Understanding Rheumatoid Arthritis -- Treatment

The main treatment goals with rheumatoid arthritis are to control inflammation, ease pain, and reduce disability linked to RA.

Treatment usually includes medications, occupational or physical therapy, and exercise. Some people need surgery to correct joint damage. Early treatment is key to good results. And with today’s treatments, joint damage can often be slowed or stopped.

Drugs for Rheumatoid Arthritis

NSAIDs

As part of rheumatoid arthritis treatment, your doctor will probably prescribe a nonsteroidal anti-inflammatory drug (NSAID). These medications reduce pain and inflammation but don’t slow RA. So if you have moderate to severe RA, you’ll probably also need to take other drugs to prevent further joint damage.

Many come as pills or tablets. Over-the-counter NSAIDs include ibuprofen and naproxen. Most people with RA need a prescription version, like celecoxib (Celebrex), as they offer a higher dose with longer-lasting results and require fewer doses throughout the day.

Prescription NSAIDs carry a warning about the higher risk of heart attack and stroke. NSAIDs can also raise blood pressure and can cause stomach irritation, ulcers, and bleeding.

You and your doctor can weigh the benefits of NSAIDs against the potential risks. You may have to try a few to find the one that’s right for you.

DMARDs

This stands for disease-modifying antirheumatic drugs. They curb your immune system to help slow RA or keep it from getting worse.

Doctors usually first prescribe methotrexate (Trexall) to treat rheumatoid arthritis. If that alone doesn’t calm the inflammation, they may try or add a different type of DMARD such as hydroxychloroquine (Plaquenil), leflunomide (Arava), sulfasalazine (Azulfidine), or tofacitinib (Xeljanz).

You can take DMARDs as a pill, but some people get methotrexate as a shot. It may take a few weeks or months for them to start to work, and longer to get the full effect.

A weakened immune system can lead to infection and a variety of other side effects. Leflunomide and methotrexate can cause birth defects. If you're planning to start a family, talk with your doctor first.

DMARDs, particularly methotrexate, have made major improvements in severe rheumatoid arthritis and can help save your joints.

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Biologics

When methotrexate or other DMARDs don’t ease RA symptoms and inflammation, doctors may recommend a biologic. These are genetically engineered proteins. They block specific parts of the immune system that play a key role in inflammation of rheumatoid arthritis. These drugs can work quickly to ease joint pain and swelling.

Many biologics block TNF, a chemical your body makes that causes inflammation. Other biologics target other chemicals -- like IL-1, IL-17, or Janus kinase (JAK) -- or immune system cells (like T or B cells).

Different biologics target different parts of the immune system. They include:

You may take biologics by injection at home, by IV in a medical center, or as a pill.

Because they slow your immune system, biologics make it harder for your body to fight infection. They can cause flare-ups of some infections that aren't active, like tuberculosis. Some people have reactions at the IV or at the injection site. 
More widespread IV reactions may include chest pain, trouble breathing, and hives. Each drug has its own set of side effects that you should talk about with your doctor.

Steroids

For severe RA or when symptoms flare, your doctor may recommend steroids to ease pain and stiffness. In most cases, they can be used temporarily to calm a flare. But some people need to take steroids for a longer time to control pain and inflammation. Common ones include hydrocortisone (Cortef), methylprednisolone (Medrol), and prednisone (Deltasone).

You can get steroids as a shot directly into an inflamed joint or take them as a pill. Shots cause fewer side effects. But you can't get them more than once every 3 or 4 months, because they can weaken your bones and tissues.

Steroids can cause weight gain and bone loss, making osteoporosis more likely. They also may raise blood pressure, make diabetes worse, and raise the chance of infections. Generally, taking lower doses for a shorter time means fewer side effects.

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Combination therapy

Taking more than one medication can help you move better and with less pain. It could also slow or stop joint damage caused by RA.

You’ll probably take methotrexate as part of combination therapy, plus a similar drug (such as hydroxychloroquine, leflunomide, or sulfasalazine), or with a biologic.

Taking more than one medication can't reverse joint damage that you already have, and it isn’t a cure. But it can prevent further damage and help you avoid other health problems that can come with rheumatoid arthritis, like heart attack and stroke.

Surgery for Rheumatoid Arthritis

If joint pain and inflammation become unbearable or joints are severely damaged, some people need joint replacement surgery. The hips and knees, and sometimes the shoulders, are the most common joints that get replaced. Surgery can dramatically improve pain and mobility. Most people wait until after age 50, because artificial joints tend to wear down after 15 to 20 years.

Some joints, such as the ankles, don't respond well to artificial replacement and do better with an operation called joint fusion.

Talk about your options with your doctor. You may want to ask things like:

  • What are the pros and cons?
  • What are the possible complications?
  • How long will it take to recover?
  • Will I need physical therapy?
  • How long will the joint last?

Physical and Occupational Therapy

Physical therapy and occupational therapy make a big difference to your daily life. They are key parts of any rheumatoid arthritis treatment plan.

Physical therapists can give you an exercise plan, teach you how to use heat and ice, do therapeutic massage, and encourage and motivate you.

Occupational therapists help you handle daily tasks -- like cooking or using your computer -- and show you easier ways to do those things. They can also check on whether any gadgets would help you.

How Cognitive Therapy Can Help

Because one of the most trying aspects of rheumatoid arthritis is learning to live with pain, many doctors recommend pain management training. They may call it “cognitive therapy.”

The goal is to improve your emotional and psychological well-being as you develop ways to relax, handle stress, and pace yourself. For instance, it may include activity scheduling, guided imagery, relaxation, distraction, and creative problem-solving.

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Exercise, Joint Pain, and Rheumatoid Arthritis

When your joints are stiff and painful, exercise might be the last thing on your mind. Yet with RA, exercising regularly is one of the best things you can do.

  • People who work out live longer, with or without rheumatoid arthritis.
  • Regular exercise can cut down on RA pain.
  • Your bones will be stronger. Thinning of the bones can be a problem with rheumatoid arthritis, especially if you need to take steroids.
  • Stronger muscles help you move better.
  • Your mood and energy level will benefit.

Natural Treatments for Rheumatoid Arthritis

There are some complementary medicine treatments that might help with your RA. It’s a good idea to talk it over with your doctor first. You’ll still need to take your medicine and keep up with the other parts of your treatment plan.

Heat and cold. Ice packs can reduce joint swelling and inflammation. Put a cold compress or ice pack (wrapped in a towel) on the joint. Use the ice packs for 15 minutes at a time, with 30-minute breaks in between.

Heat compresses relax muscles and stimulate blood flow. Wrap a warm towel or pad around the area that hurts. Or try a warm bath or shower.

Relaxation. Try progressive muscle relaxation. This is when you tense or tighten one muscle group and then relax it. Take deep breaths as you do. Start with the muscles of your feet. Move slowly up your body, ending with the muscles of your face.

Sleep. A lack of shut-eye can make your joints hurt. Go to bed and get up at the same time each day. Try to get some exercise every day. Avoid nicotine, caffeine, and alcohol. And don't forget to "unplug" your bedroom: Turn off TVs, computers, and phones.

Capsaicin. It's an ingredient in hot peppers. Studies show that it can ease pain when you rub your joints with cream that's got some in it. You may feel more pain at first, but it usually eases up.

Acupuncture. Studies show that acupuncture curbs pain, may lower the need for painkillers, and is good for helping affected joints stay flexible.

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Mind/body therapy. Mind/body therapies can help with stress management, plus improve sleep and how you react to pain. Strategies include deep belly breathing, relaxing your muscles one by one from head to toe, visualization (such as picturing a calming scene), meditation, and tai chi.

Biofeedback. You work with a therapist who helps you recognize when you feel tense and learn ways to calm yourself. This can help you handle pain.

Electrical stimulation (TENS). Although it's rarely used for RA, it may help. TENS is a small device that sends electrical signals into your body through electrodes placed on your skin near the area that hurts.

It's not clear exactly how it works. One theory is that it interrupts pain signals in your nerves. Another idea is that it triggers your body to release natural painkillers called endorphins.

A home TENS unit may get you through a flare-up. Most people hurt less while the device is on, but after they turn it off, the pain usually comes back.

Nutritional supplements. Keep in mind that even natural supplements can interact with medicines. So tell your doctor about all medicines and supplements you take. They can make sure they’re OK for you.

Research shows that omega-3 fatty acids in fish oil may help ease inflammation in the body. Several studies have shown that fish oil supplements may help reduce morning stiffness with RA.

Some studies show that borage seed oil, along with anti-inflammatory painkillers, can reduce RA symptoms. In people with RA, joints were less tender and swollen after 6 weeks.

Don’t Smoke!

If you smoke, make it a priority to quit. If you keep smoking, it may make your RA treatment less effective.

Can I Cut Back on My RA Medications if I Feel OK?

If pain and stiffness start to fade, you may wonder if you can change your medications.

RA is a long-term condition, and medicine keeps your symptoms under control. But with guidance from their doctor, some people may be able to lower the amount of medication they take.

When was your last flare?

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Studies show that people who stop their RA medicine are likely to have a flare of symptoms 4 to 8 weeks later. If your disease stays active, you're more likely to get permanent joint damage.

Your doctor will want to know how long it's been since you had any problems. They’ll also do some tests. If everything looks good, your doctor may slowly lower the dose of your medications, usually starting with NSAIDs.

You want to keep a constant and effective level of your RA drugs in your system, so if you are able to cut back on your medicine, it would be a slow change. It helps if you take your medicine at the same time every day.

Do you have any trouble with side effects from your meds?

If so, tell your doctor about them. They may be able to adjust your medicine. For example, many drugs used to treat RA can cause an upset stomach. To help, your doctor may suggest that take it at a different time or with food. They may also recommend medication to ease nausea and help with stomach acid.

Do you use reminders to help you take medicine on time?

When you feel better, you might find that you forget to take the medications that got rid of your pain in the first place. Try some simple tips that can help keep your treatment on schedule.

  • Use a pillbox to track which meds to take and when to take them.
  • Pair your drugs with a daily event -- like brushing your teeth or breakfast -- so that you take them at the same time every day.
  • Program a reminder alarm in your cellphone, computer, or digital watch, or download an app that keeps track of your medication schedule.
  • When you renew your prescriptions, make a note on your calendar so you'll know when to get the next refill.

Rheumatoid Arthritis Prevention

There’s no way to prevent rheumatoid arthritis. But early treatment can usually keep it from getting worse.

WebMD Medical Reference Reviewed by David Zelman, MD on October 15, 2020

Sources

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