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 you—and your joints—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!)
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