ruderman tells WebMD. Biologic drugs target immune triggers that cause joint inflammation and damage in rheumatoid arthritis. Biologic drugs that may be used include:
- Tumor necrosis factor (TNF) inhibitors. These drugs include adalimumab (Humira), certolizumab (Cimzia), etanercept (Enbrel), and infliximab (Remicade). They work by blocking TNF, a type of protein called a cytokine that triggers inflammation.
- Anakinra (Kineret). This drug targets another cytokine called interleukin-1 or IL-1.
- Abatacept (Orencia). Abatacept inactivates immune cells called T cells.
- Rituximab (Rituxan). This drug targets B cells, another type of immune cell.
Biologic drugs are often combined with methotrexate to improve their effectiveness. Today, the biologics are administered intravenously or by injection. But the next phase in drug development, Ruderman says, will be oral medications that can achieve the same results.
All of these drugs can have side effects, which is why rheumatologists monitor their RA patients very carefully. For example, methotrexate can cause liver problems. People who take this drug will need to have regular liver function tests.
Infection is one of the biggest concerns with DMARDs. “In a simplistic sense, RA is a disease of an overactive immune system or an immune system that is over-stimulated in certain areas,” says Ruderman. “All of these drugs work by trying to suppress that level of over-activity. But they also suppress normal areas of the immune system.” RA patients who take DMARDs need to be vigilant about hand washing as well as other preventive strategies to avoid getting sick.
Other Treatment Options for Chronic Rheumatoid Arthritis: Steroids, NSAIDs, and Pain Relievers
DMARDs and biologic response modifiers are important agents used to treat chronic rheumatoid arthritis. But they aren’t the only options. Several other medications can be used to treat severe RA, including the following:
- Steroid medications, such as prednisone. Steroids can quickly reduce RA pain and swelling and slow damage to the joints. They aren’t recommended for long-term use. That’s because they become less effective over time, and they can have serious side effects, including cataracts, diabetes, and thinning bones.
- Nonsteroidal anti-inflammatory drugs or NSAIDS. NSAIDS such as ibuprofen (Motrin, Advil) and naproxen sodium (Aleve) help relieve pain and inflammation, and are often used together with DMARDs.
- Pain relievers such as acetaminophen (Tylenol). These medications are another option for relieving pain. They don’t, however, affect joint inflammation.
RA Therapy Is Trial-and-Error
Often it takes several attempts to find the right drug or combination of drugs that effectively treats chronic RA. “That’s one of the most frustrating things in rheumatology today, that it is very much trial and error,” Ruderman says. “We end up trying something, and if it doesn’t work, we try something else."
John Melendez tried several different medications, including prednisone and Enbrel, with varying degrees of success. Then Samuels put him on a combination of methotrexate and Humira. “When I talk with Dr. Samuels, he calls it ‘cocktails,’” Melendez says. “He’s trying to find the right cocktail for the right person.”
Samuels started him on the steroid prednisone, which he says helped with the swelling. Then he began taking the biologic drug Enbrel. “I did improve, but it was very slight,” he says. “The doctor and I weren’t very happy with the progress.” After a few months, he switched to his current “cocktail” -- a combination of methotrexate and Humira. Although the methotrexate tends to upset his stomach, Melendez has tolerated his medications pretty well.
Non-Medication Options for Severe RA
Ruderman tells WebMD that medication has become so effective at preventing joint degeneration that joint replacements for chronic RA are a lot less common than they used to be. But for patients whose RA doesn’t respond to medication, surgery to repair damaged joints may still be an option. Surgery involves replacing the entire joint (arthroplasty), repairing the tendons around the joint, or removing the joint lining (synovectomy).
Finding the Right RA Treatment
Getting relief from the pain of severe RA starts with a visit to an experienced rheumatologist. The doctor can start you on medication and adjust the drug and dose until your symptoms and joint damage start to improve.
A year after his diagnosis, Melendez says his medications have dramatically improved his rheumatoid arthritis symptoms. “It’s a big difference,” he says. “I guess I’m never going to be 100%, where I say there’s no pain. But compared to what it was in the beginning, it’s like 90% better.” After taking a short break from work, he says he feels well enough to get back on the job.