How is rheumatoid arthritis treated?

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 your joints. The warmth relaxes your 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 peoples pain responds better to heat and other 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 you ways to use your body efficiently to reduce stress on your joints. It also can help you learn to decrease tension on the joints through the use of specially designed splints. Your occupational therapist can help you develop strategies for coping with daily life by adapting to your environment and using different assistive devices.
Prosorba column: This is not a drug but a medical device. It filters antibodies linked to rheumatoid arthritis out of the blood. This procedure is available only in some medical centers and generally is used only for very severe rheumatoid arthritis.
In some cases, reconstructive surgery and/or joint replacement operations provide the best outcome.

   There is no known cure for rheumatoid arthritis. To date, the goal of treatment in rheumatoid arthritis is to reduce joint inflammation and pain, maximize joint function, and prevent joint destruction and deformity. Early medical intervention has been shown to be important in improving outcomes. Aggressive management can improve function, stop damage to joints as seen on x-rays, and prevent work disability. Optimal treatment for the disease involves a combination of medications, rest, joint strengthening exercises, joint protection, and patient (and family) education. Treatment is customized according to many factors such as disease activity, types of joints involved, general health, age, and patient occupation. Treatment is most successful when there is close cooperation between the doctor, patient, and family members.

   Two classes of medications are used in treating rheumatoid arthritis: fast-acting "first-line drugs" and slow-acting "second-line drugs" (also referred to as Disease-Modifying Antirheumatic Drugs or DMARDs). The first-line drugs, such as aspirin and cortisone (corticosteroids), are used to reduce pain and inflammation. The slow-acting second-line drugs, such as gold, hydroxychloroquin(Plaquenil) promote disease remission and prevent progressive joint destruction, but they are not anti-inflammatory agents.

   The degree of destructiveness of rheumatoid arthritis varies from patient to patient. Patients with uncommon, less destructive forms of the disease or disease that has quieted after years of activity ("burned out" rheumatoid arthritis) can be managed with rest, pain and anti-inflammatory medications alone. In general, however, patients improve function and minimize disability and joint destruction when treated earlier with second-line drugs (disease-modifying antirheumatic drugs), even within months of the diagnosis. Most patients require more aggressive second-line drugs, such as methotrexate, in addition to anti-inflammatory agents. Sometimes these second-line drugs are used in combination. In some patients with severe joint deformity, surgery may be necessary.

"First-line" drugs

Acetylsalicylate (Aspirin), naproxen (Naprosyn), ibuprofen (Advil, Medipren, Motrin), and etodolac (Lodine) are examples of nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs are medications that can reduce tissue inflammation, pain and swelling. NSAIDs are not cortisone. Aspirin, in doses higher than that used in treating headaches and fever, is an effective antiinflammatory medication for rheumatoid arthritis. Aspirin has been used for joint problems since the ancient Egyptian era. The newer NSAIDs are just as effective as aspirin in reducing inflammation and pain, and require fewer dosages per day. Patients' responses to different NSAID medications vary. Therefore, it is not unusual for a doctor to try several NSAID drugs in order to identify the most effective agent with the fewest side effects.

The most common side effects of aspirin and other NSAIDs include stomach upset, ticlekey=1908">sucralfate (Carafate), proton-pump inhibitors (Prevacid, and others), and misoprostol (Cytotec).

Corticosteroid medications can be given orally or injected directly into tissues and joints. They are more potent than NSAIDs in reducing inflammation, and in restoring joint mobility and function. Corticosteroids are useful for short periods during severe flares of disease activity, or when the disease is not responding to NSAIDs. However, corticosteroids can have serious side effects, especially when given in high doses for long periods of time.

These side effects include weight gain, facial puffiness, thinning of the skin and bone, easy bruising, cataracts, risk of infection, muscle wasting, and destruction of large joints, such as the hips. Corticosteroids also carry some increased risk of contracting infections. These side effects can be partially avoided by gradually tapering the doses of corticosteroids as the patient achieves improvement of the disease. Abruptly discontinuing corticosteroids can lead to flares of the disease or other symptoms of corticosteroid withdrawal, and is discouraged. Thinning of the bones due to osteoporosis may be prevented by calcium and vitamin D supplements. For further information on corticosteroids, please read the article on prednisone.

"Second-line" or "slow-acting" drugs
(Disease-modifying anti-rheumatic drugs or DMARDs)

While "first-line" medications (NSAIDs and corticosteroids) can relieve joint inflammation and pain, they do not necessarily prevent joint destruction or deformity. Rheumatoid arthritis requires medications other than NSAIDs and corticosteroids to stop progressive damage to cartilage, bone, and adjacent soft tissues. The medications needed for ideal management of the disease are also referred to as Disease-modifying Anti-rheumatic Drugs or DMARDs.

They come in a variety of forms and are listed below. These "second-line" or "slow-acting" medicines may take weeks to months to become effective. They are used for long periods of time, even years, at varying doses. If effective, DMARDs can promote remission, thereby retarding the progression of joint destruction and deformity. Sometimes a number of second-line medications are used together as combination therapy. As with the first-line medications, the doctor may need to use different second-line medications before treatment is optimal.

Recent research suggests that patients who respond to a DMARD with control of the rheumatoid disease may actually decrease the known risk (small, but real) of lymphoma that exists from simply having rheumatoid arthritis.

Hydroxychloroquine (Plaquenil) is related to quinine, and is also used in the treatment of malaria. It is used over long periods for the treatment of rheumatoid arthritis. Possible side effects include upset stomach, skin rashes, muscle weakness, and vision changes. Even though vision changes are rare, patients taking Plaquenil should be monitored by an eye doctor (ophthalmologist).

Sulfasalazine (Azulfidine) is an oral medication traditionally used in the treatment of mild to moderately severe inflammatory bowel diseases, such as ulcerative colitis and Crohn's colitis. Azulfidine is used to treat rheumatoid arthritis in combination with antiinflammatory medications. Azulfidine is generally well tolerated. Common side effects include rash and upset stomach. Because Azulfidine is made up of sulfa and salicylate compounds, it should be avoided by patients with known sulfa allergies.

Methotrexate has gained popularity among doctors as an initial second-line drug because of both its effectiveness and relatively infrequent side effects. It also has an advantage in dose flexibility (dosages can be adjusted according to needs). Methotrexate is an immune suppression drug. It can affect the bone marrow and the liver, even rarely causing cirrhosis. All patients taking methotrexate require regular blood test monitoring of blood counts and liver function blood tests.

Gold salts have been used to treat rheumatoid arthritis throughout most of the past century. Gold thioglucose (Solganal) and gold thiomalate (Myochrysine) are given by injection, initially on a weekly basis for months to years. Oral gold, auranofin (Ridaura) was introduced in the 1980's. Side effects of gold (oral and injectable) include skin rash, mouth sores, kidney damage with leakage of protein in the urine, and bone marrow damage with anemia and low white cell count. Patients receiving gold treatment are regularly monitored with blood and urine tests. Oral gold can cause diarrhea. These gold drugs have lost such favor that many companies no longer manufacture them.

D-penicillamine (Depen, Cuprimine) can be helpful in selected patients with progressive forms of rheumatoid arthritis. Side effects are similar to those of gold. They include fever, chills, mouth sores, a metallic taste in the mouth, skin rash, kidney and bone marrow damage, stomach upset, and easy bruising. Patients on this medication require routine blood and urine tests. D-penicillamine can rarely cause symptoms of other autoimmune diseases.

Immunosuppressive medicines are powerful medications that suppress the body's immune system. A number of immunosuppressive drugs are used to treat rheumatoid arthritis. They include methotrexate (Rheumatrex, Trexall) as described above, azathioprin(Imuran), cyclophosphamide (Cytoxan), chlorambucil (Leukeran), and cyclosporine (Sandimmune). Because of potentially serious side effects, immunosuppressive medicines (other than methotrexate) are generally reserved for patients with very aggressive disease, or those with serious complications of rheumatoid inflammation, such as blood vessel inflammation (vasculitis). The exception is methotrexate, which is not frequently associated with serious side effects and can be carefully monitored with blood testing. Methotrexate has become a preferred second-line medication as a result.

Immunosuppressive medications can depress bone marrow function and cause anemia, a low white cell count and low platelets counts. A low white count can increase the risk of infections, while a low platelet count can increase the risk of bleeding. Methotrexate rarely can lead to liver cirrhosis and allergic reactions in the lung. Cyclosporin can cause kidney damage and high blood pressure. Because of potentially serious side effects, immunosuppressive medications are used in low doses, usually in combination with anti-inflammatory agents.

Newer treatments

Newer "second-line" drugs for the treatment of rheumatoid arthritis include leflunomide (Arava), and the "biologic" medications etanercept (Enbrel), infliximab (Remicade), anakinra (Kineret), and adalimumab (Humira).

Leflunomide (Arava) is available to relieve the symptoms and halt the progression of the disease. It seems to work by blocking the action of an important enzyme that has a role in immune activation. Arava can cause liver disease, diarrhea, hair loss, and/or rash in some patients. It should not be taken just before or during pregnancy because of possible birth defects.

Other medications that represent a novel approach to the treatment of rheumatoid arthritis and are the products of modern biotechnology. These are referred to as the biologic medications or biological response modifiers. In comparison with traditional DMARDs, the biologic medications have a much more rapid onset of action and can have powerful effects on stopping progressive joint damage. In general, their methods of action are also more directed, defined, and targeted.

Etanercept (Enbrel), infliximab (Remicade), and adalimumab (Humira) are biologic medications. These medications intercept a protein in the joints (tumor necrosis factor, or TNF) that causes inflammation before it can act on its natural receptor to "switch on " inflammation. This effectively blocks the TNF inflammation messenger from calling out to the cells of inflammation. Symptoms can be significantly, and often rapidly, improved in patients using these drugs. Etanercept (Enbrel) must be injected subcutaneously once or twice a week. Infliximab (Remicade) is given by infusion directly into a vein (intravenously).

Adalimumab (Humira) is injected subcutaneously either every other week or weekly. Each of these medications will be evaluated by doctors in practice to determine what role they may have in treating various stages of rheumatoid arthritis. Research has shown that biological response modifiers also prevent the progressive joint destruction of rheumatoid arthritis. They are currently recommended for use after other second-line medications have not been effective. The biological response modifiers (TNF-inhibitors) are expensive treatments. They are also frequently used in combination with methotrexate and other DMARDs. Futhermore, it should be noted that the TNF-blocking biologics all are more effective when combined with methotrexate.

Anakinra (Kineret) is another biologic treatment that is used to treat moderate to severe rheumatoid arthritis. Anakinra (Kineret) works by binding to a cell messenger protein (IL-1, a proinflammation cytokine). Anakinra (Kineret) is injected under the skin daily. Anakinra (Kineret) can be used alone or with other DMARDs. The response rate of anakinra (Kineret) does not seem to be as high as with other biologic medications.

Rituxan (rituximab) is an antibody that was first used to treat lymphoma, a cancer of the lymph nodes. Rituxan can be effective in treating autoimmune diseases like rheumatoid arthritis because it depletes B-cells, which are important cells of inflammation and in producing abnormal antibodies that are common in these conditions. Rituxan is now available to treat moderate to severely active rheumatoid arthritis in patients who have failed the TNF-blocking biologics. Preliminary studies have shown that Rituxan was also found to be beneficial in treating severe rheumatoid arthritis complicated by blood vessel inflammation (vasculitis) and cryoglobulinemia.

Orencia (abatacept) is a recently developed biologic medication that blocks T-cell activation. Orencia (abatacept) is now available to treat adult patients who have failed a traditional DMARD or TNF-blocking biologic medication.

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 unacceptible risk for serious infections.

The Prosorba column therapy involves pumping blood drawn from a vein in the arm into an apheresis machine, or cell separator. This machine separates the liquid part of the blood (the plasma) from the blood cells. The Prosorba column is a plastic cylinder about the size of a coffee mug that contains a sand-like substance coated with a special material called Protein A. Protein A is unique in that it binds unwanted antibodies from the blood that promote the arthritis.

The Prosorba column works to counter the effect of these harmful antibodies. The Prosorba column is indicated to reduce the signs and symptoms of moderate to severe rheumatoid arthritis in adult patients with long standing disease who have failed or are intolerant to disease-modifying anti-rheumatic drugs (DMARDs). The exact role of this treatment is being evaluated by doctors and it is not commonly used currently.

Other treatments

There is no special diet for rheumatoid arthritis. One hundred years ago it was touted that "night-shade" foods, such as tomatos, would aggrevate rheumatoid arthritis. This is no longer accepted as true. Fish oil may have anti-inflammatory beneficial effects, but so far this has only been shown in laboratory experiments studying inflammatory cells. Likewise, the benefits of cartilage preparations remain unproven. Symptomatic pain relief can often be achieved with oral acetaminophen (Tylenol) or over-the-counter topical preparations, which are rubbed into the skin. Antibiotics, in particular the tetracycline drug minocycline (Minocin), have been tried for rheumatoid arthritis recently in clinical trials. Early results have demonstrated mild to moderate improvement in the symptoms of arthritis. Minocycline has been shown to impede important mediator enzymes of tissue destruction, called metalloproteinases, in the laboratory as well as in humans.

The areas of the body, other than the joints, that are affected by rheumatoid inflammation are treated individually. Sjogren's syndrome (described above, see symptoms) can be helped by artificial tears and humidifying rooms of the home or office. Medicated eye drops, cortisporine ophthalmic drops (Restasis), are also available to help the dry eyes in those affected. Regular eye check-ups and early antibiotic treatment for infection of the eyes are important. Inflammation of the tendons (tendinitis), bursae (bursitis) and rheumatoid nodules can be injected with cortisone. Inflammation of the lining of the heart and/or lungs may require high doses of oral cortisone.

Proper, regular exercise is important in maintaining joint mobility, and in strengthening the muscles around the joints. Swimming is particularly helpful because it allows exercise with minimal stress on the joints. Physical and occupational therapists are trained to provide specific exercise instructions and can offer splinting supports. For example, wrist and finger splints can be helpful in reducing inflammation and maintaining joint alignment. Devices, such as canes, toilet seat raisers, and jar grippers can assist daily living. Heat and cold applications are modalities that can ease symptoms before and after exercise.

Surgery may be recommended to restore joint mobility or repair damaged joints. Doctors who specialize in joint surgery are orthopedic surgeons. The types of joint surgery range from arthroscopy to partial and complete replacement of the joint. Arthroscopy is a surgical technique whereby a doctor inserts a tube-like instrument into the joint to see and repair abnormal tissues. For more information, please read the Arthroscopy article.

"Total joint replacement" is a surgical procedure whereby a destroyed joint is replaced with artificial materials. For example, the small joints of the hand can be replaced with plastic material. Large joints, such as the hips or knees, are replaced with metals. For more information, please read the Total Hip Replacement and Total Knee Replacement articles.

Finally, minimizing emotional stress can help improve the overall health of the patient with rheumatoid arthritis. Support and extracurricular groups afford patients time to discuss their problems with others and learn more about their illness.

Future treatments

Scientists throughout the world are studying many promising areas of new treatment approaches for rheumatoid arthritis. These areas include treatments that block the action of the special inflammation factors, such as tumor necrosis factor (TNFalpha) and interleukin-1 (IL-1), as described above. Many other drugs are being developed that act against certain critical white blood cells involved in rheumatoid inflammation. Also, new NSAIDs with mechanisms of action that are different from current drugs are on the horizon.

Better methods of more accurately defining which patients are more likely to develop more aggressive disease are becoming available. Recent antibody research has found that the presence of citrulline antibodies in the blood (see above in diagnosis) has been associated with a greater tendency toward more destructive forms of rheumatoid arthritis.

Studies involving various types of the connective tissue collagen are in progress and show encouraging signs of reducing rheumatoid disease activity. Finally, genetic research and engineering is likely to bring forth many new avenues of earlier diagnosis and accurate treatment in the near future. Gene profiling, also known as gene array analysis, is being identified as a helpful method of defining which people will respond to which medications. Studies are underway that are using gene array analysis to determine which patients will be at more risk for more aggressive disease. This is all occurring because of technology improvements. We are at the threshold of tremendous improvements in the way rheumatoid arthritis is managed.

Rheumatoid Arthritis At A Glance

Rheumatoid arthritis is an autoimmune disease that can cause chronic inflammation of the joints and other areas of the body.
Rheumatoid arthritis can affect persons of all ages.
The cause of rheumatoid arthritis is not known.
Rheumatoid arthritis is a chronic disease, characterized by periods of disease flares and remissions.
In rheumatoid arthritis, multiple joints are usually, but not always, affected in a symmetrical pattern.
Chronic inflammation of rheumatoid arthritis can cause permanent joint destruction and deformity.
Damage to joints can occur early and does not correlate with symptoms.
The "rheumatoid factor" is an antibody blood test that can be found in 80 % of patients with rheumatoid arthritis.
There is no known cure for rheumatoid arthritis.
The treatment of rheumatoid arthritis optimally involves a combination of patient education, rest and exercise, joint protection, medications, and occasionally surgery.
Early treatment of rheumatoid arthritis results in better outcomes.

Self-Care at Home

If you have joint pain or stiffness, you may think it is just a normal part of getting older and that there is nothing you can do. Nothing could be further from the truth. You have several options for medical treatment and even more to help prevent further joint damage and symptoms. You should discuss these measures with your health care provider to find ways to make them work for you.

First of all, dont delay diagnosis or treatment. Having a correct diagnosis allows your health care provider to form a treatment plan. Delaying treatment increases your risk that the arthritis will get worse and that you will develop serious complications.
Learn everything you can about your condition. Ask your health care provider if you have questions. If you want to learn more, ask him or her to direct you to reliable sources of information. Some Internet resources are listed later in this article.
Become an active participant in your care. Know the pros and cons of all of your treatment options, and work with your health care provider to decide on the best options for you. Understand your treatment plan and what benefits and side effects you can expect. If you dont understand, ask.
Learn about your symptoms. If you have rheumatoid arthritis, you probably have 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 1 hour after an activity probably means that that activity was too stressful and should be avoided.

Increase your physical activity.

Exercise is a very important part of a complete treatment plan for rheumatoid arthritis.
You may think that exercise is bad for arthritic joints, but research overwhelmingly shows that exercise in rheumatoid arthritis helps reduce pain and fatigue, increases your range of motion (flexibility) and strength, and keeps you feeling 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 your lower body.
Talk to your health care provider about how to start an exercise program and what types of exercises to do. He or she may refer you to a physical therapist or exercise specialist.

Protect your 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 your joints
Avoid situations that are likely to strain your joints. Remember that your 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 your body in ways that reduce the stress on your joints. This is especially true for your hands, since you want to protect their flexibility. Ask your health care provider 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 your fingers, for example, if your 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 your health care provider 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 your joints in the same position for too long a time. Get up and move; use your hands.
Holding the joint still for long periods just promotes stiffness. Keep the joints moving to keep them flexible.
If you must sit for long periods, say at work or while traveling, take a short break every hour: stand up, walk around, stretch, and flex your joints.
Rest before you become tired or sore.

Take part in activities you enjoy every day.

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

Take steps toward a healthier lifestyle.

Losing weight not only helps you look better, it helps youâ€”and your jointsâ€”feel better. Reducing weight helps take stress off joints and reduces pain. A healthy weight also can help you 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. Make sure you are getting enough vitamin C and calcium. Ask your health care provider if you think you are not getting sufficient vitamins and minerals.
Quit smoking. Not only will you feel better, but also you will be reducing your risk of complications of rheumatoid arthritis. You will also be reducing your risk of lung cancer, emphysema, and other breathing problems.

Get the most out of your treatment.

Take your medications as directed by your health care provider. If you think a medication is not working or is causing side effects, talk to your health care provider 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.
Help yourself. If you feel tired and achy, a warm bath before bed can help you relax and feel better. Massages feel good and may help increase your energy and flexibility. Apply an ice pack or cold compress to a joint to reduce pain and swelling. (Keep a reusable ice pack in your freezer or try a bag of frozen vegetables!)