There is no cure for rheumatoid arthritis (RA), but fortunately patients with the disease have a variety of effective treatment options from which to choose. Depending on the severity of the disease, the treatments currently available offer most patients good to excellent relief of its symptoms and can make it possible for them to continue to function at or near normal levels of activity.
The goal of treatment is to minimize patients' symptoms and disability. Treatment also aims to interrupt the immune response that leads to inflammation, and ultimately, stop the progression of the disease before joints are permanently damaged. When started early, aggressive management of the disease has been shown to improve function and prevent work disability.
Because the disease affects individuals in such different ways, treatment too must be tailored. Doctors traditionally customize treatment by taking into consideration a variety of different factors that include the extent of the disease activity, the types of joints involved, and the patient's general health, age and occupation. No single therapy is effective for everyone, and it is common for patients to find that they need to change treatment strategies during the course of their disease.
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Combinations of treatments are often found to be effective, but in addition to medications, therapy may include rest, joint strengthening exercises, joint protection and patient and family education. Sometimes surgery may be necessary to correct joint damage. For all these reasons, it is common for several different providers to be involved in the overall management of the disease. Expertise is often required from a multidisciplinary team that includes a rheumatologist, a primary care physician and physical and occupational therapists.
The Role of Medication
Rheumatoid arthritis medications range from over the counter products to highly advanced prescription therapies. Most can relieve the symptoms and many can also slow or halt the progression of the disease. Treatments for rheumatoid arthritis include:
- NSAIDs and COX-2 inhibitors are often the first line of treatment. They quickly reduce joint inflammation and the symptoms associated with the disease. They vary in strength from nonprescription to more powerful prescription medications that include ibuprofen (Motrin® and others), naproxen (Naprosyn®, Aleve®), celecoxib (Celebrex®) and many others.
- Corticosteroids, such as prednisone, may be given orally at low doses or via injection into the joints to reduce inflammation and pain and to slow joint damage.
- Disease-modifying antirheumatic drugs, also called DMARDs, comprise several classes of medication and are typically used to treat other conditions, such as cancer or inflammatory bowel disease or to reduce the body's risk of rejection of a transplanted organ. When they are used to treat rheumatoid arthritis, the doses are significantly lower and the risks of side effects tend to be considerably less. Examples of DMARDs include hydroxychloroquine sulfate (Plaquenil®), the gold compound auranofin (Ridaura®), sulfasalazine (Azulfidine EN-tabs®), minocycline hydrochloride (Dynacin®, Minocin®) and methotrexate (Rheumatrex®).
- Immunosuppressants tame the immune system by attacking and eliminating the cells associated with the disease. Immunosuppressants commonly used to treat rheumatoid arthritis include leflunomide (Arava®), azathioprine (Imuran®), cyclosporine (Neoral®, Sandimmune®) and cyclophosphamide (Cytoxan®).
- TNF-alpha blockers. A new class of medications, referred to as biologic response modifiers or "biologic agents," can specifically target parts of the immune system that lead to inflammation as well as joint and tissue damage. FDA-approved treatments include adalimumab (Humira®), etanercept (Enbrel®) and infliximab (Remicade®).
- Costimulation modulators. Abatacept (Orencia®) is the first in this new class of medication approved to treat rheumatoid arthritis. It works by inactivating the T cells that stimulate the inflammation response.
- A monoclonal antibody called rituximab (Rituxan®), which has typically been used to treat cancer, was recently approved for the treatment of rheumatoid arthritis. It targets and reduces the number of B cells in the body; B cells are believed to play a role in the initiation and development of the disease.
- Interleukin-1 receptor antagonist, or IL-1Ra, is another type of biologic response modifier. Anakinra (Kineret®) is approved for use in people with moderate to severe rheumatoid arthritis who haven't responded adequately to conventional DMARD therapy.
However, for treatment to be most effective, other forms of therapy may be required. They include the following:
- Antidepressants. Some people with arthritis also experience symptoms of depression that may be relieved with antidepressants. In many cases, the most effective therapy for rheumatoid arthritis involves the use of these medications in various combinations. Usually, they are combined with methotrexate to increase their effectiveness.
- Rest and exercise. It's important to rest inflamed joints, especially during periods when the disease flares. Modified exercise programs are also recommended to keep joints flexible and to strengthen muscles that surround the joints.
- Joint care. Splints may be necessary to reduce the stress on joints. Self-help devices that make it easier for people to carry out daily activities, like opening a jar, may also prove useful.
- Stress reduction. Hypnosis, deep breathing, muscle relaxation and other forms of stress reduction can help control pain and discomfort.
- Healthy diet. Eating lots of fruits, vegetables and whole grains will control weight. Excess weight puts added strain on the joints.
- Hot and cold compresses. Applying heat can ease pain and discomfort and increase blood flow. Cold, on the other hand, can dull sensation in inflamed joints. It may also decrease muscle spasms.
- Surgery. In some cases, surgery may become necessary when therapies can't help joints that are already severely damaged. The surgery may involve tightening loose tendons, loosening tendons that are too tight, removing diseased bones or replacing damaged joints with artificial metal or plastic ones.