Treatment Options

There is no known cure for rheumatoid arthritis yet.

The goal of treatment in rheumatoid arthritis is to reduce joint inflammation and pain, maximize joint function, and prevent joint destruction and deformity.

Optimal treatment for the disease involves a combination of medications, rest, joint and muscle strengthening exercises, joint protection, physical and occupational therapy, surgical intervention, patient (and family) education, social and emotional support for the patient. It is essential that the patient and the patient’s family be educated about the nature and course of the disease.

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. Due to the fact that RA is a chronic disease, the treatment must be a long lasting one and always directed by the rheumatologist (in cooperation with the patient) according to the factors mentioned before.

Early medical intervention has been shown to be important in improving outcomes. Intensive management can improve function, stop damage to joints and prevent work disability.

 

Medications

Medications can reduce inflammation in your joints in order to relieve pain and prevent or slow joint damage.

The goals of treatment with rheumatoid arthritis medications are to achieve remission or Low Disease Activity (in established patients with long lasting RA) and to prevent further damage of the joints and loss of function, without causing permanent or unacceptable side effects.

The type and intensity of rheumatoid arthritis treatment with medication depends upon individual factors and potential drug side effects. In most cases, the dose of a medication is increased until inflammation is suppressed or until drug side effects become unacceptable.

All patients with rheumatoid arthritis who use medications need regular medical care and blood tests to monitor for complications. If side effects occur, they can often be minimized or eliminated by reducing the dose or by switching to a different drug.

Several classes of drugs are used to treat rheumatoid arthritis: non-steroidal anti-inflammatory drugs (NSAIDs), disease modifying antirheumatic drugs (DMARDs) (which include both traditional DMARDs and biologic agents), glucocorticoids, and, if needed, pain medications.

 

NSAIDs

Non-steroidal anti-inflammatory drugs (NSAIDs) can relieve pain and reduce minor inflammation but do not slow progression of RA and they should rarely be used to treat RA without the parallel use of DMARDs (See below). Patients' responses to different NSAID vary. Therefore, it is not unusual for a doctor to try several NSAID in order to identify the most effective agent with the fewest side effects.

The most common side effects of NSAIDs include stomach upset, abdominal pain, ulcers, liver and kidney damage, heart problems, raised blood pressure, and even gastrointestinal bleeding. In order to reduce gastrointestinal side effects, NSAIDs are usually taken with food, or additional medications are frequently recommended to protect the stomach from the effects of NSAIDs. You should not take two NSAIDs at the same time due to the risk of adverse effects. You and your doctor can weigh the benefits of NSAIDs against the potential risks.

 

Steroids

Corticosteroid medications, such as prednisone or methyl-prednisolone, reduce inflammation, stiffness and pain and slow joint swelling. Doctors often prescribe a corticosteroid for short periods to relieve acute symptoms during severe flares, to treat RA that severely limits a person’s ability to function normally or as a “bridge-therapy” until the positive effect of DMARDs install, with the goal of gradually tapering off the steroids medication. Corticosteroid medications can be given orally or injected directly into tissues and joints.

Corticosteroids may have serious side effects, especially when given in high doses for long periods of time. Side effects may include thinning of bones (osteoporosis), cataracts, weight gain and diabetes, facial puffiness, easy bruising, risk of infection, or muscle wasting. These side effects can be partially avoided by gradually tapering the doses of corticosteroids as the individual achieves improvement in symptoms. Abruptly discontinuing corticosteroids can lead to flares of the disease or other symptoms of corticosteroid withdrawal that can even be life-threatening and so it is discouraged.

 

Disease-modifying antirheumatic drugs (DMARDs).

While "first-line" medications (NSAIDs and corticosteroids) can relieve joint inflammation and pain, they do not necessarily prevent joint destruction or deformity. DMARDs, however, can slow the progression of rheumatoid arthritis and save the
joints, bone and other tissues from permanent damage, controlling the signs and symptoms of joint involvement, improving the functional status and quality of life.

Common DMARDs include methotrexate (Trexall), leflunomide (Arava), hydroxychloroquine (Plaquenil), sulfasalazine (Azulfidine), Gold salts, minocycline (Dynacin, Minocin, others), azathioprine (Imuran, Azasan), cyclosporine (Neoral, Sandimmune, Gengraf) and cyclophosphamide (Cytoxan). These medications are immunosuppressants and they act to tame your immune system, which is out of control in rheumatoid arthritis.
Side effects vary but may include liver damage, bone marrow suppression, anemia, a low white cell count, and low platelet counts and severe infections (lung infections more frequently). That’s why you should always be controlled (monitored) by having regular lab tests when taking this medications.

These drugs are generally prescribed as soon as a diagnosis of RA has been made to reduce disease activity, control joint damage and prevent disability. Sometimes a number of DMARD medications are used together as combination therapy in aggressive RA. The doctor may need to try different options 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 (cancer of lymph nodes) that exists from simply having rheumatoid arthritis.

These medicines may take weeks to months to become effective. That’s why you may be prescribed corticoids, as a “bridge” therapy.

 

Biologics

The newest and most effective treatments for rheumatoid arthritis are called biologics. They are designed to inhibit specific components of the immune system that play a pivotal role in inflammation, a key component in rheumatoid arthritis. Among these components of immune system the central role played in mechanism of RA belongs to TNF-alpha.

Tumor necrosis factor-alpha (TNF-alpha) is an inflammatory substance produced by your body. TNF-alpha inhibitors are a type of biologics that can help reduce pain, morning stiffness, and tender or swollen joints. Examples include etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), golimumab (Simponi) and certolizumab pegol (Cimzia).

Potential side effects of TNF-alpha inhibitors include increased risk of serious infections, congestive heart failure and certain cancers. Anti-TNF agents are not recommended for people who have lymphoma or who have been treated for lymphoma; more research is needed to define this risk.

There are additional biologics that target other molecules instead of TNF. These are usually used for people with arthritis that is not well-controlled with methotrexate and one of the anti-TNF agents. These drugs include anakinra (Kineret), abatacept (Orencia), rituximab (Rituxan) and tocilizumab (Actemra). Side effects vary but may include itching, severe abdominal pain, headache, runny nose or sore throat. Biologic agents interfere with the immune system's ability to fight infection and should not be used in people with serious infections.

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.

Unlike DMARDs, which can take a month or more to begin working, biologics tend to work rapidly, within two weeks for some medications and within four to six weeks for others.

All biologic agents must be injected. Some can be injected under the skin by the patient or a family member, or nurse. There are others that must be injected into a vein (intravenous infusion), which is typically done in a doctor's office or clinic; this takes between one and six hours to complete.
Testing for tuberculosis (TB) is necessary before starting anti-TNF therapy. People who have evidence of prior TB infection should be treated because there is an increased risk of developing active TB while receiving anti-TNF therapy.

 

Special situations

Treatment during pregnancy

Rheumatoid arthritis therapy during pregnancy is complicated by the fact that none of the drugs discussed above have been shown to be safe in pregnant women with adequate, controlled studies. Although joint symptoms frequently remit during pregnancy, this effect is not universal. Treatment decisions require careful consideration of the risks and benefits to the mother and fetus.

All DMARD therapy should be stopped in women planning to conceive and in pregnant and lactating women. Evidence of the risks of these agents to the fetus either exists or cannot be ruled out.

Although safety has not been proven in controlled trials, no evidence exists for risks to the fetus of low dose prednisone (less than 20mg daily) or of NSAIDs used in the first two trimesters. Although both NSAIDs and prednisone are excreted in the breast milk, both are considered compatible with breast-feeding by the American Academy of Pediatrics.


Non-pharmacological therapies

Non-pharmacological therapies include treatments other than medications and there are a wide variety of them available.

Surgery

Surgery may help restore your ability to use your joint. It can also reduce pain and correct deformities. Rheumatoid arthritis surgery may involve one or more of the following procedures:

  • Joint fusion. Surgically fusing a joint may be recommended to stabilize or realign a joint and for pain relief when a joint replacement isn't an option.
  • Total joint replacement. During joint replacement surgery, your surgeon removes the damaged parts of your joint and inserts a prosthesis made of metal and plastic.
  • Arthoplasty
  • Tendon repair. Inflammation and joint damage may cause tendons around your joint to loosen or rupture. Your surgeon may be able to repair the tendons around your joint.

Surgery carries a risk of bleeding, infection, and pain. The primary physician, the rheumatologist, and the orthopedist should all help the patient to understand the risks and benefits of the surgical procedure. The decision to have surgery is a complex one that must take into consideration the motivation and goals of the patient, their ability to undergo rehabilitation, and their general medical status.

 

Education and counselling

Educational and skills training concentrates on information and strategies for increasing patient involvement in treatment.

Education and counseling can help you to better understand the nature of rheumatoid arthritis and cope with the challenges of this condition. You and your healthcare providers can work together to formulate a long-term treatment plan, define reasonable expectations, and evaluate both standard and alternative treatment options.

Education and support can be given to you on different areas, like:

  1. Ability to perform activities of daily living (like dressing, eating, personal hygiene, transfer, sleeping, toileting etc.);
  2. Recreational or leisure activities;
  3. Occupational (vocational) activities including job, housework and schoolwork;
  4. Sexual activities;
  5. Affective function (depression, anxiety, mood)
  6. Coping skills;
  7. Social and interpersonal relationships;
  8. Ability to fulfill social roles;
  9. Family functioning

 

Nutrition and dietary therapy

People with active rheumatoid arthritis sometimes lose their appetite or are unable to eat an adequate amount of food. Dietary therapy helps to ensure that you eat an adequate amount of calories and nutrients. However, 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 is one risk factor for coronary disease that can respond to changes in diet. A nutritionist can recommend specific foods to eat or avoid achieving a desirable cholesterol level.

Changes in diet have been investigated as treatments for rheumatoid arthritis. However, there is no diet that can cure rheumatoid arthritis. No herbal or nutritional supplements, such as cartilage or collagen, can cure rheumatoid arthritis. Keep in mind that natural supplements can interact with medicines. Be sure your doctor is aware of all medicines and supplements you are taking.

 

Smoking and alcohol

Several different studies have shown that smoking is a risk factor for rheumatoid arthritis and that quitting smoking can improve disease. People who smoke need to quit completely. Assistance in quitting should be obtained, if needed.

Moderate alcohol consumption is not harmful to rheumatoid arthritis, although it may increase the risk of liver damage from some drugs such as methotrexate. People should discuss the safety of alcohol use with their doctor, because recommendations depend on the medications a person is taking and on their other medical conditions.

 

Measures to reduce bone loss

Rheumatoid arthritis causes bone loss, which can lead to osteoporosis. Bone loss is more likely in people who are inactive. The use of glucocorticoids, such as prednisone, further increases the risk of bone loss, especially in postmenopausal women.

Several measures can minimize the bone loss associated with steroid therapy, like using the lowest possible dose of glucocorticoids for the shortest possible time, consuming an adequate amount of calcium and vitamin D, both in the diet and by taking supplements, or using medications (like bisphosphonates) that can reduce bone loss, including that which is caused by glucocorticoids.

 

Rheumatoid arthritis prevention

Though arthritis is not preventable, many people are able to prevent disability with early treatment and a well-designed exercise program.

Smoking is associated with the development of rheumatoid arthritis although it isn’t clear that you can prevent rheumatoid arthritis by not smoking.

A healthy life style will always be the best advice in having a high quality life.

 

Psychosocial therapy

The most common psychosocial problems in RA and other rheumatic diseases are depression and anxiety, uncertainty and loss of control regarding the disease process, altered body image and reduced physical ability, decreased self-esteem and self-confidence, fear of becoming physically dependent and disabled, loss of independence and security in career and personal roles, increased stress related to social changes and disability limitations.

If these problems occur and interfere with everyday functioning or full-participation in treatment one might consider individual, family or group therapy. The following techniques are commonly used in medical groups:

  • cognitive behavioural therapy – it focuses on changing faulty and distorted perceptions and thoughts that interfere with healthy adjustement;
  • relaxation therapy (like biofeedback, progressive muscle relaxation and imagery/visualization deep abdominal breathing, meditation, and tai chi) have been useful in decreasing pain and depression, in helping you recognize feelings of increased tension and learn ways to calm yourself etc.)
  • coping skills training that provides adaptive coping styles to improve problem-solving and reduce negative coping strategies such as catatrophizing and/or wishful thinking;
  • stress management – mind/body therapy;
  • supportive therapy which can reduce feelings of isolation and helplessness and encourage expression of emotions related to illness.

 

Rest and exercise

Fatigue is a common symptom of rheumatoid arthritis. Inflamed joints should be rested, but physical fitness should be maintained as much as possible. Pain and stiffness often prompt people with rheumatoid arthritis to become inactive.

Unfortunately, inactivity can lead to a loss of joint motion, contractions, and a loss of muscle strength. Weakness, in turn, decreases joint stability and further increases fatigue. Several studies have shown that physical fitness improves the quality of sleep, which in turn helps with fatigue. The advice of physical and occupational therapists should be sought for help with fitness programs, if joint pain or limited joint motion interferes with exercise activities.

Three types of rest are known:

  • Local rest – it is performed in a specific joint utilizing splinting techniques to reduce pain, inflammation or to prevent contracture;
  • Systemic rest – it is used for a period of up to 4 weeks if appropriate anti-inflammatory medication and outpatient rehabilitation management are ineffective;
  • Short rest periods – they are a preventive and proactive means of managing inflammation and fatigue. The patient interrupts daily activities that last longer than 30 continuous minutes to take short breaks.

Regular exercise has a lot of beneficial effects, such as: making you live longer, reducing pain and the need of pain killers, preventing or reducing contractures, enhancing endurance, keeping bones strong (especially important if you take corticoids!), maintaining or increasing muscle strength, improving functional ability and lets you do more for yourself. People with rheumatoid arthritis who exercise feel better about themselves and are better able to cope with problems.. Different kinds of exercise can be appropriate, including range-of-motion exercises to preserve and restore joint motion, exercises to increase strength (isometric, isotonic, and isokinetic exercises), and exercises to increase endurance (walking, swimming, and cycling).

The types of exercises you can do are:

  • Passive exercises – Motion is performed by the therapist or mechanical device without the help of the patient.
  • Active exercises – The patient performs the movement.
  • Active-assisted exercises – The patient performs the movement with the assistance of the therapist.

Exercise programs for people with rheumatoid arthritis should be designed by a physical therapist and tailored to the severity of your condition, extent of inflammation and deformity, your general medical condition, your build, your former activity level and types of activities that you enjoy doing (to improve compliance).

 

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.

The physical therapist can assist you to learn the use of various therapeutic and pain relieving techniques, including heat-cold, traction, diathermy, electrical stimulation, ultrasound techniques, therapeutic exercises, stretching, ambulation methods etc.

The occupational therapist can instruct you in joint protection and energy conservation. They can provide and fabricate adaptive equipment and splinting (and to improve limb and joint function and prevent deformities), especially for upper extremities. For lower extremities you can see a podiatrist who can make foot orthotics (devices that ensure correct position of the foot and toes) and supportive footwear. Occupational therapists also focus on helping people with rheumatoid arthritis to be able to continue to actively participate in work and recreational activity with special attention to maintaining good function of the hands and arms.

Occupational and physical therapists help you keep doing things you are used to doing every day. They can evaluate your daily activities, determine what you may be doing to stress your joints, and teach you easier ways to accomplish daily activities.

Occupational and physical therapists can also determine which assistive devices can help you throughout the day. Assistive devices can make it easier to avoid stressing your painful joints. For instance, using specially designed gripping and grabbing tools may make it easier to work in the kitchen if you have pain in your fingers. Try a walking stick to help you get around. Catalogs and medical supply stores also may be places to look for ideas.

 

Alternative Treatments for Rheumatoid Arthritis

Acupuncture is considered by health institutions and medical communities as an additional alternative treatment for arthritis. Studies have shown that acupuncture helps reduce pain, may lower the need for painkillers, and can help increase flexibility in affected joints. There are other alternative treatments but there are no studies results to prove the efficacy of these treatments for RA.

 

Final remarks

The therapeutic decisions in treating RA should always be a collaborative process between doctor and patient and should always be based on common decision making, focusing on the main goal of treatment (reaching clinical remission and maximizing long term quality of life, early diagnose and applying early intensive treatment for disease tight control, using combined disease activity measurements etc.).

The therapeutic process of RA should be a multidisciplinary team approach composed of:

  • Rheumatologist;
  • Nurses trained in rheumatology;
  • Kinetotherapist / physiotherapist;
  • Orthopedist;
  • Surgical orthopedist;
  • Podiatrist;
  • Occupational therapist;
  • Psychologist and psychotherapist;
  • Social workers and rehabilitation counselors;
  • Patient educators (Patient trainer / Patient Research Partners)
  • Gynecologist etc.

 

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