Progression and Stages of Rheumatoid Arthritis (RA)

Everybody's different when it comes to rheumatoid arthritis (RA). Over the long run, your symptoms may not be the same as a friend or neighbor who also has the disease. How you'll feel depends such things as:

  • How advanced your RA was when you learned you had it
  • Your age when you were diagnosed
  • How "active" your disease is

How RA Symptoms Progress Over Time

Everyone is different, but there are a few common patterns in the way RA plays out over the years:

  • Long remissions. When you're in one of these periods, your pain and stiffness go away or get much better, but you aren't cured. In a few people with RA -- about 5% to 10% -- the disease starts suddenly, and then they have no symptoms for many years, even decades.
  • Symptoms that come and go. This happens to about 15% of people with rheumatoid arthritis. You may have periods of few or no problems that can last months between flare-ups.
  • Progressive rheumatoid arthritis. Most people in this situation need a long-term treatment plan and a coordinated medical team to manage the condition and slow or stop it from getting worse.

Stages of Rheumatoid Arthritis

There are four stages. Each has its own treatment options.

Stage 1:

  • In the early stages, your joint lining, or synovium, becomes inflamed. The bones aren’t damaged yet. But the tissue around them often swells, making your joint stiff and painful.

Stage 2:

  • In this moderate stage, inflammation damages your cartilage, the cushiony stuff that protects the ends of your bones.
  • The joint will be stiff, and you won’t be able to move it as far as you used to. The doctor will say you’ve lost range of motion.

Stage 3:

  • This is the severe stage. Inflammation is wearing away cartilage and causes erosion of bones near your joints. The joints may become unstable. You might start to notice deformities as the bones move around. You’ll have pain, swelling, and loss of motion.

Stage 4:

  • In end stage RA, inflammation stops, but the damage continues. The joint might stop working. You’ll still have pain, swelling, stiffness, and lack of motion. Your muscles may be weak, too. It could be time for joint replacement surgery.

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How Your Treatment Changes as RA Progresses

Early stage. A key focus is to control the inflammation. That’s especially critical in the early phase of the disease to prevent joint damage. You may get:

Quitting smoking and losing any extra weight also can help slow your RA.

Moderate stage. This is when you may have trouble with regular daily activities because of pain. You also may tire more easily. There are several options. Your doctor may have you try combining methotrexate with two other DMARD medications, sulfasalazine and hydroxychloroquine. Another option is a stronger form of DMARDs, called biologic DMARDs, including:

Instead of a biologic, your doctor may recommend a JAK inhibitor, including:

If a certain joint is particularly inflamed, your doctor may give the joint steroid shots. Once your pain is under control, it’s important to exercise to keep ahead of your RA. You also may need physical therapy.

Severe stage. If a TNF inhibitor fails to improve your symptoms, your doctor may recommend you try a different TNF inhibitor or a different class of biologic. If you don’t respond to one, you may respond to another.

Surgery is a last-resort treatment for very severe RA. That includes when your joints are deformed and damaged and limit your mobility. The three most common surgeries for RA are:

  • Joint replacement. Surgeons replace damaged knee, hip, or other joints with man-made replacement parts.
  • Joint fusion. This is when two joints are fused and realigned.
  • Tendon repair. Your surgeon may realign damaged ligaments or transfer tendons to ease pain or to restore function.

Signs Your RA Is Progressing

How can you tell your RA is getting worse? There's no easy way, but some general signs include:

  • Flares that are intense or last a long time
  • Diagnosis at a young age, which means the disease has more time to become active in your body
  • Rheumatoid nodules -- bumps under your skin, often around your elbows
  • Active inflammation that shows up in tests of joint fluid or blood
  • Damage on X-rays when you were diagnosed
  • High levels of rheumatoid factor or citrulline antibody in blood tests

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Is Remission Possible?

Early and more aggressive treatment raise your chances of remission. But it’s more likely if you have low or good scores on these RA assessments when you’re diagnosed:

  • Disease activity score (DAS) or other measures of disease activity: It uses joint tenderness, signs of inflammation in your blood, and pain levels to rate disease activity.
  • Health assessment questionnaire (HAQ): It gauges how well you can do activities in eight daily life categories.
  • C-reactive protein levels: You’ll get a blood test to look for these signs of inflammation in your blood.

 

See Your Rheumatologist

Your RA doctor can check to see how your disease has changed. If it's getting worse, there are good treatment options to slow it down.

WebMD Medical Reference Reviewed by Michael W. Smith, MD on October 19, 2020

Sources

SOURCES: 

Wheeless’ Textbook of Orthopaedics: “Stages of Rheumatoid Arthritis.”

Arthritis Foundation: “Rheumatoid Arthritis Symptoms.”

UpToDate: “Evaluation and medical management of end-stage rheumatoid arthritis.”

National Rheumatoid Arthritis Society: “Patients.”

Drug Therapy for Rheumatoid Arthritis in Adults: An Update: “Appendix G Clinical and Self-Reported Scales and Instruments Commonly Used in Studies of Drug Therapy for Rheumatoid Arthritis and Psoriatic Arthritis,”

Mayo Clinic: “C-reactive protein test.”Breedveld, F., Annals of the Rheumatic Diseases, January 2005. 

Harris, E., Kelley's Textbook of Rheumatology, 7th edition, W.B. Saunders, 2005. 

Krishnan, E., American Journal of Medicine, Oct. 1 2003. 

Lee D. The Lancet, Sept. 15, 2001.

Rush University Medical Center: “Treating Rheumatoid Arthritis.”

Medscape: “Rheumatoid Arthritis (RA) Treatment & Management.”

Rheumatoid Arthritis Support Network: “RA Treatment: What is the Safest Treatment for Rheumatoid Arthritis?”

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