Let's Talk About Rheumatoid Arthritis Treatment
RA may be a lifelong illness, but with early diagnosis and treatment, it doesn't have to be your life. by Jerilyn Covert Health Writer
There’s no cure for rheumatoid arthritis, but don't let that get you down. There are more effective medications than ever before. In fact, early and aggressive treatment can slow down the progression of RA, prevent permanent joint damage, and even lead to remission. Yep, we said remission. Even better, if you can get symptoms under control within six months to a year, chances are the disease will have minimal impact on your life. Back up your meds with plenty of (low-impact) exercise, a diet packed with inflammation-fighting foods, and healthy sleep and stress-management strategies, and you'll be well on your way to living life on your terms. We know: easier said than done, but working with a rheumatologist will help find the right therapies for you. Fortunately, you’ve got many options.
Our Pro Panel
We went to some of the nation’s top RA experts to bring you the most scientific and up-to-date information possible.
Nilanjana Bose, M.D.
Rheumatology Center of Houston
Iris Navarro-Millan, M.D.
Rheumatologist and an NIH-funded RA clinical researcher
Hospital for Special Surgery
New York, NY
Janelle Laughlin, M.D.
University of Colorado Health Longmont Clinic
A doctor who’s specially trained in diagnosing and treating RA and other “rheumatic diseases” (musculoskeletal diseases and systemic autoimmune disorders). To see one, you typically need a referral, either from your primary care doc or another physician. For those dealing with RA, having a rheumatologist is a must.
Children diagnosed with juvenile idiopathic arthritis (JIA), the most common kind of arthritis in children, may be prescribed the same types of medications as adults are for RA, though some biologics are not recommended for use in children. The best treatment approach includes a multidisciplinary health-care team, consisting of parents, teachers, a pediatric rheumatologist, an ophthalmologist, and physical and occupational therapists.
Not at all. Many people think exercise must be frequent and intense to be effective. But really, any amount of exercise is better than none—and if you’re a beginner at exercise, you should start slow, with one or two workouts a week, and consider working with a physical therapist, too.
So far, sustained remission does not seem possible without pharmacological intervention. Exercise and healthy eating may help you feel better, but medication is needed to manage the disease.
What is Rheumatoid Arthritis Again?
Let's refresh: Rheumatoid arthritis is an autoimmune disease, which means the immune system turns its sights on healthy tissue in the body, causing inflammation.
This form of arthritis targets the synovial membrane, the tissue that lines joints. Typically, this lining is thin and delicate, and it produces a clear fluid that allows the joint to move freely. But when the membrane becomes inflamed, the fluid gets thick and begins builds up, putting painful pressure on the surrounding nerves. When that happens, pain, stiffness, and even redness can occur. That inflammation literally heats up the joint, making it feel warm.
But RA isn't only a disease of the joints. It's a systemic illness that can impact your heart, lungs, eyes, and more. Which is exactly why prompt treatment is so important.
What Is the Goal of Rheumatoid Arthritis Treatment?
The goal of treatment is pretty simple: to keep you moving in all the ways you need to. That means reducing—and ideally stopping—the pain and inflammation of RA. The ultimate target is what doctors call remission, or no disease activity. Still, low-disease activity—like a little stiffness in the morning from time to time, instead of extreme stiffness every day—is also a reasonable goal.
What is the Treat-to-Target Approach?
If you’ve ever set a huge goal for yourself, then you know you had to plan your steps to reach it—and prepare for a little trial and error along the way. That pretty much sums up the “treat to target" (T2T) strategy, which has remission (or at least low-disease activity) as its goal. The approach: Docs put newly diagnosed patients on meds right away, closely monitor progress, and adjust the scripts and doses frequently until they’ve hit that goal.
It’s a much more aggressive approach than doctors took decades ago, when there was less monitoring, more cautious treatment, and—no surprise here—a lower standard of success. Treat-to-target is now the go-to for RA treatment, and it’s helping patients live longer, healthier lives.
One study suggests T2T may improve your chances of remission by 50%. The reason: Shooting for a specific target seems to encourage doctors to change up therapies as they need to, leading to better outcomes. It makes sense: When the goal is remission, you’re more likely to achieve it.
The Importance of Early Intervention
Still, the treat-to-target strategy works best the sooner you catch RA—ideally within three to six months of the first signs of disease. Diagnose and treat early, according to the research, and you’re more likely to have a better long-term outcome. RA that’s left untreated, however, can lead to permanent joint damage within as little as two years. And because RA’s a systemic disease that can affect anywhere in the body, it can also lead to serious health complications like a weakened immune system, lung problems, and heart disease.
Luckily, doctors have grown better at spotting and treating RA. If you haven’t been diagnosed with RA but you’re concerned (for example, maybe you have a family history of RA), watch out for symptoms: pain, swelling, or stiffness in the morning in the small joints of the hands and feet that lasts longer than 30 minutes. Bottom line: If you suspect something, don’t put off calling your doctor.
What are the Medications for Rheumatoid Arthritis?
Medication is the cornerstone of RA treatment. And these days, you have more options to choose from, making it easier to find the best treatment that works for you.
Five types of drugs are commonly used to treat RA. Here they are, listed in the order in which they’re often typically prescribed:
Traditional DMARDs: These “disease-modifying anti-rheumatic drugs” are the first-line therapy for most RA patients. Traditional DMARDs not only relieve symptoms—they slow RA’s progression, doing their job of “down-regulating” (suppressing) the body’s overactive immune system. You can take any of them orally, and methotrexate is also available as an injection. Due to their immune-suppressing nature, DMARDs can come with side effects, like mouth sores, hair loss, stomach upset, infection, fatigue, or liver damage. Those side effects are why you’ll be closely monitored with regular lab tests, weekly to every few months. The most common DMARDs include:
NSAIDS: Because DMARDs can take weeks or months to build up to therapeutic levels in your system, your doctor may prescribe nonsteroidal anti-inflammatory drugs in the meantime to help ease pain and inflammation. Sure, you can find them over-the-counter, but for RA symptoms you may need a prescription-level dose (or about twice what you’ll find in OTC versions). The benefits of NSAIDs, or nonsteroidal anti-inflammatory drugs, are that they work fast, relieving pain within just hours. Still, established side effects (stomach upset and bleeding, impaired kidney function, and increased heart disease risk) make these meds a short-term fix only. Common NSAIDs include:
Bufferin, Bayer (aspirin)
Advil, Motrin (ibuprofen)
Celebrex (celecoxib) (COX-2 inhibitor), a subclass of NSAIDs that have a lower risk of internal bleeding or stomach ulcers—a common side effect of other NSAIDs that are used in large doses for a long time.
Corticosteroids: These steroid hormones are another short-term option you can use while waiting for DMARDs to kick in. Your doc might also use corticosteroids to treat severe flare-ups, or in more advanced cases in combination with other drugs. They can be taken orally, intravenously, or injected right into the joint. The most common is Deltasone (prednisone). Steroids can have serious side effects with long-term use (anything longer than 8 to 12 weeks), including high blood sugar, high blood pressure, bone loss, and glaucoma. When you’re ready to come off them, you’ll need to do so slowly over a few weeks (called a steroid taper), while your adrenal glands return to their role of pumping natural cortisone on their own. Steroids can have serious dose-dependent side effects. Infection can be a side effect but it might be okay to leave out as most patients are on lower-doses of steroids.
Biologic DMARDs: If you don’t reach low-disease activity on traditional DMARD therapy alone, your doc may introduce a biologic agent. Biologics have been a total game changer for RA treatment since they first came on the scene two decades ago. Genetically engineered from living cells, biologics, also known as biologic-response modifiers, take a super-targeted approach: They zero in on specific proteins that fuel inflammation, instead of affecting your entire immune system. Like any drug, they can have side effects, including headache, nausea, and an increased risk of infection since they suppress your immune response. The available biologics are:
Tumor-necrosis factor (TNF) inhibitors put the brakes on tumor-necrosis factor, a protein that’s overproduced in people with RA and the main cause of the first inflammation. TNF-inhibitors are delivered by self-injection or IV infusion, depending on the drug, which include:
B-cell inhibitors, like Rituxan (rituximab), are administered through an IV and kill B-lymphocytes that can spark inflammation.
Interleukin-1 (IL) blockers, like Kineret (anakinra), are self-injected daily; they target interleukin-1, an inflammatory compound in the body.
Interleukin-6 inhibitors, such as self-injected Kevzara (sarilumab) and IV-administered Actemra (tocilizumab), also available as self-administered, stop interleukin-6 proteins from attaching to cells and triggering inflammation.
T-Cell inhibitors, like Orencia (abatacept), latch on to the surface of T-cells (aka inflammation-causing white blood cells). It’s administered via IV.
Janus kinase (JAK) inhibitors: These newer synthetic drugs (also called targeted DMARDs) are another powerful option for treating RA when biologics fail, or if you just hate needles and prefer to pop a pill instead. They’re highly targeted, blocking precise pathways inside immune cells. They’re potent and they act fast, but they can be expensive. DMARDs are used with biologics. Only a minority of patients achieve remission from DMARDs alone, in which case rheumatologists will generally add another medicine (another DMARD of a biologic) instead of discontinuing the first one. Medications used in combination is the norm and very common in rheumatoid arthritis. So far, three are approved for clinical use:
It can take a few tries to find the right meds (you need to give each one at least a few months to kick in), and once you do, you’ll likely be on the drugs indefinitely, though your doc might tweak adjustments depending on your symptoms.
Best-case scenario: You can enjoy months and even years of sustained remission, which can blissfully feel like your RA has packed it up and gone away. However, those periods can be interrupted by flares, periods of increased disease activity that can show up without warning like an unwelcome guest. Depending on the severity of a flare, your doc may decide to switch up your meds.
If you’ve sustained remission long enough, your doctor may de-escalate medications, supervising slowly, tapering one at a time to see how the disease reacts. But few patients can stop drugs altogether without their symptoms returning. About 10% of patients diagnosed early—and diligently treated—achieve remission in the first year, and 40% achieve it after two years.
Managing Rheumatoid Arthritis Flares
Flares can last days or even months, and vary in severity. You may be extra tired, have joint stiffness and swelling, feel like you have the flu, or you may have serious pain to manage.
While severe flare-ups may be treated with a corticosteroid, you can usually manage more mild flares on your own. If you’re one of those people who can sense when a flare is coming, you might learn to pinpoint the things that trigger them in the first place.
Common culprits include:
Infections (cold and flu)
Physical trauma like surgery or broken bones
Giving birth (flares after childbirth are common)
Poor dental health
Certain foods (like processed snacks, red meat, and high-sugar foods)
Sudden dramatic changes in weather
If you sense a flare coming on, do whatever you can to carve out extra time to rest. You body can't heal without it!
When is Surgery Required for RA?
Surgery is reserved for RA patients who’ve suffered permanent joint damage leading to debilitating pain or loss of function. Nowadays, that typically only happens with very severe or undertreated cases.
There are two surgery types:
Synovectomy: This surgery removes the inflamed synovial membrane. It may be considered if the pain persists after six to 12 months of treatment. A synovectomy can be performed in the ankle, knee, hip, elbow, shoulder, wrist, or finger. Recovery varies depending on which joint was operated on, but physical therapy usually starts in a day or two.
Arthroplasty: For more significant joint damage, this surgery may reconstruct or replace the joint. Bones can be reshaped or replaced with metal, ceramic, or plastic parts. More than a million joint replacement surgeries are performed each year in the U.S., mostly of the hip or knee, but the shoulders, elbows, and rarely the joints in the hands and feet may be replaced as well. It’s critical to discuss with your surgeon the types of activities you want to continue after joint replacement. This will help your doctor select the appropriate type of prosthesis and implantation technique, while giving you a deeper dive into the risks and limitations of surgery, which can include infection, blood clots, or loosening of the joint.
Other Therapies for RA
Taking your medication is just one thing you can do to help you feel your best. Consider assembling a team of medical specialists (your rheum can refer you) from a variety of fields, like psychiatry, sleep medicine, physical or occupational therapy, or nutrition, who can support you wherever you may need it. Areas they can help with:
Exercise: When you’re in pain, the gym is probably the last place you want to be. But keep an open mind: Research shows that adopting a regular exercise routine can help you feel better. In RA patients specifically, exercise has been shown to reduce pain, boost strength, and improve function. Not only that—exercise can also increase energy and ease depression, and help prevent heart disease and diabetes (both common with RA). Not used to exercise? Consider working with a physical therapist, who can help come up with a safe, effective plan for you. Doctors recommend joint-friendly activities like cycling, elliptical training, and water aerobics. And don’t forget resistance training, key for maintaining muscle strength and bone density. Having a flare? Listen to your body. Don’t be afraid to back off or take more frequent breaks during your session. After all, any amount of exercise is better than none.
Sleep: As an RA patient, your sleep is critical—it eases pain sensitivity, keeps stress hormones in check, and lets the brain clear out inflammatory chemicals so you can function better the next day. Plus, RA-related inflammation tends to deplete energy levels, so a solid eight hours of sleep is crucial. The problem? Given how uncomfortable RA is, more than half of people with the condition have trouble sleeping. And some medications, like steroids and Plaquenil, may cause insomnia. Prioritize your sleep by following standard sleep hygiene advice: Dedicate some time in the late evening to relax, and power down your phone at least 30 minutes before bed. Try using pillows for extra support where you need them (like under a painful shoulder or between stacked knees). And consider working with a sleep specialist for extra help. Finally, talk to your rheumatologist if you suspect your meds are keeping you up or you have trouble sleeping due to pain.
Diet: Most evidence about the role of diet with RA is anecdotal, but some studies suggest certain foods may be helpful. In particular, the Mediterranean diet, which emphasizes fish, olive oil, and vegetables, has been shown to have some positive impact on inflammation, likely due to the omega-3 fatty acids found in some fish, like albacore tuna, herring, lake trout, mackerel, and salmon. Several smaller studies tout the helpful impact of a vegan or vegetarian diet on RA. A healthy diet can also help keep your weight in check, helping RA treatments work better and reducing pressure on achy joints. Still, changing the diet you’ve enjoyed over a lifetime isn’t easy, and you wouldn’t be the first RA patient to struggle with changing it. But you don’t need to become the model of perfect nutrition overnight: Start with small changes that you can sustain over time (like working in a serving of fish each week, and building up to two), and consider working with a registered dietitian for help.
Mental health/stress management: We don’t need to tell you that anxiety and depression can make pain worse. Depression, despair, and denial can be huge hurdles to treatment. What’s more, many RA patients identify stress as a trigger for RA flare-ups—learning to manage it well can help. Try meditation, yoga nidra (a gentle, stress-relieving form of yoga perfect for people with chronic conditions like RA), or deep breathing. And if anxiety or depression is interfering with your life or your ability to function, don’t hesitate to seek help.
3 Simple Pain Relievers
Heat and cold: It’s so simple, but you might find a warm shower or bath works wonders on your stiff, painful joints. Heat reduces muscle tension and stimulates blood circulation, which may help joints feel better. Also try hot compresses or even slipping into a fresh-from-the-dryer hoodie. A cold compress, on the other hand, may help reduce inflammation, swelling, and soreness after RA flares.
Topical creams: Applying creams or lotions containing capsaicin (an extract from chili peppers!) may soothe minor joint pain. Ditto for those with camphor, menthol, or turpentine oil. Try capsaicin infused Capzasin HP Crème or J.R. Watkins White Cream Liniment, which has both camphor and turpentine oil. Topical pain relievers also available by prescription, such as Pennsaid.
Splints: Your rheumatologist may recommend splints for your trouble spots. During severe episodes, splints will help relieve pain by immobilizing your joints.
Are There Any Natural Remedies for Rheumatoid Arthritis?
Most natural remedies don’t have enough data to support definitive claims about their benefits. But some evidence suggests these two may be helpful:
Fish oil: Possibly the most thoroughly studied dietary therapy for RA, fish oil is a direct source of omega-3 fatty acids. Moderate-quality research shows that fish oil supplements may reduce RA-related pain. Omega-3s may interfere with the formation of inflammatory molecules called prostaglandins, which in excess may contribute to RA. Still, fish oil can irritate your gut and may interfere with blood clotting and increase stroke risk when taken with aspirin or other NSAIDs. Be sure to talk to your doctor before taking it.
Turmeric: The RA community is increasingly interested in the potential anti-inflammatory effects of this golden spice. Several small studies show that turmeric and its major ingredient (curcumin) may help treat arthritis symptoms just as effectively as pain medicines like ibuprofen. Try it in smoothies, soups, and curries—its health benefits may need more research, but its deliciousness is well documented.
Should I Take Any Supplements for RA?
Some people with RA may need more of certain vitamins and minerals. The best source is always food, but if you need a little extra help you might consider adding a supplement.
Some of the commonly recommended RA supplements include:
Folic acid: This synthetic form of vitamin B9 can help manage methotrexate side effects. In fact, a recent Cochrane Review found that just 1 mg of folic acid a day was enough to help patients taking the drug.
Vitamin C: Critical for immune function, vitamin C is important for anyone with a chronic disease who may be an increased risk for infection.
Vitamin D: Levels of D tend to be low in people with RA. Research suggests RA may make you less sensitive to the nutrient, increasing the need for supplementation. Look for vitamin D3, the most easily absorbed form.
Calcium: Because RA patients have an increased risk of osteoporosis, your doctor may recommend a calcium supplement, often in combination with vitamin D, which helps improve its absorption.
Vitamin B12: Proper levels of vitamin B12 (key for energy) may help combat fatigue, a common RA symptom.
Always talk to your doctor before starting any new supplement. She may order a blood test to check for deficiencies, and can recommend the proper dose for you.
- Pharmacological treatments for RA: Johns Hopkins Arthritis Center. (n.d.) “Rheumatoid arthritis treatment.” https://www.hopkinsarthritis.org/arthritis-info/rheumatoid-arthritis/ra-treatment
- Treat-to-Target approach: Arthritis Foundation. (n.d.) “Treat to Target Approach Improves RA Outcomes.” https://www.arthritis.org/about-arthritis/types/rheumatoid-arthritis/articles/treat-to-target-rheumatoid-arthritis.php
- Self-care therapies for RA: Arthritis Foundation. (n.d.) “Rheumatoid Arthritis Self-Care.” https://www.arthritis.org/about-arthritis/types/rheumatoid-arthritis/self-care.php
- Management and treatment of RA: Cleveland Clinic. (n.d.) “Rheumatoid Arthritis: Management and Treatment.” https://my.clevelandclinic.org/health/diseases/4924-rheumatoid-arthritis/management-and-treatment
- Fish oil: Nutrients. 2017. “Marine Oil Supplements for Arthritis Pain: A Systematic Review and Meta-Analysis of Randomized Trials.” https://doi.org/10.3390/nu9010042
- Turmeric: Journal of Medicinal Food. 2016. “Efficacy of Turmeric Extracts and Curcumin for Alleviating the Symptoms of Joint Arthritis: A Systematic Review and Meta-Analysis of Randomized Clinical Trials.” 10.1089/jmf.2016.3705