How Is Rheumatoid Arthritis Treated?
Doctors use a variety of approaches to treat rheumatoid arthritis. These are used in different combinations and at different times during the course of the disease and are chosen according to the patient’s individual situation. No matter what treatment the doctor and patient choose, however, the goals are the same: to relieve pain, reduce inflammation, slow down or stop joint damage, and improve the person’s sense of well-being and ability to function.
Good communication between the patient and doctor is necessary for effective treatment. Talking to the doctor can help ensure that exercise and pain management programs are provided as needed, and that drugs are prescribed appropriately. Talking to the doctor can also help people who are making decisions about surgery.
Goals of Treatment
- Relieve pain
- Reduce inflammation
- Slow down or stop joint damage
- Improve a person's sense of well-being and ability to function
Current Treatment Approaches
- Lifestyle
- Medications
- Surgery
- Routine monitoring and ongoing care
Health behavior changes: Certain activities can help improve a person’s ability to function independently and maintain a positive outlook.
Rest and exercise: People with rheumatoid arthritis need a good balance between rest and exercise, with more rest when the disease is active and more exercise when it is not. Rest helps to reduce active joint inflammation and pain and to fight fatigue. The length of time for rest will vary from person to person, but in general, shorter rest breaks every now and then are more helpful than long times spent in bed.
Exercise is important for maintaining healthy and strong muscles, preserving joint mobility, and maintaining flexibility. Exercise can also help people sleep well, reduce pain, maintain a positive attitude, and lose weight. Exercise programs should take into account the person’s physical abilities, limitations, and changing needs.
Joint care: Some people find using a splint for a short time around a painful joint reduces pain and swelling by supporting the joint and letting it rest. Splints are used mostly on wrists and hands, but also on ankles and feet. A doctor or a physical or occupational therapist can help a person choose a splint and make sure it fits properly. Other ways to reduce stress on joints include self-help devices (for example, zipper pullers, long-handled shoe horns); devices to help with getting on and off chairs, toilet seats, and beds; and changes in the ways that a person carries out daily activities.
Stress reduction: People with rheumatoid arthritis face emotional challenges as well as physical ones. The emotions they feel because of the disease—fear, anger, and frustration—combined with any pain and physical limitations can increase their stress level. Although there is no evidence that stress plays a role in causing rheumatoid arthritis, it can make living with the disease difficult at times. Stress also may affect the amount of pain a person feels. There are a number of successful techniques for coping with stress. Regular rest periods can help, as can relaxation, distraction, or visualization exercises. Exercise programs, participation in support groups, and good communication with the health care team are other ways to reduce stress.
Healthful diet: With the exception of several specific types of oils, there is no scientific evidence that any specific food or nutrient helps or harms people with rheumatoid arthritis. However, an overall nutritious diet with enough—but not an excess of—calories, protein, and calcium is important. Some people may need to be careful about drinking alcoholic beverages because of the medications they take for rheumatoid arthritis. Those taking methotrexate may need to avoid alcohol altogether because one of the most serious long-term side effects of methotrexate is liver damage.
Climate: Some people notice that their arthritis gets worse when there is a sudden change in the weather. However, there is no evidence that a specific climate can prevent or reduce the effects of rheumatoid arthritis. Moving to a new place with a different climate usually does not make a long-term difference in a person’s rheumatoid arthritis.
Medications: Most people who have rheumatoid arthritis take medications. Some medications (analgesics) are used only for pain relief; others [corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs)] are used to reduce inflammation. Still others, often called disease-modifying antirheumatic drugs (DMARDs), are used to try to slow the course of the disease. The newest and perhaps most promising class of arthritis medications are the biologic response modifiers. These are genetically engineered medications that help reduce inflammation and structural damage to the joints by interrupting the cascade of events that drive inflammation. Currently, seven biologic response modifiers are approved for rheumatoid arthritis. They work in one of several ways:
- Four of these drugs, etanercept (Enbrel2), golimumab (Simponi), infliximab (Remicade), and adalimumab (Humira), reduce inflammation by blocking tumor necrosis factor (TNF), a cytokine or immune system protein that triggers inflammation during normal immune responses.
- nakinra (Kineret), works by blocking a cytokine called interleukin-1 (IL-1) that is seen in excess in patients with rheumatoid arthritis.
- Rituximab (Rituxan) stops the activation of a type of white blood cell called B cells. This reduces the overall activity of the immune system, which is overactive in people with rheumatoid arthritis.
- Abatacept (Orencia) blocks a particular chemical that triggers the overproduction of white blood cells called T cells that play a role in rheumatoid arthritis inflammation.
Brand names included in this booklet are provided as examples only, and their inclusion does not mean that these products are endorsed by the National Institutes of Health or any other Government agency. Also, if a particular brand name is not mentioned, this does not mean or imply that the product is unsatisfactory.
For many years, doctors initially prescribed aspirin or other pain-relieving drugs for rheumatoid arthritis, and waited to prescribe more powerful drugs only if the disease worsened. In recent decades this approach to treatment has changed as studies have shown that early treatment with more powerful drugs—and the use of drug combinations instead of one medication alone—may be more effective in reducing or preventing joint damage. Someone with persistent rheumatoid arthritis symptoms should see a doctor familiar with the disease and its treatment to reduce the risk of damage.
The person’s general condition, the current and predicted severity of the illness, the length of time he or she will take the drug, and the drug’s effectiveness and potential side effects are important considerations in prescribing drugs for rheumatoid arthritis. The table below shows currently used rheumatoid arthritis medications, along with their uses and effects, side effects, and monitoring requirements.
Many of the new drugs that help reduce disease in rheumatoid arthritis do so by reducing the inflammation that can cause pain and joint damage. However, in some instances, inflammation is one mechanism the body normally uses to maintain health, such as to fight infection and possibly to stop tumors from growing. The magnitude of the risk from the treatment is hard to judge because infections and cancer can occur in patients with rheumatoid arthritis who are not on treatment, and probably more commonly than in healthy individuals. Nevertheless, appropriate caution and vigilance are justified.
Surgery: Several types of surgery are available to patients with severe joint damage. The primary purpose of these procedures is to reduce pain, improve the affected joint’s function, and improve the patient’s ability to perform daily activities. Surgery is not for everyone, however, and the decision should be made only after careful consideration by the patient and doctor. Together they should discuss the patient’s overall health, the condition of the joint or tendon that will be operated on, and the reason for, as well as the risks and benefits of, the surgical procedure. Cost may be another factor.
Following are some of the more common surgeries performed for rheumatoid arthritis:
Joint replacement: Joint replacement involves removing all or part of a damaged joint and replacing it with synthetic components. Joint replacement is available for a number of different joints, but the most commonly replaced joints are the hips and knees. Joint replacement surgery is done primarily to relieve pain and improve or preserve function.
Although joint replacement traditionally involved a large incision and long recovery, new minimally invasive surgeries are making it possible to do some forms of joint replacement with smaller incisions and a shorter, easier recovery.
Artificial joints are not always permanent and may eventually have to be replaced. This may be an important consideration for young people.
Arthrodesis (fusion): Arthrodesis is a surgical procedure that involves removing the joint and fusing the bones into one immobile unit, often using bone grafts from the person’s own pelvis. Although the procedure limits movement, it can be useful for increasing stability and relieving pain in affected joints. The most commonly fused joints are the ankles and wrists and joints of the fingers and toes.
Tendon reconstruction: Rheumatoid arthritis can damage and even rupture tendons, the tissues that attach muscle to bone. This surgery, which is used most frequently on the hands, reconstructs the damaged tendon by attaching an intact tendon to it. This procedure can help to restore hand function, especially if the tendon is completely ruptured.
Synovectomy: In this surgery, the doctor actually removes the inflamed synovial tissue. Synovectomy by itself is seldom performed now because not all of the tissue can be removed, and it eventually grows back. Synovectomy is done as part of reconstructive surgery, especially tendon reconstruction.
Routine monitoring and ongoing care: Regular medical care is important to monitor the course of the disease, determine the effectiveness and any negative effects of medications, and change therapies as needed.
Monitoring typically includes regular visits to the doctor. It also may include blood, urine, and other laboratory tests and x rays.
People with rheumatoid arthritis may want to discuss preventing osteoporosis with their doctors as part of their long-term, ongoing care. Osteoporosis is a condition in which bones become weakened and fragile. Having rheumatoid arthritis increases the risk of developing osteoporosis for both men and women, particularly if a person takes corticosteroids. Such patients may want to discuss with their doctors the potential benefits of calcium and vitamin D supplements or other treatments for osteoporosis.
Alternative and complementary therapies: Special diets, vitamin supplements, and other alternative approaches have been suggested for treating rheumatoid arthritis.
Research shows that some of these, for example, fish oil supplements, may help reduce arthritis inflammation. For most, however, controlled scientific studies either have not been conducted on them or have found no definite benefit to these therapies.
As with any therapy, patients should discuss the benefits and drawbacks with their doctors before beginning an alternative or new type of therapy. If the doctor feels the approach has value and will not be harmful, it can be incorporated into a patient’s treatment plan. However, it is important not to neglect regular health care. The Arthritis Foundation publishes material on alternative therapies as well as established therapies, and patients may want to contact this organization for information.
Who Treats Rheumatoid Arthritis?
Diagnosing and treating rheumatoid arthritis requires a team effort involving the patient and several types of health care professionals.
The primary doctor to treat arthritis may be an internist, a doctor who specialized in the diagnosis and medical treatment of adults, or a rheumatologist, a doctor who specializes in arthritis and other diseases of the bones, joints, and muscles.
As treatment progresses, other professionals often help. These may include the following:
Orthopaedists: Surgeons who specialize in the treatment of, and surgery for, bone and joint diseases.
Physical therapists: Health professionals who work with patients to improve joint function.
Occupational therapists: Health professionals who teach ways to protect joints, minimize pain, perform activities of daily living, and conserve energy.
Dietitians: Health professionals who teach ways to use a good diet to improve health and maintain a healthy weight.
Nurse educators: Nurses who specialize in helping patients understand their overall condition and implement their treatment plans.
Psychologists: Health professionals who seek to help patients cope with difficulties in the home and workplace that may result from their medical conditions.
What You Can Do: The Importance of Self-Care
Although health care professionals can prescribe or recommend treatments to help patients manage their rheumatoid arthritis, the real key to living well with the disease are the patients themselves. Research shows that people who take part in their own care report less pain and make fewer doctor visits. They also enjoy a better quality of life.
Patient education and arthritis self-management programs, as well as support groups, help people to become better informed and to participate in their own care. An example of a self-management program is the Arthritis Self-Help Course offered by the Arthritis Foundation and developed at a NIAMS-supported Multipurpose Arthritis and Musculoskeletal Diseases Center. (See the Arthritis Foundation listing in “For More Information.”) Self-management programs teach about rheumatoid arthritis and its treatments, exercise and relaxation approaches, communication between patients and health care providers, and problem solving. Research on these programs has shown that they help people:
- Funderstand the disease
- reduce their pain while remaining active
- cope physically, emotionally, and mentally
- feel greater control over the disease and build a sense of confidence in the ability to function and lead full, active, and independent lives.
What Research Is Being Done on Rheumatoid Arthritis?
Over the last several decades, research has greatly increased our understanding of the immune system, genetics, and biology. This research is now showing results in several areas important to rheumatoid arthritis. Scientists are thinking about rheumatoid arthritis in exciting ways that were not possible even 10 years ago.
The National Institutes of Health (NIH) funds a wide variety of medical research at its headquarters in Bethesda, MD, and at universities and medical centers across the United States. One of the NIH institutes, the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), is a major supporter of research and research training in rheumatoid arthritis through grants to individual scientists, Specialized Centers of Research, Multidisciplinary Clinical Research Centers, and Multipurpose Arthritis and Musculoskeletal Diseases Centers.
Following are examples of current research directions in rheumatoid arthritis supported by the Federal Government through the NIAMS and other parts of NIH.
Genetics
Researchers are studying genetic factors that predispose some people to developing rheumatoid arthritis, as well as factors connected with disease severity. In recent years, NIAMS-supported research in this area has led to several important genetic discoveries including the following:
Variation in a gene involved in controlling T-cell activation doubles rheumatoid arthritis risk: The variation—called a single nucleotide polymorphism (SNP)—is located within a gene that codes for PTPN22, an enzyme known to be involved in controlling the activation of white blood cells called T cells that play an important role in the body’s immune system. Where the SNP is present in one or both copies of a person’s genes for this enzyme, T cells and other immune cells respond too vigorously, causing increased inflammation and tissue damage. Scientists say the implications of this finding go beyond a better understanding of rheumatoid arthritis risk; it may also help explain why different autoimmune diseases tend to run in families. Other studies have the same SNP with type-1 diabetes and juvenile arthritis.
Genetic variation increases risk of rheumatoid arthritis and lupus: Separate research found a SNP in a large segment of the STAT4 gene increases the risk of both rheumatoid arthritis and another autoimmune disease, systemic lupus erythematosus (lupus). The STAT4 gene encodes a protein that plays an important role in the regulation and activation of certain cells of the immune system. One variant form of the gene was present at a significantly higher frequency in rheumatoid arthritis patient samples from the North American Rheumatoid Arthritis Consortium (NARAC)—a consortium formed to collect, analyze and make available clinical and genetic data on 1,000 sibling pairs with rheumatoid arthritis—as compared with controls. Scientists replicated that result in two independent collections of rheumatoid arthritis cases and controls.
Twin study shows genetic differences in rheumatoid arthritis: Because identical twins have the exact same genes at conception, scientists believe that changes in the genes after the genome is constructed may account for why one of a twin pair can have rheumatoid arthritis while the other does not. To better understand what those changes might be, scientists have used a sophisticated technique called microarray to examine the expression of more than 20,000 genes at a time in 11 pairs of disease-discordant identical twins (meaning one twin had the disease, the other did not). The examination led to the detection of differences in expression of 827 genes. The most significantly overexpressed gene was laeverin, an enzyme that breaks down certain types of proteins; second was 11ß-hydroxysteroid dehydrogenase type 2 (11ß-HSD2), important in a steroid pathway linked to inflammation and bone erosion; and third was cysteine-rich angiogenic inducer 61 (Cyr61), which is known for its role in angiogenesis, the formation of new blood vessels. The scientists say their findings are exciting because they offer new insights into the mechanisms by which rheumatoid arthritis is mediated.
Genetic region associated with rheumatoid arthritis risk: Using the relatively new genome-wide association approach, which makes it possible to analyze between 300,000 and 500,000 single nucleotide polymorphisms, researchers in the United States and Sweden identified a region of chromosome 9 containing two genes relevant to chronic inflammation: TRAF1 (encoding tumor necrosis factor receptor-associated factor 1) and C5 (encoding complement component 5). Scientists say it is not yet known how the genes in the TRAF1-C5 region influence rheumatoid arthritis risk, but they hope that by learning more about the genes and their role in the disease, they may find clues to influencing treatment of the disease.
Rheumatoid Arthritis and Disability
During the past 20 years, significant changes in managing rheumatoid arthritis, including new and more powerful drugs and more aggressive treatment, have improved both shortand long-term disability outcomes. Using data from 3,035 patients enrolled in the ARAMIS (Arthritis, Rheumatism, and Aging Medical Information System) data bank—a large data bank with treatment history for a broad range of patients, and containing widely accepted disability measurements—NIAMS-supported researchers found that average disability levels in patients with rheumatoid arthritis have declined by 40 percent since 1977 at a rate of about 2 percent a year.
Despite recent improvements in treatment and disability outcomes, women with rheumatoid arthritis may have difficulty maintaining jobs, one NIAMS-supported study shows. Researchers who followed two groups of women with rheumatoid arthritis 11 years apart—the first group beginning in 1987, the second in 1998—found the rate at which women left the workforce did not fall significantly. They found that more than a quarter of the women in both groups stopped working within 4 years after being diagnosed with rheumatoid arthritis.
Researchers cited several possible reasons to explain why the rate of stopping work did not decline, even while disease activity did. They concluded that patients’ reasons for leaving work had changed between the time the 1987 and 1998 groups were studied, and that more women were leaving work in 1998 for reasons other than increased disease activity.
Potential Treatments
Researchers continue to identify molecules that appear to play a role in rheumatoid arthritis and thus are potential targets for new treatments. The path between identifying the molecule and developing a drug that targets it is long and difficult. Fortunately, this path has been successfully negotiated and new drugs have emerged that successfully reduce symptoms and damage in rheumatoid arthritis. Researchers continue to identify more candidate drugs, with hopes that these will have fewer side effects or will cure more patients.
Understanding Joint Destruction
Advances in understanding the processes that lead to joint destruction are bringing NIAMS-supported researchers a step closer to new therapies to stop the destructive process. In one NIAMS study researchers found a factor they suspect plays a crucial role in joint destruction: an adhesion molecule on cells of the synovium called cadherin-11. Adhesion molecules allow individual cells to stick together to form tissues. At normal levels, cadherin-11 enables the cells (synoviocytes) to adhere together to form the lining layer of the synovium. But when overgrowth of the synovium occurs, cadherin plays a key role in the destructive behavior of the synovium; namely, eroding the cartilage, which causes permanent destruction to the joint. In studies of mice prone to a disease similar to human rheumatoid arthritis, blocking cadherin-11 prevented cartilage destruction. The next step is to determine whether an agent to block an excess of the molecule has the same beneficial effect in people with rheumatoid arthritis.
In other research scientists found that a lack of apoptosis (programmed cell death) contributes to a proliferation of cells in the joint lining and the failure to eliminate immune cells that react against self. In animal studies, mice lacking two proteins that mediate the process of apoptosis developed arthritis.
Preventing Related Problems
Having rheumatoid arthritis does not make people immune to other medical problems. Thus, reducing the risk of problems that can be associated with rheumatoid arthritis is a focus of NIAMS research. One recent study showed that treatment with hydroxychloroquine, a medication used to treat rheumatic diseases and malaria, reduced the incidence of diabetes in people with rheumatoid arthritis. People with rheumatoid arthritis who took the medication for more than 4 years showed a reduction in risk of diabetes of up to 77 percent.
Hope for the Future
Scientists are making rapid progress in understanding the complexities of rheumatoid arthritis: how and why it develops, why some people get it and others do not, why some people get it more severely than others. Results from research are having an impact today, enabling people with rheumatoid arthritis to remain active in life, family, and work far longer than was possible 20 years ago. There is also hope for tomorrow, as researchers begin to apply new technologies such as stem cell transplantation and novel imaging techniques. (Stem cells have the capacity to differentiate into specific cell types, which gives them the potential to change damaged tissue in which they are placed.) These and other advances will lead to an improved quality of life for people with rheumatoid arthritis.
Check Out These Other Health and Wellness Websites
Medications
Weight Control
Nutrition
Cosmetics
Medical Devices
Diabetic Supplies
Cosmetic Surgery
LASIK Vision
Arthritis
Hair Restoration
FDA Compliance
Clinical Trials
Cancer Treatments
Chemotherapy
Imaging & Radiology
Biologics & Blood
Mesothelioma
Pet Care
Free Debt Consultation — Deal Debt A Fatal Blow Today!
Call Now! 1800 DEBT.COM (that's 1800 332-8266) or Click Here
| 
