Rheumatoid arthritis : Treatment

Treatments for rheumatoid arthritis can help reduce inflammation in the joints, relieve pain, prevent or slow down joint damage, reduce disability and enable you to be as active as possible.

Although there's no cure for rheumatoid arthritis, early treatment and support (including medicine, lifestyle changes, 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.

There are medicines available to help stop rheumatoid arthritis from getting worse and reduce your risk of further problems.

These are often divided into main 2 types: disease-modifying anti-rheumatic drugs (DMARDs) and biological treatments.


Disease-modifying anti-rheumatic drugs (DMARDs)

If you've been diagnosed with rheumatoid arthritis, you'll usually be offered a combination of DMARD tablets as part of your initial treatment.

These medicines ease the symptoms of the condition and slow down its progression.

DMARDs work by blocking the effects of the chemicals released when your immune system attacks your joints, which could otherwise cause further damage to nearby bones, tendons, ligaments and cartilage.

The DMARDs that may be used include:

  • methotrexate
  • leflunomide
  • hydroxychloroquine
  • sulfasalazine

Methotrexate is usually the 1st medicine given for rheumatoid arthritis, often with another DMARD and a short course of steroids (corticosteroids) to relieve any pain.

These may be combined with biological treatments.

Common side effects of methotrexate include:

The medicine can also affect your blood cells and liver, so you'll have regular blood tests to monitor this.

Less commonly, methotrexate can affect the lungs, so you may have a chest X-ray and possibly a breathing test when you start taking it. This is 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 medicine, even if you do not notice it working at the beginning.

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 find the most suitable DMARD, you'll usually have to take the medicine long term.

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Biological treatments

Biological treatments, such as etanercept and infliximab, are a newer form of treatment for rheumatoid arthritis.

They're usually taken in combination with methotrexate or another DMARD, and are usually only used if DMARDs have not been effective on their own.

Biological medicines are given by injection. They work by stopping particular chemicals in your blood from activating your immune system to attack your joints.

Side effects from biological treatments are usually mild but include:

  • skin reactions at the site of the injections
  • infections
  • feeling sick
  • a high temperature
  • 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

JAK inhibitors are a new type of medicine available on the NHS to adults with severe rheumatoid arthritis.

It is offered to people who cannot take DMARDs or biologicals, or tried them but found they were not effective.

This medicine is taken as a tablet once or twice a day, and is usually used in combination with methotrexate. These medicines include:

  • tofacitinib
  • baricitinib

JAK inhibitors can also be taken on their own by adults who cannot take methotrexate.

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Medicine to relieve pain

In addition to the medicines used to control the progression of rheumatoid arthritis, you may also need to take medicine specifically to relieve pain.

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 medicines do not treat the inflammation in your joints, but they may be helpful in relieving pain.

For example, they may be recommended while you're waiting to see a specialist or when 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 your doctor may prescribe a type called a COX-2 inhibitor, such as celecoxib or etoricoxib.

These medicines can help relieve pain while also reducing inflammation in the joints, although they will not 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 it.

Although uncommon, taking NSAIDs 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 NSAID tablets, you'll often be given another medicine to take with it, such as a proton pump inhibitor (PPI).

Taking a PPI reduces the amount of acid in your stomach, which reduces the risk of damage to your stomach lining.

Steroids

Steroids are powerful medicines that can help reduce pain, stiffness and inflammation.

They can be given as:

  • a tablet (for example, prednisolone)
  • an injection directly into a painful joint
  • an injection into a muscle (to help lots of joints)

They're usually used to provide short-term pain relief – for example, while you're waiting for DMARD medicines to take effect or during a flare-up.

Steroids are usually only taken for a short time because long-term use can have serious side effects, such as:

  • weight gain
  • osteoporosis (weakening 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 doing 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.

Using a support for your joints, such as a splint, may also be recommended, or devices that can help you 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 taking medicines, your joints may still become damaged. If this happens, you may need surgery to help restore your ability to use your joint.

Surgery may also be recommended to reduce pain or fix 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). Find out more about carpal tunnel syndrome
  • release of tendons in the fingers to treat abnormal bending
  • removal of inflamed tissue that lines the finger joints

Arthroscopy

This is a procedure to remove inflamed joint tissue.

During an arthroscopy, a thin tube with a light and camera attached to it (arthroscope) is inserted into the joint through a small cut in the skin so the surgeon can see the affected joint.

Special instruments are inserted through other small cuts in the skin to remove the damaged tissue.

You usually do not have to stay in hospital overnight 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 prosthetic joints have a lifespan of 10 to 20 years, and some function may not be restored after a damaged joint is replaced by a prosthetic one. 

Find out more about knee replacement and hip replacement.

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Complementary 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 short-term benefit from them.

Nutritional supplements and dietary changes

There's no strong evidence to suggest that specific dietary changes can 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. A Mediterranean-style diet, which is based on vegetables, fruits, legumes, nuts, beans, cereals, grains, fish and unsaturated fats such as olive oil, is recommended.

There's also little evidence supporting the use of supplements in rheumatoid arthritis, although some can be useful in preventing side effects of medicines you may be taking.

For example, calcium and vitamin D supplements may help prevent osteoporosis if you're taking steroids, and folic acid supplements 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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