How is rheumatoid arthritis treated?

The goals of rheumatoid arthritis treatment are to:

  • Control a patient's signs and symptoms.
  • Prevent joint damage.
  • Maintain the patient’s quality of life and ability to function.

Joint damage generally occurs within the first two years of diagnosis, so it is important to diagnose and treat rheumatoid arthritis in the “window of opportunity” to prevent long-term consequences.

Treatments for rheumatoid arthritis include medications, rest, exercise, physical therapy/occupational therapy, and surgery to correct damage to the joint.

The type of treatment will depend on several factors, including the person's age, overall health, medical history, and the severity of the arthritis.

Non-pharmacologic therapies

Non-pharmacologic therapy is the first step in treatment for all people who have rheumatoid arthritis. Non-pharmacologic therapies include the following:

Rest

When joints are inflamed, the risk of injury to the joint and to nearby soft tissue structures (such as tendons and ligaments) is high. This is why inflamed joints should be rested. However, physical fitness should be maintained as much as possible. Maintaining a good range of motion in your joints and good fitness overall are important in coping with the overall features of the disease.

Exercise

Pain and stiffness often prompt people with rheumatoid arthritis to become inactive. However, inactivity can lead to a loss of joint motion, contractions, and a loss of muscle strength. These, in turn, decrease joint stability and increase fatigue.

Regular exercise, especially in a controlled fashion with the help of physical therapists and occupational therapists, can help prevent and reverse these effects. Beneficial workouts include: range-of-motion exercises to preserve and restore joint motion; exercises to increase strength, and; exercises to increase endurance (walking, swimming, and cycling).

Physical and occupational therapy

Physical and occupational therapy can relieve pain, reduce inflammation, and help preserve joint structure and function for patients with rheumatoid arthritis.

Specific types of therapy are used to address specific problems of rheumatoid arthritis:

  • The application of heat or cold can relieve pain or stiffness.
  • Ultrasound can help reduce inflammation of the sheaths surrounding tendons (tenosynovitis).
  • Exercises can improve and maintain range of motion of the joints.
  • Rest and splinting can help reduce joint pain and improve joint function.
  • Finger-splinting and other assistive devices can prevent deformities and improve hand function.
  • Relaxation techniques can relieve secondary muscle spasm.

Occupational therapists also focus on helping people with rheumatoid arthritis continue to actively participate in work and recreational activity, with special attention to maintaining good function of the hands and arms.

Nutrition and dietary therapy

Weight loss may be recommended for overweight and obese people to reduce stress on inflamed joints.

People with rheumatoid arthritis have a higher risk of developing coronary artery disease. High blood cholesterol (a risk factor for coronary artery disease) can respond to changes in diet. A nutritionist can recommend specific foods to eat or avoid in order to reach a desirable cholesterol level.

Changes in diet have been investigated as treatments for rheumatoid arthritis, but no diet has been proven to cure it. No herbal or nutritional supplements, such as cartilage or collagen, can cure rheumatoid arthritis. These treatments can be dangerous and are not usually recommended.

Medications

There are many medications to decrease joint pain, swelling, and inflammation, and prevent or slow down the disease. The type of drugs that your doctor recommends will depend on how severe your arthritis is and how well you respond to the medications.

These medications include:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen, or naproxen
  • Corticosteroids (oral and injectable forms)
  • COX-2 inhibitor (celecoxib [Celebrex®])
  • Disease-modifying anti-rheumatic drugs (DMARDs) such as hydroxychloroquine (Plaquenil), methotrexate (Rheumatrex®, Trexall®), sulfasalazine (Azulfidine®), and leflunomide (Arava®)

It may take four to six weeks of treatment with methotrexate, one to two months with sulfasalazine, and two to three months with hydroxycholoroquine to see an improvement in symptoms.

  • Biologic agents, such as infliximab (Remicade®), etanercept (Enbrel®), adalimumab (Humira®), certolizumab (Cimzia®), golimumab (Simponi®), tocilizumab (Actemra®), rituximab (Rituxan®), abatacept (Orencia®), anakinra (Kineret®), tofacitinib (Xeljanz®)

Biologics tend to work rapidly, within two weeks for some medications and within four to six weeks for others. Biologics may be used alone or in combination with other DMARDs. Usually they are reserved for patients who do not adequately respond to DMARDs, or if the prognosis (outlook) for the patient is problematic.

Other precautions to note with these drugs:

  • DMARDs and biologic agents interfere with the immune system's ability to fight infection and should not be used by people who have serious infections.
  • Anti-TNF agents such as infliximab, etanercept, adalimumab, certolizumab and golimumab are not recommended for people who have lymphoma or who have been treated for lymphoma. People with rheumatoid arthritis--especially those with severe disease--have an increased risk of lymphoma, regardless of what treatment is used. Anti-TNF agents have been associated with a further increase in the risk of lymphoma in some studies but not others. More research is needed to define this risk.
  • Testing for tuberculosis (TB) is needed before starting anti-TNF therapy. People who have evidence of earlier TB infection should be treated for TB, because there is an increased risk of developing active TB while receiving anti-TNF therapy.

Some of these medications are traditionally used to treat other conditions, such as cancer, inflammatory bowel disease and malaria. When these drugs are used to treat rheumatoid arthritis, the doses are much lower and the risks of side effects tend to be considerably less. However, the risk of side effects from treatment must be weighed against the benefits on an individual basis.

When you are prescribed any medication, it is important to meet with your physician regularly so he or she can watch for any side effects.

Surgery

When bone damage from the arthritis has become severe or pain is not controlled with medications, surgery is an option to restore function to a damaged joint.

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