Painful, tender joints can make even the simplest activities difficult for those with this inflammatory disease. Recently, pharmaceutical breakthroughs have revolutionized rheumatoid arthritis treatment, enabling many to again lead active and productive lives.
What is rheumatoid arthritis?
In healthy joints, the surfaces of bones and the cartilage that cushions them glide smoothly against one another, allowing easy, pain-free movement. But for those with rheumatoid arthritis (RA), the cartilage becomes inflamed and breaks down, causing pain, stiffness, and swelling. If the disease progresses, bones and ligaments can permanently wear away. The heart, lungs, muscles, and skin can become damaged. There’s an increased risk for blood or lymph cancers.
Unlike the simple joint wear and tear of osteoarthritis, rheumatoid arthritis arises from an immune system gone awry, which mistakenly attacks healthy joint tissue. Nobody knows what triggers this. Scientists speculate it may be the result of an infection, perhaps combined with genetic factors that make you susceptible to the disease. During a rheumatoid arthritis flare-up, white blood cells collect in your joints and mount an inflammatory attack, secreting substances called cytokines that join the battle. One form of cytokine is a destructive protein called tumour necrosis factor (TNF); another is interleukin-1. In response, cells in the besieged joint release defensive chemicals called prostaglandins. They cause the joint to become red, sore, and swollen. This is the basic inflammatory process, although some forms of RA are milder than others.
Treatment for rheumatoid arthritis
The most important aspect of rheumatoid arthritis treatment is stopping the joint inflammation. The past decade has seen dramatic changes: New medications can now halt inflammation and progression of disease. Self-care measures are also important, and selected surgical and nonsurgical treatments may be helpful for advanced disease. There are so many options to choose from, so talk with your doctor about which ones may be right for you. While none is a cure, some may offer long-term relief.
The least aggressive medicines, such as aspirin, have traditionally been used first. If they didn’t work, progressively stronger medications—with more severe side effects—were tried. Now doctors start with aggressive therapies to quell inflammation and halt the disease at an early stage, before damage is severe. Such treatment may be particularly beneficial for those with more serious rheumatoid arthritis. Just remember: You will have “good days” and “bad days” and even long periods when the condition seems to quiet down altogether.
Medications for rheumatoid arthritis
Many new drugs for rheumatoid arthritis have become available in recent years. The key is to find the right one for you. A simple pain reliever, such as aspirin or another OTC or prescription nonsteroidal anti-inflammatory drug (NSAID), such as naproxen, ibuprofen, or indomethacin, often provides prompt relief. NSAIDs are available as pills and in pain-relieving creams. A newer class of NSAID called COX-2 inhibitors modulate inflammation-causing prostaglandins and may cause fewer side effects. COX-2s include celecoxib (Celebrex) and valdecoxib (Bextra). If NSAIDs are not strong enough to control the inflammation, you may need more potent drugs.
Although they may have serious side effects, some of the best drugs to control rheumatoid inflammation fast are powerful anti-inflammatory oral corticosteroids. One way to minimize the side effects of prednisone, a commonly prescribed steroid, is to take it when your body naturally produces it—early in the morning, between 5 am and 7 am. Steroids may also be injected directly into joints for relief of rheumatoid arthritis flare-ups. This practice should be minimized because it may ultimately damage joints.
Stronger disease-fighting drugs are often started quickly to protect joints and organs from long-term damage. These medicines are called DMARDs, or disease-modifying anti-rheumatic drugs. Most commonly prescribed is methotrexate (Rheumatrex). Originally developed as a cancer drug, methotrexate in low doses eases pain and other symptoms by switching off underlying inflammation. Others include sulfasalazine (Azulfidine); injectable or oral gold; hydroxychloroquine (Plaquenil); penicillamine (Cuprimine, Depen); and the immune suppressant cyclosporine (Sandimmune, Neoral). Leflunomide (Arava) eases inflammation by blocking the action of the protein interleukin-1. Arava increases the risk of serum infections. DMARDs are sometimes given in combination.
You may also benefit from a new class of arthritis drugs called biologic response modifiers. When used early, they forestall progressive joint erosion. These include infliximab (Remicade), which is infused by IV every four to six weeks in a doctor’s office, etanercept (Enbrel), which you can learn to self-inject twice a week at home, and adalimumab (Humira). All these block the inflammatory cytokine tumor necrosis factor (TNF) and are sometimes called TNF blockers. Another biologic response modifier called anikinra (Kineret) may also help. In tests, patients felt better after taking these drugs. Some had complete relief of certain symptoms. Using these drugs with methotrexate or other DMARDs may be even more effective. For very severe rheumatoid arthritis flare-ups and recurrences, powerful immunosuppressants, such as azathioprine (Imuran), chlorambucil (Leukeran), or cyclophosphamide (Cytoxan), may be given. These medications suppress the overall immune system but can be very toxic.
With any of these drugs, you may feel better after several weeks, but treatment is usually continued long-term. Your dose may be reduced over time, or you may be given new drug combinations.
Despite the seriousness of rheumatoid arthritis, you can take certain steps to help yourself feel better.
- Low-impact exercise may have benefits. Try walking, cycling, or learn the slow, graceful movements of tai chi.
- Spa therapy, with natural hot spring water, has long been used to relieve rheumatic complaints. Research confirms that warm-water exercise programs can be beneficial; optimal water temperature is 83° to 88°F. Gentle massage performed by a professional can also relax muscles and maintain flexibility.
- Melted paraffin baths can be effective in easing hand stiffness and pain, especially prevalent early in the morning. Paraffin bath kits, available commercially, make the procedure easier.
- Plenty of rest is necessary, particularly during flare-ups, to preserve energy and optimize your ability to cope.
- A diet rich in fruits and vegetables that contain the antioxidant vitamins C and E may protect the joints from damage (although no foods can cure rheumatoid arthritis). Zinc, found in meats, eggs, dairy, seafood, and nuts, also has antioxidant properties.
Related Procedures for Rheumatoid Arthritis
A novel blood-filtration procedure called prosorba (protein-A immunoadsorption) therapy may benefit those who have not responded to medications for rheumatoid arthritis. Blood is drawn from one arm, filtered through a special cylinder that pulls out inflammatory substances, then returned through your other arm. Sessions are once a week for 12 weeks. You should start feeling better soon after your last treatment, and benefits may continue for a year and a half. Only if deterioration is severe will surgical procedures, such as hip, knee, or finger joint replacement, be necessary.
Alternative Therapies for Rheumatoid Arthritis
Evening primrose oil (1,000 mg three times a day) has anti-inflammatory properties that may soothe sore joints. Boswellia (150 mg three times a day) has long been used in India to reduce inflammation. Cayenne creams with capsaicin can be applied to affected joints three or four times a day. A food elimination diet, to identify the foods that trigger your rheumatoid arthritis symptoms, is advocated by nutritionally-oriented physicians to curb painful symptoms.
Questions for Your Doctor
- What type of rheumatoid arthritis do I have—mild or severe? Are my symptoms likely to keep getting worse?
- How long will I need to stay on medications?
- Will changing my diet help?
- Can I get pregnant while being treated?
- Are all my symptoms related to my illness, or are some a side effect of the medications I’m taking?
- Do I need to go on disability?
- Will I need joint replacement surgery?
Living with Rheumatoid Arthritis
If you're living with Rheumatoid Arthritis, here are a few quick tips to help you take control:
- Assemble a medical team. A rheumatologist (a physician who specializes in arthritis) may be particularly valuable in tailoring a state-of-the-art treatment program that’s right for you. You also need a primary care physician to monitor your overall health, a physical therapist to help keep your joints flexible, and an occupational therapist to offer tips on making the most of your life at home or at work.
- Be careful about drug combos. Don’t take prednisone and an NSAID together—this can increase your risk of developing a stomach ulcer.
- Start treatment early. A study in the Journal of Rheumatology found that those with early rheumatoid arthritis who delayed treatment by nine months continued to feel worse (even three years later) than those who began therapy promptly. Early treatment is key to reducing damage and the need for more costly treatments, including surgery.
- If you smoke, quit. Studies show that smoking can make rheumatoid arthritis symptoms worse. If you undergo joint replacement surgery, smoking can prolong your recovery.
Adapted from Knowing Your Options: The Definitive Guide to Choosing The Medical Treatments, Reader's