Rheumatoid arthritis - Treatment

Treatment-Rheumatoid arthritis




Treatment for rheumatoid arthritis can help reduce inflammation in the joints, relieve pain, prevent or slow joint damage, reduce disability and enable you to live as active a life as possible.
Although there's no cure for rheumatoid arthritis, early treatment and support (including lifestyle changes, medication, supportive treatments and surgery) can reduce the risk of joint damage and limit the impact of the condition.
Your treatment will usually involve care from your GP and a number of different specialists.
The National Institute for Health and Care Excellence (NICE) has produced guidance on the management of rheumatoid arthritis in adults.
There are a number of medications available that can be used to help stop rheumatoid arthritis getting worse and reduce your risk of further problems.
These are often divided into 2 types of medication: disease-modifying anti-rheumatic drugs (DMARDs) and biological treatments.

Disease-modifying anti-rheumatic drugs (DMARDs)

If you have been diagnosed with rheumatoid arthritis, you'll normally be offered a combination of DMARD tablets as part of your initial treatment.
These medications are particularly effective at easing symptoms of the condition and slowing down its progression.
DMARDs work by blocking the effects of the chemicals released when the immune system attacks the joints, which could otherwise cause further damage to nearby bones, tendons, ligaments and cartilage.
There are many different DMARDs that can be used, including:
  • methotrexate
  • leflunomide
  • hydroxychloroquine
  • sulfasalazine
Methotrexate is normally the first medicine given for rheumatoid arthritis, often alongside another DMARD and a short-course of corticosteroids to relieve any pain.
It may also be combined with the biological treatments mentioned below.
Common side effects of methotrexate include:
The medication can also sometimes have an effect on your blood count and your liver, so you'll have regular blood tests to monitor this.
Less commonly, methotrexate can affect the lungs, so you'll usually have a chest X-ray and possibly breathing tests when you start taking it to provide a comparison if you develop shortness of breath or a persistent dry cough while taking it. But most people tolerate methotrexate well.
It can take a few months to notice a DMARD working. It's important to keep taking the medication, even if you don't notice it working at first.
You may have to try 2 or 3 types of DMARD before you find the one that's most suitable for you.
Once you and your doctor work out the most suitable DMARD, you'll usually have to take the medicine in the long term.

Biological treatments

Biological treatments are a newer form of treatment for rheumatoid arthritis.
They include:
  • etanercept
  • infliximab
  • adalimumab
  • certolizumab
  • golimumab
  • rituximab
  • abatacept
  • tocilizumab
  • sarilumab
They're usually taken in combination with methotrexate or another DMARD, and are normally only used if these medications alone haven't been effective.
Biological medications are given by injection. They work by stopping particular chemicals in the blood from activating your immune system to attack your joints.
Side effects from biological treatments are usually mild and include:
  • skin reactions at the site of the injections
  • infections
  • feeling sick
  • a high temperature (fever)
  • headaches
Some people may also be at risk of getting more serious problems, including the reactivation of infections such as tuberculosis (TB) if they have had them in the past.

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Jak inhibitors

A new type of treatment (Jak inhibitors) is now available on the NHS for people with moderate to severe rheumatoid arthritis.
This medicine is taken as a tablet once or twice a day, and usually in combination with methotrexate.
These medicines include:
  • tofacitinib
  • baricitinib
These medicines are for adults who have already tried taking DMARDs or biologicals, but these haven't been effective or they can't take them.
These medicines can also be taken on their own in adults who can't take methotrexate.

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Medication to relieve pain

In addition to the medications used to control the progression of rheumatoid arthritis, you may also need to take medication specifically to relieve pain.
Some of the different medicines that may be used to relieve pain are outlined below.

Painkillers

In some cases, you may be advised to use painkillers, such as paracetamol or a combination of paracetamol and codeine (co-codamol), to relieve the pain associated with rheumatoid arthritis.
These medications don't help treat the underlying inflammation of your joints, but they can sometimes be helpful in relieving pain.
For example, they may be recommended while you're waiting to see a specialist or during periods where your symptoms are particularly bad (flare-ups).

Non-steroidal anti-inflammatory drugs (NSAIDs)

In addition to, or instead of, the painkillers mentioned above, your doctor may prescribe a non-steroidal anti-inflammatory drug (NSAID).
This may be a traditional NSAID (such as ibuprofen, naproxen or diclofenac) or an alternative type called a COX-2 inhibitor (such as celecoxib or etoricoxib).
These medications can help relieve pain while also reducing inflammation in the joints, although they won't stop rheumatoid arthritis getting worse over time.
Your doctor will discuss with you what type of NSAID you should take, and the benefits and risks associated with each of them.
Although uncommon, taking an NSAID tablet can increase the risk of serious stomach problems, such as internal bleeding.
This is because the medications can break down the lining that protects the stomach against damage from stomach acids.
If you're prescribed an NSAID tablet, you'll often have to take another medicine, such as a proton pump inhibitor (PPI), as well.
Taking a PPI reduces the amount of acid in your stomach, which greatly reduces the risk of damage to your stomach lining.

Corticosteroids

Corticosteroids are powerful medications that can help reduce pain, stiffness and inflammation.
They can be used as:
  • a tablet (for example, prednisolone)
  • an injection directly into a painful joint
  • an injection into the muscle (to help lots of joints)
They're usually used to provide short-term pain relief – for example, while you're waiting for DMARD medication to take effect or during a flare-up.
Corticosteroids are normally only used in this way because long-term use of corticosteroids can have serious side effects, such as:
  • weight gain
  • osteoporosis (thinning of the bones)
  • easy bruising
  • muscle weakness
  • thinning of the skin

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Supportive treatments

Your doctor may also refer you to other services that might be able to help you with your rheumatoid arthritis symptoms.

Physiotherapy

A physiotherapist may help you improve your fitness and muscle strength, and make your joints more flexible.
If your hands or wrists are affected, you can try a tailored hand exercise programme. This involves face-to-face sessions with a trained therapist and carrying out the exercises yourself at home.
A physiotherapist may also be able to help with pain relief using heat or ice packs, or transcutaneous electrical nerve stimulation (TENS).
A TENS machine applies a small pulse of electricity to the affected joint, which numbs the nerve endings and can help ease the pain of rheumatoid arthritis.

Occupational therapy

If rheumatoid arthritis causes you problems with everyday tasks, occupational therapy may help.
An occupational therapist can provide training and advice that will help you to protect your joints, both while you're at home and at work.
Some type of support for your joints, such as a splint, may also be recommended, or devices that can help open jars or turn on taps.

Podiatry

If you have problems with your feet, a podiatrist may be able to help.
You may also be offered some type of support for your joints or shoe insoles that can ease pain.

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Surgery

Sometimes, despite medication, damage to your joints may occur. In such cases, you may need surgery to help restore your ability to use your joint.
Surgery may also be recommended to reduce pain or correct deformities.

Finger, hand and wrist surgery

There are different types of surgery to correct joint problems in the hand.
Examples include:
  • carpal tunnel release (cutting a ligament in the wrist to relieve pressure on a nerve – see treating carpal tunnel syndrome for more information)
  • release of tendons in the fingers to treat abnormal bending
  • removal of inflamed tissue that lines the finger joints

Arthroscopy

Arthroscopy is a procedure to remove inflamed joint tissue.
During the operation, a thin tube with a light source and camera (arthroscope) is inserted into the joint through a small cut in the skin so the surgeon can see the affected joint.
Special surgical instruments are inserted through other small cuts in the skin to remove the damaged tissue.
You usually don't have to stay overnight in hospital for this kind of surgery, but the joint will need to be rested at home for several days.

Joint replacement

Some people with rheumatoid arthritis need surgery to replace part or all of a joint, such as the hip, knee or shoulder joint.
This is known as a joint replacement or arthroplasty.
Replacement of these joints is a major operation that involves several days in hospital followed by months of rehabilitation.
The latest joints have a limited lifespan of 10 to 20 years. They're not perfect and some function may not be restored after the damaged joint is replaced by a new one. 
Read about knee replacement and hip replacement.

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Complementary and alternative therapies

Many people with rheumatoid arthritis try complementary therapies, such as:
In most cases, there's little or no evidence these are effective in the long term, although some people may experience a short-term benefit from them.

Nutritional supplements and dietary changes

There's no strong evidence to suggest that specific dietary changes can help improve rheumatoid arthritis, although some people with rheumatoid arthritis feel their symptoms get worse after they have eaten certain foods.
If you think this may be the case for you, it may be useful to try avoiding problematic foods for a few weeks to see if your symptoms improve.
But it's important to ensure your overall diet is still healthy and balanced.
There's also little evidence supporting the use of supplements in rheumatoid arthritis, although some can be useful in preventing side effects of medications you may be taking.
For example, calcium and vitamin D supplements may help prevent osteoporosis if you're taking steroids, and folic acidsupplements may help prevent some of the side effects of methotrexate.
There's some evidence to suggest that taking fish oil supplements may help reduce joint pain and stiffness caused by rheumatoid arthritis.

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