Rheumatoid Arthritis (RA)

    Medical Author: Catherine Burt Driver, MD
    Medical Editor: Melissa Conrad Stöppler, MD

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Rheumatoid Arthritis (RA) Definition and Facts

What Is Rheumatoid Arthritis?
What Is Rheumatoid Arthritis?

Rheumatoid arthritis is a chronic joint disease that damages the joints of the body. It is also a systemic disease that potentially affects internal organs of the body and leads to disability. The joint damage is caused by inflammation of the joint lining tissue. Inflammation is normally a response by the body's immune system to "assaults" such as infections, wounds, and foreign objects. In rheumatoid arthritis, the inflammation is misdirected to attack the joints. Rheumatoid arthritis is often referred to as RA.

    The inflammation in the joints causes joint pain, stiffness, swelling, and loss of function.
    The inflammation often affects other organs and systems of the body, including the lungs, heart, and kidneys.
    If the inflammation is not slowed or stopped, it can permanently damage the affected joints and other tissues.

Rheumatoid arthritis can be confused with other forms of arthritis, such as osteoarthritis or arthritis associated with infections. Rheumatoid arthritis, however, is an autoimmune disease. This means that the body's immune system mistakenly attacks the tissues it is supposed to protect. Rheumatoid arthritis is the most common form of autoimmune, inflammatory arthritis in adults. It can also affect children.

    The immune system in rheumatoid arthritis is misdirected and produces specialized cells and chemicals that are released into the bloodstream and attack body tissues.
    This abnormal immune response causes inflammation and thickening of the membrane (synovium) that lines the joint. Inflammation of the synovium is called synovitis and is the hallmark of an inflammatory arthritis such as rheumatoid arthritis.
    As the synovitis expands inside and outside of the joint, it can damage the bone and cartilage of the joint and the surrounding tissues, such as ligaments, tendons, nerves, and blood vessels. This leads to deformity and loss of function.

Rheumatoid arthritis most often affects the smaller joints, such as those of the hands and/or feet, wrists, elbows, knees, and/or ankles, but any joint can be affected. The symptoms often lead to significant discomfort and disability.

    Many people with rheumatoid arthritis have difficulty carrying out normal activities of daily living, such as standing, walking, dressing, washing, using the toilet, preparing food, and carrying out household chores.
    The symptoms of rheumatoid arthritis interfere with the ability to work for many people.
    On average, life expectancy is somewhat shorter for people with rheumatoid arthritis than for the general population. This higher mortality rate does not mean that everyone with rheumatoid arthritis has a shortened life span. Rheumatoid arthritis itself is not a fatal disease. However, it can be associated with many complications and treatment-related side effects that can contribute to premature death.

Although rheumatoid arthritis most often affects the joints, it is a disease of the entire body. It can affect many organs and body systems besides the joints. Therefore, rheumatoid arthritis is referred to as a systemic disease.

About 1.3 million people in the United States are believed to have rheumatoid arthritis.

    About 75% of those affected are women. Women are two to three times more likely to develop rheumatoid arthritis than men.
    Rheumatoid arthritis affects all ages, races, and social and ethnic groups.
    It is most likely to strike people 35-50 years of age, but it can occur in children, teenagers, and elderly people. Rheumatoid arthritis that begins in people under 16 years of age is similar but not identical to the disease in adults and is referred to as juvenile idiopathic arthritis (formerly juvenile rheumatoid arthritis).
    Worldwide, about 1% of people are believed to have rheumatoid arthritis, but the rate varies among different groups of people. For example, rheumatoid arthritis affects about 5%-6% of some Native-American groups, while the rate is very low in some Caribbean people of African descent.
    The rate is about 2%-3% in people who have a close relative with rheumatoid arthritis, such as a parent, brother or sister, or child.

Although there is no cure for rheumatoid arthritis, the disease can be controlled in most people. Early, aggressive therapy, soon after the initial diagnosis, which is optimally targeted to stop or slow down inflammation in the joints can prevent or reduce symptoms, prevent or reduce joint destruction and deformity, and prevent or lessen disability and other complications.

Although rheumatoid arthritis most often affects the joints, it is a disease of the entire body. It can affect many organs and body systems besides the joints. Therefore, rheumatoid arthritis is referred to as a systemic disease.

How Does Rheumatoid Arthritis Affect the Entire Body?

    Musculoskeletal structures: Damage to muscles surrounding joints may cause atrophy (shrinking) that results in weakness. This is most common in the hands. Atrophy also may result from not using a muscle, such as from pain or swelling. Damage to bones and tendons can cause deformities, especially of the hands and feet. Osteoporosis and carpal tunnel syndrome are other common complications of rheumatoid arthritis.
    Skin: Many people with rheumatoid arthritis develop small, firm nodules on or near the joint that are visible under the skin. These are known as rheumatoid nodules and are most noticeable under the skin on the bony areas that stick out when a joint is flexed. Dark purplish areas on the skin (purpura) are caused by bleeding into the skin from weakened blood vessels. Purpura is particularly common in those patients who have taken cortisone medication, such as prednisone.
    Heart: A collection of fluid around the heart (pericardial effusion) from inflammation is not uncommon in rheumatoid arthritis. This usually causes only mild symptoms, if any, but it can be very severe and lead to poor heart function. Rheumatoid arthritis-related inflammation can affect the heart muscle, the heart valves, or the blood vessels of the heart (coronary arteries). Heart attacks are more frequent in patients with rheumatoid arthritis than those without it, therefore, monitoring cholesterol and cardiovascular health is important.
    Lungs: Rheumatoid arthritis' effects on the lungs may take several forms. Fluid may collect around one or both lungs and is referred to as a pleural effusion. Inflammation of the lining tissues of the lungs is known as pleuritis. Less frequently, lung tissues may become stiff or scarred, referred to as pulmonary fibrosis. Any of these effects can have a negative effect on breathing. Lung infections are more common with rheumatoid arthritis. Rheumatoid nodules of local inflammation can occur in the lungs.
    Digestive tract: The digestive tract is usually not affected directly by rheumatoid arthritis. Dry mouth, related to Sjögren's syndrome, is the most common symptom of gastrointestinal involvement. Digestive complications are much more likely to be caused by medications used to treat the condition, such as gastritis (stomach inflammation) or stomach ulcer caused by NSAID therapy.
    Kidneys: The kidneys are not usually affected directly by rheumatoid arthritis. Kidney problems in rheumatoid arthritis are much more likely to be caused by medications used to treat the condition. Nevertheless, severe, long-standing disease can uncommonly lead to a form of protein deposition and damage to the kidney, referred to as amyloidosis.
    Blood vessels: Inflammation of the blood vessels can cause problems in any organ but is most common in the skin, where it appears as purple patches (purpura) or skin ulcers.
    Blood: Anemia or "low blood" is a common complication of rheumatoid arthritis. Anemia means that there is an abnormally low number of red blood cells and that these cells are low in hemoglobin, the substance that carries oxygen through the body. (Anemia has many different causes and is by no means unique to rheumatoid arthritis.) A low white blood cell count (leukopenia) can occur from Felty's syndrome, a complication of rheumatoid arthritis that is also characterized by enlargement of the spleen.
    Nervous system: The deformity and damage to joints in rheumatoid arthritis often lead to entrapment of nerves. Carpal tunnel syndrome is one example of this. Entrapment can damage nerves and may lead to serious consequences.
    Eyes: The eyes commonly become dry and/or inflamed in rheumatoid arthritis. This is a result of inflammation of the tear glands and is called Sjögren's syndrome. The severity of this condition depends on which parts of the eye are affected. There are many other eye complications of rheumatoid arthritis, including inflammation of the whites of the eyes (scleritis), which often require the care of an ophthalmologist.

Like many autoimmune diseases, rheumatoid arthritis typically waxes and wanes. Most people with rheumatoid arthritis experience periods when their symptoms worsen (known a flare-up or active disease) separated by periods in which the symptoms improve. With successful treatment, symptoms may even go away completely (remission, or inactive disease).
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The term arthritis refers to stiffness in the joints. See Answer

What Are Symptoms and Signs of Rheumatoid Arthritis?

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Although rheumatoid arthritis can have many different symptoms, joints are always affected. Rheumatoid arthritis almost always affects the joints of the hands (such as the knuckle joints), wrists, elbows, knees, ankles, and/or feet. The larger joints, such as the shoulders, hips, and jaw, may be affected. The vertebrae of the neck are sometimes involved in people who have had the disease for many years. Usually at least two or three different joints are involved on both sides of the body, often in a symmetrical (mirror image) pattern. The usual joint symptoms include the following:

    Stiffness: The joint does not move as well as it once did. Its range of motion (the extent to which the appendage of the joint, such as the arm, leg, or finger, can move in different directions) may be reduced. Typically, stiffness is most noticeable in the morning and improves later in the day.
    Inflammation: Red, tender, and warm joints are the hallmarks of inflammation. Many joints are typically inflamed (polyarthritis).
    Swelling: The area around the affected joint is swollen and puffy.
    Nodules: These are hard bumps that appear on or near the joint. They often are found near the elbows. They are most noticeable on the part of the joint that juts out when the joint is flexed.
    Pain: Pain in rheumatoid arthritis has several sources. Pain can come from inflammation or swelling of the joint and surrounding tissues or from working the joint too hard. The intensity of the pain varies among individuals.

These symptoms may keep someone from being able to carry out normal activities. General symptoms include the following:

    Malaise (a "blah" feeling)
    Fever
    Fatigue
    Loss of appetite or lack of appetite
    Weight loss
    Myalgias (muscle aches)
    Weakness or loss of energy

The symptoms usually come on very gradually, although in some people they come on very suddenly. Sometimes, the general symptoms come before the joint symptoms, and an individual may think he or she has the flu or a similar illness.

The following conditions suggest that rheumatoid arthritis is quiet, referred to as "in remission":

    Morning stiffness lasting less than 15 minutes
    No fatigue
    No joint pain
    No joint tenderness or pain with motion
    No soft-tissue swelling

What Are the Different Types of Rheumatoid Arthritis?

Symptoms of rheumatoid arthritis usually begin gradually in several joints. Sometimes the symptoms begin only in one joint, and sometimes the symptoms begin initially in the whole body, with generalized stiffness and aching, and then localize to the joints.

    Typical "classic" rheumatoid arthritis is the most common type of rheumatoid arthritis. Classic rheumatoid arthritis involves three or more joints. Usually, people have a gradual onset of joint pain, stiffness, and joint swelling, usually in the fingers, wrists, and forefeet. Elbows, shoulders, hips, ankles and knees are also commonly affected.
        About 80% of people with rheumatoid arthritis are classified as "seropositive," which simply means the rheumatoid factor (RF) blood test is abnormal. Some people with an abnormal rheumatoid factor also have an abnormal anti-CCP (anti-citrulline antibody) blood test. This is another blood test for rheumatoid arthritis.
        Approximately 20% of people with rheumatoid arthritis are classified as "seronegative," which means the rheumatoid factor blood test is negative, or normal. In this case, the anti-CCP blood test may be abnormal or normal. Other blood tests, such as the ESR (sed rate) measure of inflammation, may be abnormal.

Palindromic rheumatism

    Uncommonly, the onset of rheumatoid arthritis is episodic. One or several joints may be swollen and painful for several hours to several days. The inflammation then subsides for days to months, and then occurs again. This is known as palindromic rheumatism. People with this condition often develop typical "classical" rheumatoid arthritis.

Atypical presentations of RA

    Persistent arthritis of just one joint may be the first symptoms of rheumatoid arthritis in some people.
    Some people experience generalized aching, stiffness, weight loss, and fatigue as their initial symptoms of rheumatoid arthritis.

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Osteoarthritis vs. Rheumatoid Arthritis

Osteoarthritis is the most common type of arthritis, affecting about 27 million people in the United States. Osteoarthritis is caused by degeneration of cartilage, and is also known as degenerative arthritis. In contrast, rheumatoid arthritis is caused by the immune system attacking the joints. This autoimmune process causes systemic inflammation, while in osteoarthritis, mechanical degeneration causes localized inflammation.

Osteoarthritis commonly affects a single joint, such as one knee. Trauma, such as multiple injuries playing sports, is a risk factor for osteoarthritis. On the other hand, rheumatoid arthritis usually affects three or more joints, in a symmetric distribution (both wrists, both ankles, and/or the toes on both feet). Rheumatoid arthritis frequently, but not always, causes elevation in blood levels of substances that are markers of systemic inflammation such as the ESR (sed rate or erythrocyte sedimentation rate) and CRP (C-reactive protein). In contrast, osteoarthritis does not cause abnormal blood test results. Both osteoarthritis and rheumatoid arthritis are hereditary. For example, if a woman (or man) has osteoarthritis or rheumatoid arthritis, her/his children are at increased risk of developing the same type of arthritis.

What Are Causes and Risk Factors of Rheumatoid Arthritis?

The cause of rheumatoid arthritis is not known. Many risk factors are involved in the abnormal activity of the immune system that characterizes rheumatoid arthritis. These risk factors include

    genetics (inherited genes),
    hormones (explaining why the disease is more common in women than men), and
    possibly infection by a bacterium or virus.

Other environmental factors known to increase the risk for developing rheumatoid arthritis include

    tobacco smoking,
    silica exposure, and
    periodontal (gum) disease.

Medical scientists have shown that alterations in the microbiome (altered levels of gut bacteria that normally inhabit the bowels) exist in people with rheumatoid arthritis. Emerging research shows that the microbiome has an enormous influence on our health, immune system, and many diseases, even those previously not directly linked to the gastrointestinal tract. Studies have shown different kinds of bacteria in the intestines of people with rheumatoid arthritis than in those who do not have rheumatoid arthritis. However, it remains unknown how this information can be used to treat rheumatoid arthritis. Treatment is probably not as simple as replacing missing bacteria, but this may explain why some individuals with rheumatoid arthritis feel better with various dietary modifications.
SLIDESHOW
Rheumatoid Arthritis (RA) Symptoms & Treatment See Slideshow

What Does RA Feel Like?

    The usual symptoms of rheumatoid arthritis are stiff and painful joints, muscle pain, and fatigue.
    The experience of rheumatoid arthritis is different for each person.
    Some people have more severe pain than others.
    Most people with rheumatoid arthritis feel very stiff and achy in their joints, and frequently in their entire bodies, when they wake up in the morning.
    Joints may be swollen, and fatigue is very common.
    It is frequently difficult to perform daily activities that require use of the hands, such as opening a door or tying one's shoes.
    Since fatigue is a common symptom of rheumatoid arthritis, it is important for people with rheumatoid arthritis to rest when necessary and get a good night's sleep.
    Systemic inflammation is very draining for the body.

When Should People Seek Medical Care for Rheumatoid Arthritis?

    Joint pain or stiffness or swelling around a joint that lasts more than two weeks warrants a visit to a health-care professional.
    Someone who experiences symptoms that he or she thinks may be caused by arthritis should talk to a doctor. A doctor can explain the treatment options.

How Do Health-Care Professionals Diagnose Rheumatoid Arthritis?

On hearing someone's history of symptoms, a health-care professional will suspect that he or she has rheumatoid arthritis or another type of arthritis or rheumatic disease. The diagnosis doesn't end there though. It is very important to know exactly which type of arthritis a patient has because the treatment and outlook for each type can be different.

A health-care professional will conduct a thorough interview and physical examination to try to pinpoint the cause of the symptoms. The physician will ask about symptoms, about other medical problems now and in the past, about family medical problems, about current medications, and about habits and lifestyle.

There is no single test to confirm the diagnosis of rheumatoid arthritis. A health-care professional will use the results of the interview and physical examination, lab tests including blood tests, and imaging studies such as X-rays to determine whether or not someone has rheumatoid arthritis. At any time in the process of making the diagnosis or treating the condition, a primary-care physician may refer a patient to a rheumatologist (a specialist in diagnosing and treating rheumatoid arthritis).

Lab tests: A health-care professional may suggest any of the following tests:

    Complete blood count: This test measures how many of each type of blood cell are in the blood. This will show anemia as well as abnormalities in white blood cell counts or platelet counts that can occur with rheumatoid arthritis.
    Markers of inflammation: These include measures such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Levels of both of these are usually elevated in active rheumatoid arthritis and may be good indicators of the extent of disease activity at any given time.
    Other blood tests: Levels of electrolytes (such as calcium, magnesium, and potassium) and proteins may be tested. Kidney and liver functions also may be checked and monitored while taking medications.

Immunologic tests: Blood levels of rheumatoid factor (RF), antinuclear antibodies (ANA), and possibly other tests including CCP antibodies (Anti-cyclic citrullinated peptide or anti-citrulline antibodies) and 14.3.3 eta protein levels.

Synovial fluid analysis: The tissue that lines the joint (synovium) produces fluid that normally helps to lubricate and protect joints. This fluid may be abnormal in quality and excessive quantity from rheumatoid arthritis. It may reveal characteristic signs of inflammation that point to rheumatoid arthritis, such as an elevated number of white blood cells. A sample of this fluid is withdrawn from a joint (usually the knee) through a needle in a procedure called arthrocentesis, or joint aspiration. The fluid is examined and analyzed for signs of inflammation.

Imaging studies: X-rays and sometimes other imaging studies often are used to detect damage to the joints.

    X-rays: X-rays may be taken of sites where symptoms or signs occur. Early in rheumatoid arthritis, the X-ray may be normal or show only soft-tissue swelling, but damage can still be occurring. Over time, the usual finding is erosion of the bony part of the joint. Bone erosion occurs in nearly 80% of patients with one year of untreated disease. These changes are different than those that occur with other types of arthritis such as osteoarthritis.
    MRI: Magnetic resonance imaging (MRI) may allow earlier detection of bone erosion than plain film X-rays.
    Ultrasound: Ultrasound uses high-frequency sound waves to produce images of structures inside the body. It can be used to examine and to detect abnormal collections of fluid in the soft tissues around joints. The abnormal collection of joint fluid is referred to as a joint effusion.
    Bone scanning: In this test, a special image of the entire skeleton is obtained after a small amount of radioactive isotope is injected into a vein. Diseased or damaged bone takes up the radioisotope in a different way than healthy bone and produces a characteristic picture on X-ray films. This technique may be used to detect inflammatory changes in bone.
    Densitometry: This scan (DEXA scan) detects decreases in the thickness of bone that may indicate osteoporosis. Osteoporosis occurs more frequently in patients with rheumatoid arthritis.
    Arthroscopy: In this test, a small scope, a long narrow tube with a light and a camera on the end, is used to examine the inside of the joint. The scope is inserted through a small incision in the skin. The camera transmits pictures to a video monitor, allowing the doctor to detect signs of rheumatoid arthritis or other joint disease. This test is not always necessary.

How Do Health-Care Professionals Classify the Severity of Rheumatoid Arthritis (Stages)?

The American College of Rheumatology has developed a system for classifying rheumatoid arthritis into stages based on X-ray changes and signs of joint injury. This system helps medical professionals determine the severity of the rheumatoid arthritis.

Stage I

    No damage seen on X-rays, although there may be signs of bone thinning

Stage II

    On X-ray, evidence of bone thinning around a joint with or without slight bone damage
    Slight cartilage damage possible
    Joint mobility may be limited; no joint deformities observed
    Atrophy of adjacent muscle
    Abnormalities of soft tissue around joint possible

Stage III

    On X-ray, evidence of cartilage and bone damage and bone thinning around the joint
    Joint deformity without permanent stiffening or fixation of the joint
    Extensive muscle atrophy
    Abnormalities of soft tissue around joint possible

Stage IV

    On X-ray, evidence of cartilage and bone damage and osteoporosis around joint
    Joint deformity with permanent stiffening or fixation of the joint (ankylosis)
    Extensive muscle atrophy
    Abnormalities of soft tissue around joint possible

Rheumatologists also classify the functional status of people with rheumatoid arthritis as follows:

    Class I: Completely able to perform usual activities of daily living
    Class II: Able to perform usual self-care and work activities but limited in activities outside of work (such as playing sports, household chores)
    Class III: Able to perform usual self-care activities but limited in work and other activities
    Class IV: Limited in ability to perform usual self-care, work, and other activities

What Are Rheumatoid Arthritis Treatments?

Despite significant advances in treatment over the past decades, rheumatoid arthritis continues to be an incurable disease. While there is no cure, the goal of disease remission is frequently attainable. Treatment of rheumatoid arthritis has two major components:

    reducing inflammation and preventing joint damage and disability and
    relieving symptoms, especially pain. Although achieving the first goal may accomplish the second, many people need separate treatment for symptoms at some point in the disease.

Are There Any Home Remedies for Rheumatoid Arthritis?

If someone has joint pain or stiffness, he or she may think it is just a normal part of getting older and that there is nothing he or she can do. Nothing could be further from the truth. There are several options for medical treatment and even more to help prevent further joint damage and symptoms. Discuss these measures with a health-care professional to find ways to make them work.

    First of all, don't delay diagnosis or treatment. Having a correct diagnosis allows a health-care professional to form a treatment plan. Delaying treatment increases the risk that the arthritis will get worse and that serious complications will develop.
    Learn everything about rheumatoid arthritis. If there are any questions, ask a health-care professional. If any questions remain, ask the health-care professional to provide reliable sources of information. Some resources are listed later in this article.
    Know the pros and cons of all of treatment options, and work with a health-care professional to decide on the best options. Understand the treatment plan and what benefits and side effects can be expected.
    Learn about the symptoms. If someone has rheumatoid arthritis, he or she probably has both general discomfort (aches and stiffness) and pain in specific joints. Learn to tell the difference. Pain in a specific joint often results from overuse. Pain in a joint that lasts more than one hour after an activity probably means that that activity was too stressful and should be avoided.

Increase physical activity.

    Exercise is a very important part of a complete treatment plan for rheumatoid arthritis, particularly once the joint inflammation is controlled.
    It may seem that exercise is bad for arthritic joints, but research overwhelmingly shows that exercise in rheumatoid arthritis helps reduce pain and fatigue, increases range of motion (flexibility) and strength, and helps someone feel better overall.
    Three types of exercise are helpful: range-of-motion exercise, strengthening exercise, and endurance (cardio or aerobic) exercise. Water aerobics are an excellent choice because they increase range of motion and endurance while keeping weight off the joints of the lower body.
    Talk to a health-care professional about how to start an exercise program and what types of exercises to do and avoid. He or she may refer a patient to a physical therapist or exercise specialist.

Protect the joints.

    At least once a day, move each joint through its full range of motion. Do not overdo or move the joint in any way that causes pain. This helps keep freedom of motion in the joints.
    Avoid situations that are likely to strain the joints. Remember that the joints are more susceptible to damage when they are swollen and painful. Avoid stressing the joint at such times.
    Learn proper body mechanics. This means learning to use and move the body in ways that reduce the stress on the joints. This is especially true for the hands, since it's important to protect their flexibility. Ask a health-care professional or physical therapist for suggestions on how to avoid joint strain.
    Be creative in thinking up new ways to carry out tasks and activities.
    Use the strongest joint available for the job. Avoid using the fingers, for example, if the wrist can do the job.
    Take advantage of assistive devices to carry out activities that have become difficult. These simple devices can work very well to reduce stress on certain joints. Talk to a health-care professional or physical and/or occupational therapist about this.

Alternate periods of rest and activity through the day. This is called pacing.

    General rest is an important part of rheumatoid arthritis treatment, but avoid keeping the joints in the same position for too long a time. Get up and move; use the hands.
    Holding the joint still for long periods just promotes stiffness. Keep the joints moving to keep them flexible.
    If it's necessary to sit for long periods, say at work or while traveling, take a short break every hour; stand up, walk around, stretch, and flex the joints.
    Rest before becoming tired or sore.

Take part in enjoyable activities every day.

    This can improve one's outlook and help put the arthritis in perspective.
    Some enjoyable activities are even helpful for the joints, such as walking, swimming, and light gardening.

Take steps toward a healthier lifestyle.

    If someone is overweight, losing weight not only helps him or her look better, it helps the joints feel better. Reducing weight helps take stress off joints and reduces pain. Maintaining a healthy weight also can help prevent other serious medical conditions such as heart disease and diabetes.
    Eat a varied diet with plenty of fruits and vegetables, lean proteins, and low-fat dairy products. Some research has suggested that a fish-grain diet can decrease the chances of developing rheumatoid arthritis while a Western high-fat diet might increase the chances of developing rheumatoid arthritis. An adequate amount of dietary vitamin C and calcium can be helpful for those affected by rheumatoid arthritis.
    Quit smoking. This will reduce the risk of rheumatoid arthritis complications. This will also reduce the risk of lung cancer, emphysema, and other breathing problems as well as heart disease. Smoking, in fact, has been associated with an increased risk for developing rheumatoid arthritis. Quitting smoking has been proven to reduce rheumatoid arthritis disease activity.

Get the most out of treatment.

    Take medications as directed. If a patient thinks a medication is not working or is causing side effects, talk to a health-care professional before stopping the medication. Some medications take weeks or even months to reach their full benefit. In a few cases, stopping a medication suddenly can even be dangerous. Any natural remedies should be discussed with a health-care professional to make sure there are no harmful side effects or interactions with rheumatoid arthritis medications.
    Taking a warm bath before bed can help with relaxation. Massages feel good and may help increase energy and flexibility. Apply an ice pack or cold compress to a joint to reduce pain and swelling. (Keep a reusable ice pack in the freezer or try using a bag of frozen vegetables.)

What Are Medical Treatments for Rheumatoid Arthritis?

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Rheumatoid arthritis is a progressive inflammatory disease. This means that unless the inflammation is stopped or slowed, the condition will continue to worsen with joint destruction in most people. Although rheumatoid arthritis does occasionally go into remission without treatment, this is rare. Starting treatment as soon as possible after diagnosis of rheumatoid arthritis is strongly recommended. The best medical care combines medication and nondrug approaches.

Nondrug approaches include the following:

    Physical therapy helps preserve and improve range of motion, increase muscle strength, and reduce pain.
    Hydrotherapy involves exercising or relaxing in warm water. Being in water reduces the weight on the joints. The warmth relaxes the muscles and helps relieve pain.
    Relaxation therapy teaches techniques for releasing muscle tension, which helps relieve pain.
    Both heat and cold treatments can relieve pain and reduce inflammation. Some people's pain responds better to heat and others' to cold. Heat can be applied by ultrasound, microwaves, warm wax, or moist compresses. Most of these are done in the medical office, although moist compresses can be applied at home. Cold can be applied with ice packs at home.
    Occupational therapy teaches people ways to use their body efficiently to reduce stress on the joints. It also can help people learn to decrease tension on the joints through the use of specially designed splints. The occupational therapist can help someone develop strategies for coping with daily life by adapting to the environment and using different assistive devices.
    In some cases, reconstructive surgery and/or joint replacement operations provide the best outcome.

Drug approaches include a variety of medications used alone or in combinations.

    The goal of drug treatment is to induce remission or at least eliminate evidence of disease activity.
    Early use of disease-modifying antirheumatic drugs (DMARDs) not only controls inflammation better than less potent drugs but also helps prevent joint damage. Newer DMARDs work better than the older ones in long-term prevention of joint damage.
    People treated early with DMARDs have better long-term outcomes, with greater preservation of function, less work disability, and a smaller risk of premature death.
    The current approach, therefore, is to treat rheumatoid arthritis aggressively with DMARDs soon after diagnosis. Treating rheumatoid arthritis early, within three to 12 months after symptoms begin, is the best way to stop or slow progression of the disease and bring about remission.
    Ongoing (long-term) treatment with combinations of medications may offer the best control and prognosis of rheumatoid arthritis for the majority of people.
    Combinations of these medications do not usually have more severe adverse effects than one medication alone.

What Are Tips for Managing and Living With Rheumatoid Arthritis?

The following tips are helpful in managing and living with RA:

    Live a healthy lifestyle: Eat healthy foods. Avoid sugar and junk food. Quit smoking, or don't start. Don't drink alcohol in excess. These common-sense measures have an enormous impact on general health and help the body function at its best.
    Exercise: Discuss the right kind of exercise for you with your doctor, if necessary.
    Rest when needed, and get a good night's sleep. The immune system functions better with adequate sleep. Pain and mood improve with adequate rest.
    Follow your doctor's instructions about medications to maximize effectiveness and minimize side effects.
    Communicate with your doctor about your questions and concerns. They have experience with many issues that are related to rheumatoid arthritis.

What Medications Treat Rheumatoid Arthritis?

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The medications for rheumatoid arthritis fall into several different categories. These RA medications include

    disease-modifying antirheumatic drugs (DMARDs),
    biologic response modifiers,
    JAK modifiers, glucocorticoids,
    nonsteroidal anti-inflammatory drugs (NSAIDs),
    analgesics.

Disease-Modifying Antirheumatic Drugs (DMARDs) and RA

Disease-modifying antirheumatic drugs (DMARDs): This group of drugs includes a wide variety of agents that work in many different ways. What they all have in common is that they interfere in the immune processes that promote inflammation in rheumatoid arthritis. DMARDs can actually stop or slow the progression of rheumatoid arthritis. They can also suppress the ability of the immune system to fight infections. Anyone taking one of these drugs must be very vigilant to watch for early signs of infection, such as fever, cough, or sore throat. Early treatment of infections can prevent more serious problems. Conventional DMARDs include methotrexate (Rheumatrex, Rasuvo, and others), sulfasalazine (Azulfidine), leflunomide (Arava), and hydroxychloroquine (Plaquenil). These are used alone or in combination (most commonly for moderate to severely active rheumatoid arthritis).

    Methotrexate (Rheumatrex, Folex PFS): This drug relieves symptoms of inflammation such as pain, swelling, and stiffness. People taking methotrexate must have regular blood tests to measure whether the drug is having any adverse effects on the liver, kidneys, or blood cells. This drug is not suitable for some people with liver problems or women who are or may become pregnant.
    Sulfasalazine (Azulfidine): This drug decreases inflammatory responses by an effect similar to that of aspirin or NSAIDs. People taking sulfasalazine must have regular blood tests to measure whether the drug is having any adverse effects on blood cells.
    Leflunomide (Arava): This drug interferes with cells of the immune system and reduces inflammation. It reduces symptoms and may even slow the progression of rheumatoid arthritis. People taking leflunomide must have regular blood tests to measure whether the drug is having any adverse effects on the liver or blood cells. This agent is not suitable for some people with liver or kidney problems or women who are or may become pregnant.
    Hydroxychloroquine (Plaquenil): This drug was first used against the tropical parasite malaria. It inhibits certain cells that are necessary for the immune response that causes rheumatoid arthritis. People taking hydroxychloroquine must have eye examinations at least yearly to determine whether the drug is having any adverse effects on the retina.
    Gold salts (aurothiomalate, auranofin [Ridaura]): These compounds contain very tiny amounts of the metal gold. Apparently, the gold infiltrates into immune cells and interferes with their activities. People taking gold must have regular blood and urine tests to measure whether the drug is having any adverse effects on blood cells and the kidney. This medication is less commonly used today.
    Azathioprine (Imuran): This drug stops the production of cells that are part of the immune response associated with rheumatoid arthritis. Unfortunately, it also stops production of some other types of immune cells and thus can have serious side effects. It strongly suppresses the entire immune system and thus leaves the person vulnerable to infections and other problems. It is used only in severe cases of rheumatoid arthritis that have not gotten better with other DMARDs. People taking azathioprine must have regular blood tests to measure whether or not the drug is having any adverse effects on liver and blood cells.
    Cyclosporine (Neoral): This drug was developed for use in people undergoing organ transplantation or bone-marrow transplantation. These people must have their immune system suppressed to prevent rejection of the transplant. Cyclosporine blocks an important immune cell and interferes with the immune response in several other ways. People taking cyclosporine must have regular blood tests and blood pressure checks to measure whether the drug is having any adverse effects on blood cells and blood pressure. It is not used during pregnancy or in women who may become pregnant.

Biologic Response Modifiers and RA

Biologic response modifiers: These agents act like substances produced normally in the body and block other natural substances that are part of the immune response. They block the process that leads to inflammation and damage of the joints. These are targeted treatments that are directed at specific processes in the immune system that are involved in the disease development and progression. Prior to taking biologic response modifiers, patients typically receive screening tests for hepatitis B, hepatitis C, and tuberculosis (TB). Live forms of vaccinations are not generally administered while persons are taking biologic medications.

    Etanercept (Enbrel): This agent blocks the action of tumor necrosis factor, which in turn decreases inflammatory and immune responses. It is given by subcutaneous injection twice weekly. People taking etanercept must have regular blood tests to measure whether the drug is having any adverse effects on blood cells.
    Infliximab (Remicade): This antibody blocks the action of tumor necrosis factor. It is often used in combination with methotrexate in people whose rheumatoid arthritis does not respond to methotrexate alone. It is given by intravenous infusion every six to eight weeks. People taking infliximab must have regular blood tests to measure whether the drug is having any adverse effects on blood cells.
    Adalimumab (Humira): This is another blocker of tumor necrosis factor. It reduces inflammation and slows or stops worsening of joint damage in fairly severe rheumatoid arthritis. It is given by subcutaneous injection every two weeks. People taking adalimumab must have regular blood tests to measure whether the drug is having any adverse effects on blood cells.
    Certolizumab (Cimzia): This is another blocker of tumor necrosis factor. It reduces inflammation and slows or stops worsening of joint damage in fairly severe rheumatoid arthritis. It is given by subcutaneous injection every four weeks. People taking certolizumab must have regular blood tests to measure whether the drug is having any adverse effects on blood cells.
    Golimumab (Simponi): This is another blocker of tumor necrosis factor. It reduces inflammation and slows or stops worsening of joint damage in fairly severe rheumatoid arthritis. It is given by subcutaneous injection every four weeks. The intravenous form of golimumab (Simponi Aria) is given every eight weeks. People taking golimumab must have regular blood tests to measure whether the drug is having any adverse effects on blood cells.
    Anakinra (Kineret): This agent blocks the action of interleukin-1, which is partly responsible for the inflammation of rheumatoid arthritis. This in turn blocks inflammation and pain in rheumatoid arthritis. This agent is usually reserved for people whose rheumatoid arthritis has not improved with DMARDs. It is given by subcutaneous injection daily. The intravenous form of golimumab (Simponi Aria) is given every eight weeks. People taking golimumab must have regular blood tests to measure whether the drug is having any adverse effects on blood cells.
    Abatacept (Orencia): This agent inhibits T-lymphocytes that contribute to the inflammation and pain associated with rheumatoid arthritis. This drug is reserved for individuals who do not respond to DMARDs, methotrexate, or TNF blockers. It is administered by intravenous infusion. Abatacept may increase the risk of serious infections.
    Rituximab (Rituxan): Given by intravenous infusion over four to five hours, twice, two weeks apart, every four to 10 months, this biologic response modifier decreases the number of B-cells, a type of immune cell that plays an integral role in causing rheumatoid inflammation and damage. Rituximab may increase the risk of serious infections.
    Tocilizumab (Actemra): The agent blocks the chemical messenger interleukin-6 (IL-6) that plays a role in activating the immune system that is responsible for rheumatoid arthritis. Tocilizumab is given intravenously once a month. Regular blood testing is required to monitor for potential side effects on blood cells, liver, and cholesterol levels.

While biologic medications are often combined with traditional DMARDs in the treatment of rheumatoid arthritis, they are generally not used with other biologic medications because of the unacceptable risk for serious infections.

JAK Inhibitors and RA

    Tofacitinib (Xeljanz) is the first in a new class of "small molecule" medications used to treat rheumatoid arthritis called JAK inhibitors. Tofacitinib is a treatment for adults with moderate to severe active RA in which methotrexate was not very effective. Patients can take tofacitinib with or without methotrexate, and this prescription drug is taken by mouth two times a day. Tofacitinib is a "targeted" drug that only blocks Janus kinase, special enzymes of inflammation, within cells. This is why it is referred to as a JAK inhibitor. JAK inhibitors are not used with biologic medications.

Glucocorticoids and RA

Glucocorticoids: These very potent agents rapidly block inflammation and other immune responses. They are often called steroids. These agents all work in the same way; they differ only in their potency and in the form in which they are given. Steroids may be given as pills, intravenously, or as injections into a muscle or directly into a joint. In high doses, they can cause many serious side effects and are therefore given only for the shortest possible periods and at the lowest doses possible for the condition. These drugs generally tapered and not stopped abruptly.

    Prednisone (Deltasone, Meticorten, Orasone)
    Prednisolone (Medrol)
    Betamethasone (Celestone)

Nonsteroidal Anti-inflammatory Drugs (NSAIDs) and Analgesics for RA

Nonsteroidal anti-inflammatory drugs (NSAIDs): These drugs reduce swelling and pain but do not stop joint damage and alone are not sufficient to treat rheumatoid arthritis. These drugs work by blocking an enzyme called cyclo-oxygenase (COX) that promotes inflammation. There are at least two forms of the enzyme: COX-1 and COX-2. Some people with a history of stomach ulcers or liver problems should not take these drugs. This group includes aspirin, although aspirin is rarely used in rheumatoid arthritis because it is not as safe as other agents.

    COX-2 inhibitors: These agents block only the COX-2 enzyme and are often referred to as selective NSAIDs. They have fewer side effects than the other NSAIDs while still reducing inflammation. Only celecoxib (Celebrex) is sold in the U.S. market.
    Nonselective NSAIDs: These drugs block both COX-1 and COX-2. They include ibuprofen (Motrin, Advil, etc.), ketoprofen (Oruvail), naproxen (Naprosyn), piroxicam (Feldene), and diclofenac (Voltaren, Cataflam).

Analgesics: These medicines reduce pain but do not affect swelling or joint destruction.

    Acetaminophen (Tylenol, Feverall, Tempra): This drug is often used by people who cannot take NSAIDs because of hypersensitivity, ulcers, liver problems, or interactions with other drugs.
    Tramadol (Ultram)
    Opioids: These drugs may be used to treat moderately severe to severe pain that is not relieved by other analgesics.

For more information on these medications, see Understanding Rheumatoid Arthritis Medications.

RA Diet and Other Therapy

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There is little scientific research on the role of herbs, natural products, and nutritional supplements in the treatment of rheumatoid arthritis. High-dose fish oil (omega-3 fatty acids) has been shown in small studies to reduce rheumatoid arthritis disease activity, and in some cases, fish oil supplementation may allow patients to discontinue NSAIDs. People with rheumatoid arthritis are using turmeric with varying degrees of success in reducing inflammation.

Other dietary changes that some people with rheumatoid arthritis can find helpful including increasing hydration for the dry mouth of Sjögren's syndrome, increasing fish intake (especially salmon) for fish oil supplementation to reduce inflammation, and taking anti-inflammatory medications with food to avoid stomach irritation (gastritis and dyspepsia). As described above, some research has suggested that a fish-grain diet can decrease the chances of developing rheumatoid arthritis while a Western high-fat diet might increase the chances of developing rheumatoid arthritis. There are currently no particular foods that are universally recommended that people with rheumatoid arthritis avoid, but dietary discretion is individualized based on patients' own experiences.

A variety of complementary approaches may be effective in relieving pain. These include acupuncture and massage.

When Is Surgery Needed for Rheumatoid Arthritis?

Some people with rheumatoid arthritis need several operations over time. Examples include removal of damaged synovium (synovectomy), tendon repairs, and replacement of badly damaged joints, especially the knees or hips. Surgical fusion of damaged rheumatoid wrists can alleviate pain and improve function. Sometimes rheumatoid nodules in the skin that are irritating are removed surgically.

Some people with rheumatoid arthritis have involvement of the vertebrae of the neck (cervical spine). This has the potential for compressing the spinal cord and causing serious consequences in the nervous system. This is important to identify prior to anesthesia intubation procedures for surgery. These people with serious spinal involvement occasionally need to undergo surgical fusion of the spine.

Follow-up for Rheumatoid Arthritis

A specialist or primary-care physician should regularly monitor the patient's condition, response to treatment, and side effects and other problems related to the rheumatoid arthritis or treatment. The best way to monitor the condition is to see if there is any disability (loss of function) and, if so, how much.

The frequency of these visits depends on the activity of the rheumatoid arthritis. If the treatment is working well and the patient's condition is stable, the visits can be less frequent than if the rheumatoid arthritis is getting worse, there are complications, or if the patient is having severe side effects of treatment. Each person's situation must be decided individually.

Can RA Be Prevented?

There is no known way to prevent rheumatoid arthritis, although progression of the disease usually can be stopped or slowed by early, aggressive treatment.

What Is the Prognosis of Rheumatoid Arthritis?

As a rule, the severity of rheumatoid arthritis waxes and wanes. Periods of active inflammation and tissue damage marked by worsening of symptoms (flares) are interspersed with periods of little or no activity, in which symptoms get better or go away altogether (remission). The duration of these cycles varies widely among individuals.

Outcomes are also highly variable. Some people have a relatively mild condition, with little disability or loss of function. Others at the opposite end of the spectrum experience severe disability due to pain and loss of function. Disease that remains persistently active for more than a year is likely to lead to joint deformities and disability. Approximately 40% of people have some degree of disability 10 years after their diagnosis. For most, rheumatoid arthritis is a chronic progressive illness, but about 5%-10% of people experience remission without treatment. This is uncommon, however, after the first three to six months.

Rheumatoid arthritis is not fatal, but complications of the disease shorten life span by a few years in some individuals. Although generally rheumatoid arthritis cannot be cured, the disease gradually becomes less aggressive and symptoms may even improve. However, any damage to joints and ligaments and any deformities that have occurred are permanent. Rheumatoid arthritis can affect parts of the body other than the joints.

The early treatment and use of DMARDs and biologic response modifiers in rheumatoid arthritis has resulted in patients experiencing more profound relief of symptoms and less joint damage and less disability over time. So the prognosis is best when treatment is started early. New treatments are on the horizon.

What Are Complications of Rheumatoid Arthritis?

Common complications of rheumatoid arthritis include the following:

    Peripheral neuropathy and carpal tunnel syndrome: This condition results from damage to nerves, most often those in the hands and feet. It can result in tingling, numbness, or burning.
    Anemia: This is a low level of hemoglobin, a protein in the blood that carries essential oxygen to cells and tissues. Symptoms include weakness, low energy, pallor, and shortness of breath.
    Scleritis: This is a serious inflammation of the blood vessels in the white portion (sclera) of the eye that can damage the eyes and impair vision.
    Infections: People with rheumatoid arthritis have a higher risk for infections. This is due partly to the abnormal immune system in rheumatoid arthritis and partly to the use of immune-suppressing medications for treatment.
    Digestive tract problems: Many people experience stomach and intestinal distress. Again, this is more often a side effect of medications used to treat rheumatoid arthritis.
    Osteoporosis: Osteoporosis, or the loss of bone density, is more common in women with rheumatoid arthritis than in women in general. The hip is particularly affected. The risk for osteoporosis also appears to be higher than average in men with rheumatoid arthritis who are older than 60 years.
    Lung disease: Certain conditions involving inflammation of the lungs seem to be more common in people with rheumatoid arthritis than in the general population. These include pleurisy and pleuritis, lung infections, lung nodules, and pulmonary fibrosis. However, a definite link between cigarette smoking and rheumatoid arthritis may at least partly account for this finding. Cigarette smoking, in any case, may increase the severity of the disease.
    Heart disease: Rheumatoid arthritis can affect the blood vessels and may increase the risk for coronary heart disease.
    Sjögren's syndrome: This is another autoimmune rheumatic disease, like rheumatoid arthritis. It causes extreme dryness of certain body tissues, especially the eyes and mouth. Dryness of the eyes is common in people with rheumatoid arthritis.
    Felty's syndrome: This condition combines enlargement of the spleen with impairment of the immune system (low white blood cell count), leading to recurrent bacterial infections. This syndrome sometimes responds to DMARD therapy.
    Lymphoma and other cancers: The risk for lymphoma, a cancer of the lymph nodes, is higher than normal in people with rheumatoid arthritis. This is thought to be a result of abnormalities in the immune system. The risk of lymphoma is higher in those patients with active inflammatory disease. Other cancers that may be more common in people with rheumatoid arthritis include prostate and lung cancers.
    Fibromyalgia, a chronic pain syndrome, is more common in people with autoimmune diseases such as rheumatoid arthritis and lupus than in the general population.
    Rheumatoid vasculitis: This is an autoimmune inflammation of the blood vessels that can occur in patients who have severe, active rheumatoid arthritis for many years. The symptoms of this are a very specific-looking rash or nonhealing ulcerations on the legs.
    Macrophage activation syndrome: This is a life-threatening complication of rheumatoid arthritis. It is diagnosed by bone marrow testing and requires immediate treatment. Symptoms include persistent fever, weakness, drowsiness, and lethargy.

Overall, the rate of premature death is higher in people with rheumatoid arthritis than in the general population. The most common causes of premature death in people with rheumatoid arthritis are infection, vasculitis, and poor nutrition. Fortunately, the manifestations of severe, long-standing disease, such as nodules, vasculitis, and deforming are becoming less common with optimal treatments.

Is There a Cure for Rheumatoid Arthritis?

There is no known cure for rheumatoid arthritis. However, with early, aggressive treatment with DMARDs, many patients are able to achieve remission, meaning the symptoms of RA are quiet. Sometimes, the dose of medications may be reduced when remission is achieved. It is unusual for rheumatoid arthritis to remain in remission if medications are stopped, and when this does occur (rarely), symptoms and signs usually come back over time. For this reason, it is not advisable to stop rheumatoid arthritis medications unless advised to do so by a rheumatologist.