Rheumatoid Arthritis Treatment: A Guide to Symptom Management

From verywellhealth.com

Treatment goals for rheumatoid arthritis (RA) are to reduce pain and inflammation and prevent disability. An RA treatment plan usually includes medications and nondrug therapies. Surgery is considered when joints are damaged or no longer work.

Rheumatoid arthritis is a chronic disease that causes inflammation of the synovial linings of joints. RA inflammation can be so severe that it damages joints and other body tissues. There is no cure for RA.

Medications used in the treatment of RA include nonsteroidal anti-inflammatory drugs (NSAIDs) and other pain-relief drugs and topicals, non-biologic disease-modifying anti-rheumatic drugs (DMARDs) like methotrexate, biologic DMARDs, corticosteroids, and Janus kinase (JAK) inhibitors.

Non-drug options include physical therapy, style therapies, and home remedies. Surgery is considered when other therapies have not helped or joints are damaged and no longer function correctly.

This article will cover nondrug and medical treatments for RA, treatment in early RA and as RA progresses, managing flares, and more. 

Rheumatoid Arthritis Non-drug Treatments

Treating RA with medications is crucial, but some nondrug remedies might help to relieve pain and stiffness from RA. 

Illustration by Julie Bang for Verywell Health

Physical Therapy

According to the American College of Rheumatology (ACR), physical therapy is vital to managing RA. Research from the ACR shows people with RA who engage in physical therapy see improvement in pain levels and physical function.

Physical therapy combines exercise, hands-on care, and patient education. A physical therapist can examine you and develop a treatment plan that improves movement, restores function, prevents disability, and manages pain.

Joint Protection

For people with RA, occupational therapy services can include managing daily activities, joint protection, activity pacing, fatigue management, work simplification, splints, orthotics (custom-made shoe inserts), use of assistive devices, stress management, and more.

Assistive devices can help take the stress off inflamed joints and protect them from injury. For example, if you have an inflamed knee or hip joint, consider using a cane on the opposite side to reduce weight on the joint and improve stability. 

You might also consider pens, toothbrushes, and cooking utensils that are easier to hold for people with joint pain. If raising your arms is painful, consider using a reach tool to reach items on high shelves. 

Exercise 

Exercise is an integral part of your RA treatment plan and is most effective when done every day. Physical activity includes aerobic, aquatic, and resistance exercise:

• Aerobic exercise improves cardiorespiratory fitness and muscular endurance. Examples include cycling, running, hiking, walking, and aerobic workouts.
• Resistance exercises increase muscle strength and include free weights, resistance bands, and Pilates.
• Aquatic exercises provide both aerobic and resistance benefits. They include activities like swimming, water walking, and water aerobics. 

Rest

RA is a disease that goes through periods of flare-ups in which symptoms become worse and periods of remission in which symptoms improve. Getting plenty of rest when your RA flares up can help reduce joint inflammation and pain, as well as improve fatigue. 

Hot and Cold Therapies

Ice packs and heating pads relieve local pain, swelling, and stiffness. Cold therapy can bring down inflammation to reduce pain and other RA symptoms. Heat therapy increases blood flow to ease joint stiffness and cramping in the muscles around the joints. You can alternate between cold and hot therapy options as needed.

The ACR also recommends heat and cold therapy as medical treatment. Examples of heat and cold therapy in the medical setting include cryotherapy, therapeutic ultrasound, infrared sauna, paraffin therapy, and cold laser therapy.

Diet 

A healthy diet helps to protect overall well-being, improves energy, manages weight, keeps the immune system strong, and boosts mental health. While diet alone can't treat RA, eating a healthy and balanced diet can go a long way in helping you to feel better.

The ACR recommends adherence to a Mediterranean-style diet over no formally defined diet.1 This diet promotes eating vegetables, fruits, whole grains, nuts, seeds, and olive oil, with moderate amounts of low-fat dairy and fish. Many of these foods can help to keep inflammation down.

The Mediterranean diet also limits sugars, sodium, processed foods, refined carbs, and saturated fats—all believed to increase inflammation. 

Stress Management 

Stress can make RA symptoms worse, although researchers are not entirely sure about the link between RA and stress. It is believed that the body's stress response might contribute to inflammation. Stress response can increase pain, affect your sleep and mood, and create a vicious pain, sleep, and mood cycle.

Consider all how you can manage stress as you work to keep your RA in check. Your stress management plan might include meditation, exercise, talking to a friend or a mental health professional, and finding ways to exercise self-care (i.e., getting plenty of rest, pacing yourself, taking breaks, etc.).

 Do Not Smoke

Some people with RA smoke, sometimes as a way to manage stress. However, studies have shown that smoking can worsen RA and reduce the effects of medications used to treat the condition.

Chang K, Yang SM, Kim SH, Han KH, Park SJ, Shin JI. Smoking and rheumatoid arthritis. Int J Mol Sci. 2014;15(12):22279-22295. doi:10.3390/ijms151222279

 RA is also a risk factor for heart disease, and smoking can further increase your risk.

If you are having a hard time quitting, let your healthcare provider know. They can give you information about programs and products to help you quit.

Complementary and Alternative Medicine (CAM)

CAM therapies are non-traditional therapies typically used in addition to your RA treatments. CAM therapies can offer pain relief and symptom improvement.  

Your CAM options for managing RA might include:

• Acupuncture
• Massage
• Mind-body practices (i.e., meditation, relaxation techniques, tai chi, yoga, etc.)
• Ayurvedic medicine: A combination of products (mainly derived from plants), diet, exercise, and lifestyle to manage a health condition
• Supplements and herbal remedies (i.e., fish oil, turmeric, Boswellia)

If you want to try any of these CAM therapies to manage RA symptoms and pain, ask your healthcare provider which might help you and if these therapies are safe for you to try. Some herbs and supplements can interact with medications you are taking.

Rheumatoid Arthritis Medication List 

The target-to-treat approach for RA is backed by good evidence. With this approach, healthcare providers decide on a goal and adjust medications and other treatments until the goal is achieved. This approach aims to achieve remission or low disease activity in which symptoms are managed and quality of life is maintained.

Medication options are numerous for treating RA. They include over-the-counter (OTC) and prescription pain relievers, corticosteroids, non-biologic DMARDs, biologic DMARDs, and JAK inhibitors. Your healthcare provider can recommend the best options for managing RA.

OTC Pain Relief

Most healthcare providers recommend NSAIDs for reducing RA pain and inflammation. These are sold over the counter (without a prescription) under different brand names, including Advil and Motrin (ibuprofen) and Aleve (naproxen). Tylenol (acetaminophen) can help with mild joint pain but does not reduce inflammation.

You can also use OTC topical pain relievers to manage RA pain. These are applied over painful joint areas and will have fewer side effects than oral pain relievers. These fall into a few general categories—salicylates, NSAIDs, lidocaine, menthol/camphor, capsaicin, and newer cannabidiol (CBD) options.

Always follow the manufacturer's instructions for safe and effective use. Inform your healthcare provider if you experience side effects, including skin irritation.

Prescription Pain Relief

Your healthcare provider can prescribe more potent versions of oral OTC pain relievers. They can also prescribe others unavailable over the counter, such as Celebrex (celecoxib) and Mobic (meloxicam), and prescription-strength topical pain relievers, including Pennsaid (2% diclofenac) and lidocaine patches. A less-potent version of diclofenac, sold under brand names such as Voltaren, is available without a prescription. 

Corticosteroids 

Corticosteroids like betamethasone, cortisone, methylprednisolone, and prednisone can help reduce inflammation in RA. They are available as oral medicines and injections. These drugs might also reduce pain and damage from inflammation. 

These medicines are typically not recommended for long-term use. They are known for causing severe side effects, including stomach ulcers, high blood sugar, high blood pressure, mood changes, eye problems, and osteoporosis.

Non-Biologic DMARDs

DMARDs can decrease inflammation by slowing down the progression of RA. When the disease processes are slowed down, you will experience fewer symptoms and less damage over time.

Some of the most common non-biologic DMARDs used to treat RA are:

• Arava (leflunomide) 
• Azulfidine (sulfasalazine)
• Plaquenil (hydroxychloroquine)
• Rheumatrex, Trexall (methotrexate)

Biologic DMARDs

Biologics, another type of DMARDs, target specific molecules that lead to inflammation. These drugs work much quicker than non-biologic ones and might have fewer side effects.

Biologics are given as injections and infusion treatments. Biologic DMARD classes include tumour necrosis factor (TNF), B-cell, T-cell, and interleukin-6 (IL-6) inhibitors.

Some of the most common biologic DMARDs used to treat RA are:

• B-cell inhibitor: Rituxan (rituximab)
• IL-6 inhibitors: Actemra (tocilizumab) and Kevzara (sarilumab)
• T-cell inhibitor: Orencia (abatacept)
• TNF inhibitors: Humira (adalimumab), Cimzia (certolizumab pegol), Enbrel (etanercept), Remicade (infliximab), Simponi (golimumab)

JAK Inhibitors 

Your healthcare provider may prescribe a JAK inhibitor when non-biologic and biologic DMARDs aren't helping to manage RA symptoms. These medicines can affect genes and the activity of immune cells to prevent inflammation and stop joint and tissue damage.

Currently, three JAK inhibitors are available to treat RA. These include:

• Olumiant (baricitinib)
• Rinvoq (upadacitinib)
• Xeljanz, Xeljanz XR (tofacitinib)
  

Managing RA While Pregnant

It is possible to continue treating RA during pregnancy. About 50% of pregnant people with RA will experience remission during pregnancy. Only 20% will experience worsening disease activity during pregnancy and will need medication adjustments. The remaining number of pregnant people with RA will have unchanged disease. 

Some RA medications should not be taken before pregnancy, during pregnancy, and if breastfeeding. 

These include:

• Acetaminophen 
• Corticosteroids 
• NSAIDs
• JAK inhibitors 
• Leflunomide
• Methotrexate 

Some medications might be safer for you to take before pregnancy, during, and after, and may include:

• Some biologics, including some TNF inhibitors. 
• Hydroxychloroquine
• Sulfasalazine 

Your healthcare provider will monitor your RA progression during pregnancy. As symptoms and function improve, your provider will adjust medicines or recommend nondrug options for managing disease symptoms. 

RA Treatment Effectiveness 

Guidelines for treating RA come from the ACR and get updated every few years. Updates usually occur as new treatments are released, older drugs are reassessed, and new evidence emerges regarding nondrug treatments.

Many medications used to treat RA are potent and can produce side effects, but are used because the evidence suggests that the benefits outweigh the risks.

Each person's treatment approaches for RA are tailored based on disease severity. Disease severity is typically classified from mild to moderate, severe, and end-stage. 

Early to Moderate RA

In stage 1, or early RA, you will experience the earliest symptoms of RA, including morning stiffness and pain in the small joints of the hands and feet. Symptoms during this stage are subtle, which may make it harder for a healthcare provider to make a diagnosis.

If you are diagnosed early on and start treating the condition, there is a better chance of disease remission. Treatment options in early RA include NSAIDs, methotrexate, other non-biologic DMARDs, and low-dose steroids.

In stage 2, or moderate RA, inflammation of the joint linings may cause damage, and you will experience pain and limited motion in affected joints. Inflammation may affect other body tissues, especially the skin and eyes.

Most people get a diagnosis during stage 2, and treatment can reduce further damage and get symptoms under control. Your healthcare provider may add a biologic drug or JAK inhibitor to your treatment plan at this stage. 

Severe RA

By the time RA progresses to stage 3, it is considered severe. There might be more pain and swelling. Some people may also have muscle weakness, mobility loss, and bone and joint damage. If biologics and JAK inhibitors fail to manage symptoms, your healthcare provider will recommend another biologic or a different class biologic.

Stage 4, or end-stage RA means that affected joints no longer work, and symptoms include severe pain, swelling, stiffness, and loss of function. Progression to the stage can take years or decades, and most people who treat RA effectively never make it to stage 4.

Surgery is a last-resort treatment for RA that has damaged joints and limited mobility. Common RA surgeries are joint replacement surgery, joint fusion, and tendon surgery.

Does RA Progression Affect Life Expectancy? 

RA is generally not a fatal condition, but disease progression and complications of the condition might affect life expectancy. Mortality risk in people with RA can increase over time and seems to peak 20 years after diagnosis. Respiratory conditions and cardiovascular diseases are significant risk factors for premature death.

Fortunately, newer, more aggressive RA treatments have reduced such complications and increased the potential for disease remission, which means people with RA are living longer.

Integrated Approaches to RA Treatment 

Treatments and outcomes for RA have significantly advanced over the past couple of decades. In addition, earlier diagnoses, better treatment approaches like target-to-treat, and improvements in DMARDs have allowed people with RA to live with less pain, fatigue, and disability. 

RA medications work best with integrative therapies (psychotherapy approaches), including mind and body therapies, talk therapy, and cognitive behavioural therapy. Some CAM and nondrug therapies, including acupuncture, exercise, and diet, are also considered integrated therapies.

If you want to try integrated therapies to manage RA better, talk to your healthcare provider. They can make recommendations based on your unique health situation. 

How to Manage RA During Flares

People with RA have periods in which the disease flares up, and inflammation levels and disease activity are high. The most common symptoms of a flare-up are severe joint pain, swelling, stiffness, and fatigue. A flare-up can last for a few days, or it can last for weeks or months.

Specific events can trigger RA flares. Triggers include diet, stress, illness or infection, weather changes, overdoing activities, missing medicine doses, and smoking. You can reduce flare frequency by avoiding triggers.

Resting is OK if you feel you need extra sleep during a flare. But you will still want to try to move your joints. Consider activities that are easy on the joints, such as stretching and walking.

Keep stress levels down while recovering. Try massage, warm baths, and OTC oral and topical pain relievers to manage pain and reduce inflammation. Try to make healthy food choices by avoiding inflammation-producing foods and adding anti-inflammatory options to your diet.

Contact your healthcare provider if your flare-up lasts longer than a few days or worsens. They can prescribe a corticosteroid or other treatments to quickly reduce inflammation and manage symptoms, including pain.

RA Treatment Advancements 

RA is a chronic condition without a cure. Fortunately, you have plenty of options for treating it, and therapies for treating RA continue to increase. As researchers develop and improve treatments, your healthcare provider might change your treatment plan to manage your disease better. 

Some of the newest treatment options available and in testing include:

• Biosimilars: These drugs are very close in structure and function to biological drugs. Biosimilars offer a more affordable option for some people with RA.
• IL-inhibitors: These agents inhibit the action of interleukins, which are proteins that promote inflammation.
• Targeted synthetic DMARDs, including JAK inhibitors, target specific parts of the immune system to halt inflammation and inflammatory processes.

Talk to your healthcare provider to learn more about the latest available treatment options. They can share all the potential benefits and risks of changes to your treatment plan. They can also recommend lifestyle changes and the best ways to improve your outcomes. 

Summary 

Rheumatoid arthritis is a chronic disease without a cure. Fortunately, the condition is treatable and manageable. Treating RA aims to achieve the lowest possible disease activity or remission, minimize joint damage, and improve function and quality of life. 

Treating RA involves an integrated approach that includes nondrug and drug options. Non-drug options for RA include physical and occupational therapies, lifestyle changes, and CAM therapies.

Drug treatment options include OTC and prescription pain relievers, non-biologic DMARDs, biologic DMARDs, corticosteroids, and JAK inhibitors. Surgery is considered a last resort treatment for managing severe RA in which joint damage and loss of function have occurred. 

You will need to take medications to treat RA for the rest of your life. You must also manage disease flare-us to avoid joint damage and worsening symptoms. Manage flares with rest, some activity, diet, and corticosteroids. 

Your healthcare provider can recommend treatment options based on your disease status and overall health. They can advise you on each treatment option's potential benefits and risks. They can also recommend lifestyle changes to help improve treatment outcomes.  

https://www.verywellhealth.com/rheumatoid-arthritis-treatment-8400843