Rheumatoid arthritis (RA) is a disabling condition affecting 0.5% – 1.0% of the population in Northern Europe and America, with a lower number of people in other parts of world. Therapies aim to slow progression of the disease (with disease-modifying antirheumatic drugs or DMARDs) and treat the symptoms.
Summary of treatments
This video highlights the common treatments of RA and how to recognise it.
David Scott, Consultant Rheumatologist at Norfolk & Norwich University Hospital and Honorary Professor at the University of East Anglia, discusses signs and treatment of rheumatoid arthritis
The main symptoms of RA are pain and stiffness, especially after resting joints or in the morning, misshapen joints (see photo) and swelling, which can make certain activities difficult and may affect your ability to do your job. It often starts with the hands and can affect any joint.
Opening pill caps becomes more problematic as joints change in shape
Painkillers that are good for RA include aspirin, which is a non-steroidal anti-inflammatory drug (NSAID), and paracetamol (acetaminophen). Other NSAIDs include etoricoxib (a COX-2 inhibitor), ibuprofen and naproxen. If you have RA, you may also need stronger drugs such as codeine or tramadol, which are related to morphine.
These type of drugs are good for pain and stiffness but don’t slow down RA. They also have certain side effects, including kidney damage and stomach ulcers with NSAIDs, and constipation, nausea and drowsiness with the stronger morphine-based painkillers. It is recommended to take NSAIDs with a stomach-protecting drug, usually a proton-pump inhibitor (PPI).
Steroid injections can also be used to treat RA as they are anti-inflammatory. If you get a flare-up of symptoms which is not helped by an NSAID, your healthcare team may consider this treatment. For a few weeks, they are unlikely to produce many side effects. In the longer term, you may develop osteoporosis, frequent infections or muscle wasting.
In contrast, DMARDS can slow RA progression. They are recommended to be started as soon as possible to prevent further damage to joints. The “first line” is normally methotrexate. Others include gold injection, leflunomide, hydroxychloroquine, minocycline and sulfasalazine. DMARDs can take up to 6 months to show an effect.
Most people find they can manage the numerous possible side effects that these drugs have. They include nausea, diarrhoea, mouth ulcers, hair loss or thinning and skin rashes. Because they affect your immune system, you may also be more susceptible to infections and should check with your health care team about whether you need vaccinations.
In a small number of patients, methotrexate can cause a drop in your blood count. If you develop shortness of breath or a cough, please tell your doctor, as it can occasionally cause fibrosis of the lungs and you may need to change your treatment.
Newer drugs called biologics are also available. They use antibodies to inhibit the immune system and combat the inflammation in RA, thus also slowing down or even halting the disease altogether. They are more effective than DMARDs, and work more quickly, but are also more expensive. Examples are the TNF-a (tumour necrosis factor a, part of the immune system) inhibitors etanercept, abatacept, infliximab, adalimumab and certolizumab. Others include rituximab and tocilizumab.
The side effects include skin reactions (as they are given by injection), nausea, fever, headaches and infection. If you have had TB, blood poisoning or hepatitis B in the past, there is a small risk they can reactivate these diseases. However, most people tolerate these drugs very well.
Treating related symptoms
RA is a multisystem disease that can affect many organs in the body. For instance, you may become anaemic and require iron tablets. You may also develop problems with your liver, eyes or lungs, which should be investigated and treated as necessary. People with RA also have an increased risk of atrial fibrillation, an irregular heartbeat. If you have this, it may need treatment with anti-clotting drugs such as warfarin or aspirin to reduce your risk of stroke. Some patients also suffer from carpal tunnel syndrome due to the inflammation around the wrist. This can be treated with surgery.
Physiotherapy and complementary medicine
Having physiotherapy can help you to work with the pain and stiffness of RA to achieve what you want to achieve. Studies looking at the use of physiotherapy in RA guidelines have recommended treatments such as transcutaneous electrical nerve stimulation (TENS) and thermotherapy. Others include US, thermotherapy, low-level laser therapy, massage, passive mobilization and balneotherapy (spa therapy). Some of these will be discussed in later articles.
You many also need modifications to your environment and tools in order to continue carrying out your daily activities. Occupational therapists can provide you with materials such as padded fork and knife handles, training on energy conservation, joint splints and motor skills training.
What you can do
If you have RA, you can manage your condition by making sure you are receiving appropriate treatment and avoiding anything that might cause flare-ups. Moderate exercise is usually beneficial. Some people find that changing their diet also helps. Take good care of your teeth and gums, as gum inflammation can cause exacerbation of RA.
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