Patient education: Rheumatoid arthritis treatment (Beyond the Basics)

Author:: Kaleb Michaud, PhD
Section Editor:: James R O'Dell, MD
Deputy Editor:: Philip Seo, MD, MHS

Literature review current through: Jan 2024.

This topic last updated: Jun 30, 2022.

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RHEUMATOID ARTHRITIS OVERVIEW — Rheumatoid arthritis (RA) is a chronic inflammatory condition. It can affect many different parts of the body but most commonly affects the joints, causing pain and stiffness. The cause of RA is unknown. It is different from osteoarthritis (OA), which is the most common form of arthritis; OA occurs when the cartilage protecting the joints wears down over time.

Treatment plays a key role in controlling the inflammation of RA and in minimizing joint damage. Treatment usually involves a combination of medications and other non-drug therapies. In some cases, treatment may also involve surgery.

The treatment of RA must be tailored to each person's individual situation, including the severity of the condition, the effectiveness of specific therapies, and the presence of any side effects. Treatment choices may also be affected by the person's other health conditions, especially those affecting the liver, lungs, or kidneys. If you have RA, it is important to work closely with your rheumatologist to discuss your options and form a plan for treatment.

This topic discusses the treatment of RA. More information about RA is available separately. (See "Patient education: Rheumatoid arthritis symptoms and diagnosis (Beyond the Basics)" and "Patient education: Disease-modifying antirheumatic drugs (DMARDs) in rheumatoid arthritis (Beyond the Basics)" and "Patient education: Rheumatoid arthritis and pregnancy (Beyond the Basics)".)

GENERAL PRINCIPLES OF RHEUMATOID ARTHRITIS TREATMENT — The aim of rheumatoid arthritis (RA) treatment is to control symptoms, prevent joint damage, and maximize your quality of life and ability to function. Joint damage caused by RA generally occurs within the first two years of diagnosis when inflammation may be at its worst, though it is difficult to predict which individuals will develop long-term complications from joint damage. Therefore, the initial treatment of RA aims to eliminate or minimize inflammation. However, different treatments come with different possible side effects, and it's important to weigh their benefits and risks. In general, treatments with the potential to stop joint damage are recommended for everyone with RA.

Long-term medical care with a provider you trust is essential for the successful management of RA. This involves regular visits and tests to assess how well your treatment is working and monitor you for possible side effects.

GENERAL MEASURES — Almost all people with rheumatoid arthritis (RA) require some form of medication to control their disease. This does not diminish the importance of nonpharmacologic (non-drug) therapies, which can improve quality of life, help control symptoms, and minimize joint damage. Effective therapeutic measures include the following:

Education and counseling — Education and counseling can help you to better understand the nature of RA and cope with the challenges of your condition. You and your health care providers can work together to discuss both standard and alternative treatment options, decide on short- and long-term goals, and form a treatment plan.

Approaches such as biofeedback (a technique that teaches you to control certain body functions) and cognitive behavioral therapy (a form of therapy in which you learn to change how you react to your situation) may be helpful. These measures can reduce pain and disability and improve self-esteem. Programs on topics such as self-management skills, social support, biofeedback, and setting goals are offered by the Arthritis Foundation in the United States and by similar patient organizations worldwide. These services are also offered by many hospitals and clinics. These programs have been shown to reduce pain, depression, and disability in people with RA and to allow them to gain some control over their illness.

Exercise — Pain, stiffness, and fatigue can make it difficult to exercise, leading many people with RA to limit their physical activity. However, inactivity can lead to a loss of joint motion, contractions, and a loss of muscle strength. Weakness, in turn, decreases joint stability and increases fatigue.

Regular physical activity can help prevent and reverse these effects. Many kinds of exercise can be beneficial, including range-of-motion exercises to preserve and restore joint motion, exercises to increase strength, and activities to increase endurance (eg, walking, swimming, and cycling). Even gentle movement on a regular basis can help (eg, tai chi).

If your joint symptoms make it difficult for you to move or be active, a physical therapist can help. They can work with you to identify forms of physical activity that are appropriate based on your symptoms and health. Exercise for people with arthritis is discussed in more detail separately. (See "Patient education: Arthritis and exercise (Beyond the Basics)".)

Once you find physical activities that work for you, be sure to keep at it. Being physically active reduces inflammation, pain, and fatigue, and improves your quality of sleep and mental health, which are all areas usually made worse from RA. While being physically active is important for almost everyone, studies continue to show an even greater benefit for those with RA.

Physical and occupational therapy — Physical or occupational therapists are experts in helping you do the activities you want to do, while providing approaches to help relieve pain and help preserve joint structure and function.

Specific types of therapy are used to address specific effects of RA. For example:

●Individualized exercise programs to safely improve function and health, including resistance, mobility, and aerobic exercises.

●Functional training and activity modifications to keep you participating in desired activities in the community and at home.

●Balance training to prevent falls.

●Splints or braces (to keep a joint from moving) to support joints that need help.

●Orthotics (devices that support positioning of the feet) or shoe wear recommendations to reduce foot pain and improve walking.

●Assistive devices or modifications to aid challenging tasks, such as opening a jar or walking long distances.

●Physical or occupational therapists can work with you to design self-management plans to maintain function and manage symptoms at home.

Occupational therapists also focus on helping people with RA to be able to continue to actively participate in work and recreational activities, with special attention to maintaining good function of the hands and arms.

Nutrition and dietary therapy — Specific changes in diet have been studied as potential treatments for RA, with the Mediterranean diet showing some benefits at reducing inflammation and pain. Folic acid is an important supplement to take to reduce the side effects of methotrexate, a medicine often used for RA. The addition of fish oils rich in omega-3 fatty acids and taking vitamin D3 have modestly improved arthritis pain and joint swelling. However, there is no diet known to cure RA. In addition, some herbal or nutritional supplements, such as cartilage or collagen, can be dangerous and are usually not recommended. (See 'Complementary and alternative therapies' below.)

If you are overweight or obese, your health care provider might recommend trying to lose weight in order to reduce stress on your joints and reduce your risk of getting other diseases (see "Patient education: Losing weight (Beyond the Basics)"). People with RA have a higher risk of developing diabetes and coronary artery disease, which increases the risk of heart attack or stroke. High cholesterol is one risk factor for coronary disease that can respond to changes in diet. A nutritionist can recommend specific foods to eat or to avoid to achieve a desirable cholesterol level. (See "Patient education: High cholesterol and lipids (Beyond the Basics)".)

Smoking and alcohol — Smoking is a risk factor for RA, and quitting smoking can improve symptoms and reduce the risk of lung cancer and lung infections, which are more common with RA. If you smoke, it's important to try to quit completely. This can be very difficult to do, but your health care provider can help. (See "Patient education: Quitting smoking (Beyond the Basics)".)

Moderate to low alcohol consumption is generally not harmful, although it may increase the risk of liver damage associated with certain drugs, such as methotrexate. It may be best to take methotrexate on a day you are much less likely to drink alcohol. If you drink alcohol, it's important to discuss this with your provider, as the risks will depend on what medications you take and whether you have other health conditions.

Measures to reduce bone loss — RA causes a decrease in bone density, which can lead to osteoporosis. Bone loss is more likely in people who are inactive. The use of steroid medications, such as prednisone, further increases the risk of bone loss, especially in women who have been through menopause. This risk, along with the increased risk in older age, is often why your doctor may want to get a dual-energy X-ray absorptiometry (DEXA) scan, which is an X-ray that diagnoses osteoporosis and determines bone density. (See "Patient education: Bone density testing (Beyond the Basics)".)

Several measures can minimize the bone loss associated with steroid therapy:

●Working with your doctor to get to the lowest possible dose of steroids that are required for the shortest possible time needed to manage your RA.

●Be sure to consume an adequate amount of calcium and vitamin D, either through your diet or by taking supplements. (See "Patient education: Calcium and vitamin D for bone health (Beyond the Basics)".)

●Your doctor may prescribe other medications that also increase the risk of bone loss, including some medicines used for pain. It is important to be physically active and take other steps to counter this, as bone loss can lead to bone fractures and major disability. (See "Patient education: Osteoporosis prevention and treatment (Beyond the Basics)".)

RHEUMATOID ARTHRITIS MEDICATIONS — Medications are the cornerstone of treatment when rheumatoid arthritis (RA) symptoms are active. The goals of medication treatment are to achieve remission of symptoms and signs of RA and prevent further damage of the joints and loss of function, without causing permanent or unacceptable side effects.

The best medication(s) and dose(s) for you will depend upon individual factors as well as potential drug side effects. In most cases, the dose of a medication is increased or another medication is added until inflammation is suppressed or until drug side effects become unacceptable. This balance can pose a challenge, as the need to control inflammation must be weighed against the risk of side effects.

If you take medications for RA, you will need to see your health care provider regularly for examinations and blood tests to monitor for complications from the medications. If you do experience side effects, they can often be minimized or eliminated by reducing the dose or switching to a different drug.

Several types of medicines are used to treat RA and the inflammation and pain associated with RA. Almost all people with RA should be prescribed a disease-modifying antirheumatic drug (DMARD). In addition, they may be prescribed nonsteroidal antiinflammatory drugs (NSAIDs), steroids, and, if needed, pain medications. Sometimes additional medicines are needed to help reduce the side effects that may come from taking medicine for the RA.

DMARDs — Disease-modifying antirheumatic drugs (DMARDs) can substantially reduce the inflammation of RA, reduce or prevent joint damage, preserve joint structure and function, and enable a person to continue his or her daily activities. Although some DMARDs act slowly, they may allow you to take a lower dose of steroids to control pain and inflammation. There are several types of DMARDs:

●Conventional synthetic DMARDs (sometimes called traditional DMARDs or csDMARDs), such as methotrexate, hydroxychloroquine, and sulfasalazine, are produced by traditional drug-manufacturing techniques. These are usually in pill form, though some are injectable, and these were mostly developed before 1998.

●Biologic DMARDs (sometimes called biologics or bDMARDs) are manufactured using molecular biology (recombinant deoxyribonucleic acid [DNA]) techniques. Examples include etanercept, adalimumab, abatacept, and tocilizumab. These are either injected or provided through an intravenous (IV) infusion, and these were developed after 1998.

●Other newer DMARDs, such as tofacitinib, are produced by traditional drug-manufacturing techniques in pill form, yet are similar to the targeted biologic DMARDs and are sometimes referred to as a targeted synthetic DMARDs or tsDMARDs.

More detailed information about DMARDs, including the potential side effects, is available separately. (See "Patient education: Disease-modifying antirheumatic drugs (DMARDs) in rheumatoid arthritis (Beyond the Basics)".)

NSAIDs — Nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen (sample brand names: Advil, Motrin) and naproxen (sample brand name: Aleve), may be recommended to relieve pain and reduce minor inflammation. Your provider will likely prescribe a dose that is higher than what people typically take to relieve headaches or other minor aches and pains. However, NSAIDs do not reduce the long-term damaging effects of RA on the joints; an effective DMARD is needed to do that.

NSAIDs must be taken continuously and at a specific dose to optimize their antiinflammatory effect. Even at the correct doses, NSAIDs generally need to be used for several weeks before taking full effect. If the initial dose of NSAIDs does not improve symptoms, a clinician may recommend increasing the dose gradually or switching to another NSAID. You should not take two different NSAIDs at the same time.

Many NSAIDS have significant side effects, including gastrointestinal bleeding, fluid retention, and an increased risk of heart disease. The risks need to be weighed carefully against the benefits when taking these drugs, and it is important to find the smallest dose of NSAID that helps you maintain the level of pain and function you need.

More detailed information about NSAIDs is available separately. (See "Patient education: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)".)

Steroids — Steroids, also called glucocorticoids or corticosteroids, have strong antiinflammatory effects (see "Patient education: Disease-modifying antirheumatic drugs (DMARDs) in rheumatoid arthritis (Beyond the Basics)"). Drugs in this class include prednisone and prednisolone for oral administration, and hydrocortisone, methylprednisolone acetate (sample brand name: Depo-Medrone), and triamcinolone for injection. Steroids may be taken by mouth, by intramuscular or intravenous injection, or injected directly into a joint. Steroids quickly improve RA symptoms such as pain and stiffness and decrease joint swelling and tenderness.

Steroids are generally used to treat RA that severely limits a person's ability to function normally. In this situation, steroid treatment may help control symptoms and preserve function until other slower-acting drugs with greater ability to prevent joint damage begin to work. Steroids may also be used to treat flares of disease while a person is receiving other treatments. Low doses of steroids are sometimes prescribed for long-term use along with DMARDs if necessary to control disease activity. (See 'Treatment of flares' below.)

Steroid side effects — Steroids have many possible side effects, including weight gain, bone loss (osteopenia and osteoporosis), worsening diabetes, insomnia, development of cataracts in the eyes, and an increased risk of infection. Because of this, when steroids are used in the treatment of RA, the goal is to use the lowest possible dose for the shortest period of time.

Non-NSAID pain relievers — These pain relievers can help with pain, but they have no effect on inflammation. Examples include acetaminophen (sample brand name: Tylenol) and capsaicin cream or ointment.

Use of opioid medications like codeine, oxycodone, hydrocodone, and tramadol is generally discouraged because they also have no effect on inflammation. There is also risk of dependence and addiction because of the long-term nature of RA. However, treatment with a long-acting opioid may be considered for people with late-stage RA and severe joint damage who cannot undergo joint replacement surgery; this should only be done under the supervision of a rheumatologist or pain specialist.

Treatment of flares — Flares are periods in which RA symptoms temporarily worsen; these can occur in addition to the ongoing inflammation. Unfortunately, flares are relatively common with RA, and you may take different approaches in treating your flare until it resolves. Your provider may recommend treating flares by increasing the doses of the drugs you are already taking, changing drugs, or adding additional drugs (such as injectable or oral steroids) that may help most over shorter periods until the flare is gone. With experience of flares often comes understanding of how some flares start, such as not taking medication, lack of sleep, a stressful period, etc, which hopefully leads to treatments and behaviors that reduce future flares.

Which treatment will I get? — The type of drugs that your doctor recommends will depend on how severe your RA is, how well you respond to the medications, and what drugs are available to you. If you have early, mild arthritis, your treatment will likely be different from someone who has more severe arthritis or whose symptoms persist despite initial treatments. There are now many different effective drugs to treat RA, which improves your chances of finding a drug that helps you the most.

In general, nearly everyone with RA will receive a DMARD as part of their treatment program. A different DMARD will be substituted for or added to the initial drug if treatment is not effective enough. It is often recommended to increase the dose or consider adding or an alternative DMARD until adequate control of the RA is achieved. What "adequate control" means will depend upon what goals you may have set with your doctor. (See 'Education and counseling' above and "Patient education: Disease-modifying antirheumatic drugs (DMARDs) in rheumatoid arthritis (Beyond the Basics)".)

SURGERY — Even with treatment, some people will progress to "end-stage" rheumatoid arthritis (RA), meaning that there is significant joint damage and loss of function even in the absence of ongoing inflammation. The goals of treatment in end-stage RA include pain relief, slowing or prevention of additional joint damage, maintaining current levels of function, and relief of fatigue and weakness. Nonpharmacologic treatment such as physical and occupational therapy is particularly important. (See 'Physical and occupational therapy' above.)

In some cases, surgery is recommended to improve pain and function in people with end-stage RA. This may involve surgery to stabilize or replace a damaged joint. (See "Patient education: Total hip replacement (Beyond the Basics)" and "Patient education: Total knee replacement (Beyond the Basics)".)

COMPLEMENTARY AND ALTERNATIVE THERAPIES — Complementary and alternative medicine (CAM) is defined by the National Center for Complementary and Alternative Medicine as "a group of diverse medical and healthcare systems, practices, and products that are not presently considered to be part of conventional medicine." The term "alternative medicine" is used when treatments are used instead of conventional medicine, whereas in "complementary medicine," they are used along with conventional medical treatments.

Many complementary and alternative therapies have been marketed for the treatment of rheumatoid arthritis (RA). While some approaches may be helpful in certain situations, they should not be used in place of standard medical treatment, and evidence supporting many of these therapies is limited. It's also important to be cautious, especially if you are trying things like supplements or herbal treatments, as in some countries (including the United States), these products are not regulated by government agencies the same way as standard medications. In some cases, they contain ingredients that are not listed on the product and that can cause harm. They can also be expensive, especially since they will likely not be covered by health insurance.

Several different CAM therapies are discussed below. If you are interested in trying any of these, talk with your health care provider first. They can talk to you about your situation and how to stay safe while also finding ways to relieve your RA symptoms.

Massage therapy — A form of relaxation therapy, this therapy has been shown to provide temporary pain relief and improved sleep. It also can reduce muscle stiffness and reduce inflammation through improved circulation. Some people find that this helps relieve symptoms associated with RA, and it is unlikely to be harmful.

Spa therapy — Also called "balneotherapy," this involves soaking in a mineral water bath, sometimes with mud. Some people find that this helps relieve joint symptoms associated with RA, and it is unlikely to be harmful.

Fish and plant oils — Certain fish and plant oils have been found to decrease inflammation in the body. However, it's important to talk to your health care provider before trying these or other supplements, as some of them can interact with certain medications and be harmful.

Mind-body techniques — "Mind-body" techniques include practices such as biofeedback, relaxation, and meditation. There is some evidence that these techniques may be helpful in improving symptoms; they might also help with managing anxiety and stress. People of any age can learn mind-body techniques, and they are generally considered safe.

Other therapies — Many other complementary and alternative therapies also claim to be effective in treating RA. These include acupuncture, special diets, herbs and supplements, magnets, and others. In general, these approaches do not have enough scientific evidence for experts to recommend them. If you are interested in learning more about a particular therapy, ask your health care provider.

TREATMENT OF RHEUMATOID ARTHRITIS DURING PREGNANCY — Some of the medications used to treat rheumatoid arthritis (RA) are not safe to take during pregnancy. In some cases, your provider may ask if you plan on getting pregnant in the future before prescribing a particular disease-modifying antirheumatic drug (DMARD) for your RA due to these important and very serious side effects. More information about RA in pregnancy is available separately. (See "Patient education: Rheumatoid arthritis and pregnancy (Beyond the Basics)".)

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Rheumatoid arthritis (The Basics)
Patient education: Rheumatoid arthritis and pregnancy (The Basics)
Patient education: Deciding to have a hip replacement (The Basics)
Patient education: Physical activity for people with arthritis (The Basics)
Patient education: Disease-modifying antirheumatic drugs (DMARDs) (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

The following organizations also provide reliable health information:

●National Library of Medicine

(medlineplus.gov/arthritis.html, available in Spanish)

●American College of Rheumatology

(404) 633-3777

(www.rheumatology.org/I-Am-A/Patient-Caregiver)

●The Arthritis Foundation

(800) 283-7800

(www.arthritis.org)

Patient support — There are several online forums where patients can find information and support from other people with similar conditions.

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges PJW Venables, MA, MB BChir, MD, FRCP, who contributed to earlier versions of this topic review.

Disclaimer: This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circumstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof. The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms. 2024© UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.

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Patient education: Rheumatoid arthritis treatment (Beyond the Basics)