"Treatments are working better than we could have imagined 15 years ago," says Clifton O. "Bing" Bingham, MD, director of the Johns Hopkins Arthritis Center in Baltimore. Thanks to aggressive treatment, symptoms like painful, swollen joints and fatigue may go away, at least for a while, in some people, he says.
What to Expect From Treatment
As soon as your doctor tells you that you have RA, you'll probably start taking medicine, even if you don’t feel that bad.
"RA can cause irreversible joint damage in the first 3 to 6 months after you're diagnosed," says M. Elaine Husni, MD, MPH, director of the Arthritis and Musculoskeletal Center at the Cleveland Clinic. "There's not a lot of time to wait."
Doctors recommend a “DMARD,” a disease-modifying antirheumatic drug, for everyone with RA. These drugs ease symptoms and slow down or stop the disease from getting worse. Unlike some RA treatments that treat only the pain, a DMARD treats the overactive immune system that harms healthy tissue.
Most people start with a DMARD called methotrexate. "It's tried and true," Husni says. "We have a lot of experience with it and know how to manage the side effects."
Other DMARDs are “biologics.” They are genetically engineered to block specific effects of the immune system. Doctors often recommend a biologic when other treatments have not eased symptoms enough.
DMARDs take a few months to work. In the meantime, you may need painkillers or a steroid like prednisone to get your symptoms under control.
Steroids work fast, but they have long-term side effects. "Steroids are like a Band-Aid, not a real solution," Bingham says. "The goal is to get off them as quickly as possible once the DMARD starts working."
Your Custom Plan
After about 3 months on a DMARD, your doctor will check on how you're doing based on how you feel, results from blood tests and X-rays, and other things.
If your DMARD works well, great. If it's not, you have options. You may switch to another medication. Or your doctor might add a second DMARD, like a biologic. "Different DMARDs have different ways of turning down the immune response," Bingham says. Sometimes combining them works best.
What other things could affect your medication choices?
- Your symptoms. Some drugs work better with specific symptoms. For example, some RA medicines can make you more tired, but some biologic DMARDs can help relieve fatigue, Bingham says.
- Other health conditions. Some medications might not be a good fit if you have other health problems. For instance, some biologic DMARDs may not be safe if you have heart disease or MS. If you drink a lot of alcohol, methotrexate is not safe.
- Your insurance. "In a lot of cases, what the insurance company pays for is the single most important factor in determining what drug you get," Bingham says.
What About Side Effects?
DMARDs do have side effects. Some of them, like a risk of lymphoma and other cancers, are serious. But experts say that people with RA sometimes worry too much about very unlikely side effects. And they don't worry enough about the serious damage that can happen if RA isn't treated.
"We do use strong medications for RA, but that's because it's a severe disease," Bingham says. "We have to treat it aggressively." Closely watching for any side effects can prevent problems, he says. Bingham also stresses that RA itself raises the risk of some cancers.
If you're concerned about the risks of side effects, talk about them with your doctor.
Sticking With Treatment
Keep in mind that you may not see big changes from your RA treatment right away.
"People are sometimes disappointed when they don't get all the answers in that first meeting with me," Husni says. "But treating rheumatoid arthritis is a process. It takes time to come up with the best treatment plan."
Your plan might also change over time. You may have flares sometimes and have to take painkillers or steroids for a while. For reasons that aren't fully clear, a DMARD that worked for years might also stop. If that happens, your doctor has other medicines to choose from.
"Lots of people with RA are thriving these days," Husni says. "Obviously, no one wants to get it. But if you do get diagnosed, there's never been a better time to have it."