How Effective Is Your RA Treatment, Really?
Rheumatoid arthritis (RA) isn’t like an ear infection or a UTI where you dutifully take your recommended medicine and—poof!—you feel better. Nope.
RA is a long-term autoimmune disease with symptoms that ebb and flow, flare and retreat. It requires you to do the quiet, daily work of tuning in to your body to gauge whether your treatment is still working as it should. “The goal of RA treatment isn’t just to control symptoms and prevent joint damage,” says J. Eugene Huffstutter, M.D., a rheumatologist in Hixson, Tennessee. “It’s to improve your quality of life.” Use these tips to determine whether it’s time to adjust your meds.
Set Your Feel-better Expectations
How fast should you notice improvement from a drug treatment? Timelines vary. For instance:
- Corticosteroids and NSAIDs. You should feel better within hours. However, corticosteroids (a.k.a. glucocorticoids) and NSAIDs are only used for short-term relief.
- Traditional disease-modifying antirheumatic drugs (DMARDs). These slow or stop inflammation, but be mindful not to give up too soon. In fact, 41 percent of patients stopped oral Methotrexate (a DMARD) after three months, despite the fact that the drug doesn’t reach max concentration until six months.
- Biologics and JAK inhibitors. Biologics (genetically engineered DMARDs) and JAK inhibitors (a targeted DMARD) work within days or weeks.
Know That Tinkering Is the Norm
Methotrexate is one of the most popular and effective DMARD treatments prescribed today, but only 30 percent of patients achieve what’s dubbed an “adequate response” to their initial treatment. That doesn’t surprise Bruce Garner, M.D., a rheumatologist at NYU Langone Hospitals in New York City. “Everyone’s treatment needs tinkering,” he says. “And the vast majority of patients are not on one drug, but multiple drugs. Changing up your meds is not unusual and shouldn’t be discouraged.” If you’ve given your drug the recommended time to take effect and it’s still not working, discuss making adjustments with your doc.
Find out Your Score
The treat-to-target method of managing RA pain leads to better outcomes, says Dr. Huffstutter. “Here, your physician measures your disease activity at each visit with, essentially, a scorecard, such as the CDAI, Clinical Disease Activity Score, which counts how many joints are swollen or tender,” notes Dr. Huffstutter. “If you don’t achieve your desired score, then you and your doctor work together to make a change in therapy to improve your score.” CDAI is among the preferred methods of measuring disease activity by the American College of Rheumatology. Other methods that meet the criteria include DAS28-ESR/CRP, RAPID3, and SDAI.
Use the Buddy System
“I highly recommend bringing a close friend or a family member, especially one who lives with you, to your RA appointments,” says Dr. Garner. “Oftentimes, patients overplay or underplay how their treatment is going. Having a somewhat objective party with you can offer a clearer picture of how you’re doing.” Plus, two sets of ears—and two sets of questions—ensures you’ll get more out of your appointment.
Get Blood Work Done
Depending on the drug you’re on, specific blood tests and their frequency may vary, but often include:
- Full blood count (slightly low red blood cells or hemoglobin count is not uncommon in RA, but may indicate that you’re anemic)
- Blood chemistry, to monitor treatment effects on your kidney and liver
- Vectra test, a check of 12 proteins, hormones, and growth factors linked to RA
- ESR (erythrocyte sedimentation rate) and CRP (C reactive protein), both of which measure the degree of inflammation in your joints
(The latter two: Both are used because certain meds may affect one more than the other, says Dr. Huffstutter.)
Check in With Yourself
A test that tells you how much inflammation is present in your joints is certainly helpful. But you know what else is? Your own intuition. “You are the best judge of how your treatment is going,” says Dr. Garner. Look for these common clues your current treatment plan needs fine-tuning: experiencing high levels of pain; fatigue or lack of stamina; multiple warm, tender, swollen joints; difficulty sleeping; and low-grade fever.
Imaging tests are not only used to diagnose RA, but to monitor the disease’s progression. However, this practice appears to be falling out of favor. For instance, a 2019 report in JAMA noted that using MRI for RA treatment guidance doesn’t improve remission rates. And another 2019 study concluded that ultrasound offered no benefit. X-rays are still used, but not so frequently, says Dr. Garner; he suggests a hand X-ray, which shows issues like bone erosion, every two to five years to help gauge whether the treatment plan you’re on is working effectively.
Know What Your Flare Means
More than 96 percent of those with RA experience a flare (a sudden worsening of RA symptoms) at least once a year. The thing is, a flare doesn’t necessarily mean your meds aren’t working. According to the Arthritis Foundation, overexertion, poor sleep, stress, or an infection are all common flare triggers—not a med failure. That noted, repeated or consistent flares could mean you need to adjust your medication.
Gauge Your Energy Level
While less-stiff joints are a for-sure sign that your RA treatment is working, a less obvious (but equally telling) sign is an energy boon. In fact, “your energy should change with treatment,” says Dr. Garner. “Anemia, inflammation, secondary fibromyalgia from RA, all cause fatigue. So with treatment, energy should go up.” On the flip, if you’re consistently wiped out, it may be time to chat with your care team about adjusting your treatment options.
Methotrexate max concentration: Arthritis & Rheumatology. (2008). “Pharmacokinetics of oral methotrexate in patients with rheumatoid arthritis.” ncbi.nlm.nih.gov/pubmed/18975321
Adequate response to Methotrexate: The New England Journal of Medicine. (2013). “Therapies for active rheumatoid arthritis after Methotrexate failure.” pdfs.semanticscholar.org/7abb/179a7c50e89e884d50bcfe5392373326b590.pdf
Preferred methods of measuring disease activity: Arthritis Care & Research. (2019). “2019 update of the American College of Rheumatology recommended rheumatoid arthritis disease activity measures.” onlinelibrary.wiley.com/doi/full/10.1002/acr.24042
MRIs for RA treatment guidance: JAMA. (2019). “Effect of Magnetic Resonance Imaging vs conventional treat-to-target strategies on disease activity remission and radiographic progression in rheumatoid arthritis.” jamanetwork.com/journals/jama/fullarticle/2724024
Ultrasounds for RA treatment guidance: American College of Rheumatology Meeting Abstracts. (2019). “Ultrasound versus conventional treat-to-target strategies in early rheumatoid arthritis: Magnetic Resonance Imaging outcome data from a 2-year randomized controlled strategy trial.” acrabstracts.org/abstract/ultrasound-versus-conventional-treat-to-target-strategies-in-early-rheumatoid-arthritis-magnetic-resonance-imaging-outcome-data-from-a-2-year-randomized-controlled-strategy-trial/
How many experience RA flares: RA in America 2013. (2013). “Flares and Remissions.” rheumatoidarthritis.net/ra-in-america-2013/frequency-of-flares-and-remissions/
Common flare triggers: Arthritis Foundation. (2016). “Understanding RA Flares.” arthritis.org/living-with-arthritis/pain-management/flares/ra-flare-up-severity.php