I wanted to post this complete page because I think there is a lot of good information. Towards the bottom of the page is the definings of mild, moderate and severe ra. I will post a link to the page at the bottom.
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| Authors RN Maini, BA, MB BChir, FRCP, FMedSci, FRS PJW Venables, MA, MB BChir, MD, FRCP |
Section Editor RN Maini, BA, MB BChir, FRCP, FMedSci, FRS |
Deputy Editors Leah K Moynihan, RNC, MSN Paul L Romain, MD |
Last literature review version 17.1: January 2009 | This topic last updated: February 11, 2008 (More)
INTRODUCTION — Rheumatoid arthritis (RA) is a chronic inflammatory condition. The condition can affect many tissues throughout the body, but the joints are usually most severely affected. The specific causes of rheumatoid arthritis are unknown.
Rheumatoid arthritis symptoms develop gradually, and it is not always possible to know when it first developed. Many people have symptoms that are present continuously, some have symptoms which completely resolve, and others have alternating periods of bothersome symptoms and complete resolution. The onset, severity, and specific symptoms of this condition can vary greatly from person to person.
Treatment plays a key role in controlling the inflammation of rheumatoid arthritis and minimizing joint damage. Treatment usually entails a combination of drug therapy and other non-drug therapies. In some cases, treatment may also involve surgery.
The treatment of rheumatoid arthritis in a particular individual must be tailored to their particular case, including the severity of the condition, the effectiveness of specific therapies, and the occurrence of any side effects. Treatment choices may be different for a person with rheumatoid arthritis who has other illnesses, especially those of the liver or kidneys. It is important to work with a healthcare provider to create an effective and acceptable plan for treating rheumatoid arthritis.
This topic review discusses the traditional medical treatments that are used for patients with rheumatoid arthritis. A number of other topics about rheumatoid arthritis are available separately. (See "Patient information: Rheumatoid arthritis symptoms and diagnosis" and see "Patient information: Disease modifying antirheumatic drugs (DMARDs)" and see "Patient information: Rheumatoid arthritis and pregnancy" and see "Patient information: Complementary therapies for rheumatoid arthritis").
GENERAL PRINCIPLES OF TREATMENT — The aim of RA treatment is to control a patient's signs and symptoms, and to maintain their quality of life and ability to function [1]. Joint damage caused by RA generally occurs within the first two years of diagnosis, and it is difficult to predict which individuals will develop long-term complications. Therefore, the initial treatment of RA aims to eliminate or minimize inflammation. However, the risk of side effects from treatment must be weighed against the benefits. Treatments that can potentially stop joint damage are generally recommended for all patients with RA.
Long-term medical care with regularly scheduled visits is essential for the successful treatment of rheumatoid arthritis. This care often entails medical visits and tests to assess the effectiveness of treatment and monitor for side effects.
NONPHARMACOLOGIC THERAPIES — Nonpharmacologic therapies include treatments other than medications, and are the foundation of treatment for all people with RA. There are a wide variety of nonpharmacologic therapies available.
Education and counseling — Education and counseling can help a person better understand the nature of rheumatoid arthritis and cope with the challenges of this condition. People with RA and their healthcare providers can work together to formulate a long-term treatment plan, define reasonable expectations, and evaluate both standard and alternative treatment options.
Nonpharmacologic measures such as biofeedback and cognitive behavioral therapy can be very effective for controlling the symptoms of RA. These measures can reduce pain and disability and improve self-esteem. Programs on topics such as self-management skills, social support, biofeedback, and psychotherapy are offered by the Arthritis Foundation and by many hospitals and clinics (www.arthritis.org/communities/Chapters/ChapDirectory.asp). These programs have been shown to reduce pain, depression, and disability in people with arthritis and to allow them to gain some control over their illness.
Rest — Fatigue is a common symptom of RA. Resting inflamed joints by taking naps often helps restore energy. Rest can often be alternated with exercise.
Exercise — Pain and stiffness often prompt people with RA to become inactive. Unfortunately, inactivity can lead to a loss of joint motion, contractions, and a loss of muscle strength. Weakness, in turn, decreases joint stability and further increases fatigue.
Regular exercise can help prevent and reverse these effects [2]. Several different kinds of exercises can be beneficial, including range of motion exercises to preserve and restore joint motion, exercises to increase strength (isometric, isotonic, and isokinetic exercises), and exercises to increase endurance (walking, swimming, and cycling).
One study suggests that, in the short term, regular aerobic exercise improves muscle function, joint stability, aerobic capacity, physical function, and pain control without worsening arthritis; additional studies are needed to determine if the benefits persist in the long term. Another study suggests that aerobic weight-bearing exercise helps prevent the bone loss associated with steroid treatment and does not worsen rheumatoid arthritis.
Exercise programs for people with rheumatoid arthritis should be designed by a physical therapist and tailored to the severity of the condition, a person's body build, and their former activity level. A separate topic review is available that discusses exercise and arthritis. (See "Patient information: Arthritis and exercise").
Physical therapy — Physical therapy can relieve pain, reduce inflammation, and help preserve joint structure and function for patients with RA.
Specific types of physical therapy are used to address specific effects of RA:
Physical therapy may also include a consultation with a podiatrist who can make foot orthotics (devices that ensure correct position of the foot) and supportive footwear.
Nutrition and dietary therapy — People with active RA may lose their appetite or be unable to eat an adequate amount of food. Dietary therapy helps to ensure that a person consumes an adequate amount of calories and nutrients. However, weight loss may be recommended for overweight and obese people to reduce stress on inflamed joints. (See "Patient information: Weight loss treatments").
People with RA have a higher risk of developing coronary artery disease. High blood cholesterol is one risk factor for coronary disease that can respond to changes in diet. A nutritionist can recommend specific foods to eat or avoid to try to achieve a desirable cholesterol level. (See "Patient information: High cholesterol and lipids (hyperlipidemia)").
Changes in diet have been investigated as treatments for rheumatoid arthritis. The addition of fish oils and some plant oils, such as borage seed oil, have resulted in modest improvement in arthritis pain and in joint swelling [3]. However, there is no diet that can cure rheumatoid arthritis. No herbal or nutritional supplements, such as cartilage and collagen, can cure RA; these treatments can be dangerous in some cases and are not recommended. (See "Patient information: Complementary therapies for rheumatoid arthritis").
Measures to reduce bone loss — Rheumatoid arthritis causes bone loss, which can lead to osteoporosis. Bone loss is more likely with an increasing level of disability and a decreasing level of weight-bearing activity. The use of prednisone or other steroid drugs further accelerates bone loss, especially in postmenopausal women. (See "Patient information: Osteoporosis causes, diagnosis, and screening").
Several measures can minimize the bone loss associated with steroid therapy [4]:
DRUG THERAPY — Drug therapy is the cornerstone of treatment for active RA. Drug therapy is appropriate for anyone with RA, with the exception of selected people who are in remission. The goals of drug therapy are to achieve remission and prevent further damage of the joints and loss of function, without causing permanent or unacceptable side effects.
The type and intensity of drug therapy depends upon the severity of RA, the presence of factors associated with a better or worse prognosis, the effectiveness of previous treatments, and potential drug side effects. In most cases, the dose of drug therapy is increased until inflammation is suppressed or drug side effects become unacceptable.
The challenge of drug therapy is to balance the side effects against the need to control inflammation. All patients with RA who use medications need regular medical care and blood tests to monitor for complications. The frequency and type of testing is determined by the type of medication used. If side effects occur, they can often be minimized or eliminated by reducing the dose or switching to a different drug.
Several classes of drugs are used to treat rheumatoid arthritis: Non-steroidal antiinflammatory drugs (NSAIDs), disease modifying antirheumatic drugs (DMARDs), biologic response modifiers, steroids, and if needed, analgesics.
Nonsteroidal anti-inflammatory drugs — Nonsteroidal anti-inflammatory drugs (NSAIDs) may be recommended to relieve pain and reduce minor inflammation. However, NSAIDs do not reduce the long term damaging effects of rheumatoid arthritis on the joints. NSAIDs must be taken continuously and at a specific dose to have an anti-inflammatory effect (show table 1). Even at the correct doses, NSAIDs must usually be taken for two to four weeks before their effectiveness is known. If the initial dose of NSAIDs does not improve symptoms, a clinician may recommend increasing the dose gradually or switching to another NSAID. People taking an NSAID should not take a second NSAID at the same time.
Many NSAIDS have significant side effects, including gastrointestinal bleeding, fluid retention, and an increased risk of heart disease. The risks need to weighed carefully against the benefit when taking these drugs.
More detailed information about NSAIDs is available in a separate topic review. (See "Patient information: Nonsteroidal antiinflammatory drugs (NSAIDs)").
Disease-modifying antirheumatic drugs — Disease-modifying antirheumatic drugs (DMARDs) can substantially reduce the inflammation of RA, although they act slowly. However, DMARDs can help to reduce the dose of steroids that is necessary to control pain and inflammation. Studies suggest that DMARDs can reduce or prevent joint damage, preserve joint structure and function, and enable a person to continue his or her daily activities.
Drugs in this class include hydroxychloroquine (Plaquenil®), methotrexate (Rheumatrex®), gold salts (Ridaura®, Solganal®), D-penicillamine (Depen®, Cuprimine®), sulfasalazine (Azulfidine®), azathioprine (Imuran®), leflunomide (Arava®), and cyclosporine (Sandimmune®, Neoral®). Detailed information about these medications is available in a separate topic review. (See "Patient information: Disease modifying antirheumatic drugs (DMARDs)").
Several weeks to months of treatment are often necessary before the effects of DMARDs become evident. An improvement in symptoms may require four to six weeks of treatment with methotrexate, one to two months of treatment with sulfasalazine, and two to three months of treatment with hydroxychloroquine. Even longer durations of treatment may be needed to derive the full benefits of these drugs.
Minocycline — In some people with early RA, taking an antibiotic (minocycline) may have some benefit. This treatment may be a reasonable alternative to hydroxychloroquine and sulfasalazine.
Biologic response modifiers — Biologic response modifiers, also known as biologics, are medications that were designed to prevent or reduce the inflammation that damages joints. Biologics target molecules on cells of the immune system, joint, and the products that are secreted in the joint, all of which can cause inflammation and joint destruction. There are several types of biologics, each of which targets a specific type of molecule involved in this process (tumor necrosis factor, interleukin-1, and cell surface molecules on T and B lymphocytes).
Unlike DMARDs, which can take a month or more to begin working, biologics work rapidly, within two weeks for some medications (Enbrel®, Humira®, Remicade®) and within four to six weeks for others (Rituxan®, Orencia®). Biologics may be used alone or in combination with other DMARDs (eg, methotrexate), NSAIDs, and/or steroids.
Because of their cost (generally more than ,000 per year in the United States), biologics are often reserved for people who have not completely responded to DMARDs and for those who cannot tolerate DMARDs in doses large enough to control inflammation.
All biologic response modifiers must be injected. Humira®, Enbrel®, and Kineret® are injected under the skin by the patient, a family member, or nurse. Remicade®, Orencia® and Rituxan® must be injected into a vein, which is typically done in a doctor's office or clinic; this takes between one and three hours to complete.
Side effects — Biologic response modifiers interfere with the immune system's ability to fight infection and should not be used in people with serious infections.
Testing for tuberculosis is necessary before starting anti-TNF therapy. People who have evidence of prior TB infection should be treated because there is an increased risk of developing active TB while receiving anti-TNF therapy. (See "Patient information: Tuberculosis").
TNF-inhibitors are not recommended for people who have lymphoma or have been treated for lymphoma in the past; people with RA, especially those with severe disease, have an increased risk of lymphoma regardless of what treatment is used. TNF-inhibitors have been associated with a further increase in the risk of lymphoma in some studies; more research is needed to define this risk.
Steroids (glucocorticoids) — Steroids have strong anti-inflammatory effects. Drugs in this class include prednisone and prednisolone. Steroids may be taken by mouth, injected into a vein, or injected directly into a joint. Steroids quickly improve symptoms of rheumatoid arthritis such as pain and stiffness, and also decrease joint swelling and tenderness.
However, when used alone, steroids only modestly reduce damage to cartilage and bone caused by RA. Steroids are generally used to treat RA that severely limits a person's ability to function normally. For such people, steroid treatment may help control symptoms and preserve function until other, slower acting drugs begin to work.
Side effects — Steroids have many side effects, including weight gain, worsening diabetes, promotion of cataracts in the eyes, thinning of bones (osteopenia and osteoporosis), and an increased risk of infection. Thus, when steroids are used, the goal is to use the lowest possible dose for the shortest period of time.
Simple analgesics — Simple analgesics relieve pain, but they have no effect on inflammation. Drugs in this class include acetaminophen (Tylenol®), tramadol (Ultram®), and capsaicin cream or ointment (Zostrix®). Use of narcotic analgesics such as such as codeine, oxycodone, and hydrocodone is generally discouraged because of the long term nature of rheumatoid arthritis and the risk of dependence and addiction.
However, people with a badly damaged joint who cannot undergo joint replacement surgery may benefit from use of a long acting narcotic under the supervision of a rheumatologist or pain specialist.
Treatment of flares — Flares are temporary exacerbations of RA that can occur in addition to the ongoing inflammation. In people who are already taking methotrexate or oral steroids, flares can often be controlled by increasing the doses of these drugs. Alternately, flares can be controlled by steroids that are given by injection. Rest is often helpful during flares; hospitalization is rarely necessary.
WHICH TREATMENT DO I NEED? — The type and sequence of drugs used to treat RA depends upon three factors: the activity, severity, and stage of rheumatoid arthritis.
Activity of rheumatoid arthritis — The activity of rheumatoid arthritis refers to the presence of joint swelling (inflammation). This can be measured with a combination of a physical examination, blood tests, severity of symptoms (pain, stiffness), and changes in the joints seen on x-ray.
Severity of rheumatoid arthritis — The severity of RA is based upon the severity of inflammation. Severity is classified as mild, moderate, or severe.
Mild — A person with mild RA has some of the following signs and symptoms:
Mild RA is usually treated initially with nonpharmacologic therapies and an NSAID. Only one NSAID is recommended at a time. This combination is continued only until inflammation has subsided.
If one or more joints remain swollen or tender after a few weeks of treatment with an NSAID, one or more DMARDs may be recommended, including methotrexate, hydroxychloroquine, or sulfasalazine. These medications are discussed in more detail in a separate topic review. (See "Patient information: Disease modifying antirheumatic drugs (DMARDs)").
Oral glucocorticoids (steroids) are not frequently recommended for people with mild RA. However, a glucocorticoid may be injected into a joint that is particularly painful; this can quickly reduce pain and swelling until the DMARDs begin to work.
More aggressive therapy is needed if rheumatoid arthritis remains active or progresses after three to six months of treatment with hydroxychloroquine and/or sulfasalazine. (See "Moderate" below").
Moderate — A person with moderate rheumatoid arthritis has a combination of the following signs and symptoms:
Moderate rheumatoid arthritis is initially treated with nonpharmacologic therapies, a high dose NSAID, and one or more DMARD. The choice of a DMARDs is based on the activity of the rheumatoid arthritis and the harm versus benefit of a particular drug for the individual. The choice is between hydroxychloroquine, sulfasalazine, and methotrexate. These medications may also be recommended in combination.
A clinician may also recommend short-term treatment with an oral steroid; this can relieve symptoms until the DMARD becomes effective. The steroid may be injected directly into one or a few joints to rapidly control inflammation and pain.
A biologic response modifier may be recommended if inflammation persists despite high doses of one or more DMARDs or if a person cannot take methotrexate. In this case, an anti-TNF agent, such as etanercept, adalimumab, or infliximab, is usually recommended, along with methotrexate (see "Biologic response modifiers" above). If one anti-TNF agent is ineffective or causes bothersome side effects, a second anti-TNF treatment may be tried. Alternately, another biologic agent, such as abatacept or rituximab, may be tried.
Severe — A person with severe rheumatoid arthritis has one or more of the following signs and symptoms:
Severe rheumatoid arthritis is initially treated with nonpharmacologic therapies and NSAIDs plus one or more of the DMARDs. The NSAID is usually discontinued after two to four weeks because NSAIDs have no long-term benefit in preventing destruction of a joint.
Methotrexate is the DMARD of choice; it is usually taken by mouth initially, and the dose may be increased as frequently as every week or two. As the dose is increased, the healthcare provider may recommend that methotrexate be injected under the skin (subcutaneous) or into a muscle (intramuscular) to minimize bothersome side effects such as upset stomach and sore mouth. A second and perhaps third DMARD may be recommended in addition to methotrexate.
Oral steroids may be added if there are symptoms of widespread inflammation, such as fever. The dose of the steroid is reduced as the person begins to improve; the goal is to take the lowest possible dose for the shortest period of time to minimize side effects (see "Steroids (glucocorticoids)" above).
A biologic response modifier may be recommended in people with severe disease who do not respond adequately to methotrexate. An anti-TNF agent, such as etanercept, adalimumab, or infliximab, are usually recommended first, along with methotrexate. If one anti-TNF treatment is ineffective or causes bothersome side effects, a second anti-TNF agent may be tried. Alternately, another biologic agent, such as abatacept or rituximab, may be tried.
Stage of rheumatoid arthritis — The stage of RA helps to determine which treatments are best. The stage is determined by the duration of the condition and the presence of inflammation. There are three stages: early, persistently active, and end-stage rheumatoid arthritis.
Early — A person with early RA has had evidence of inflammation for no more than six months. The treatment of early rheumatoid entails aggressive measures to slow or stop ongoing inflammation and protect the joints.
Persistently active — A person with persistently active RA has had evidence of inflammation for at least six to twelve months and may have irreversible joint damage and loss of function. The treatment of persistently active rheumatoid includes aggressive measures to slow or stop ongoing inflammation and measures to slow or prevent additional changes in joint structure and function.
End-stage — A person with end-stage RA has little or no evidence of ongoing inflammation but often has significant joint damage with deformity and loss of joint function. The treatment of end-stage rheumatoid arthritis entails therapies that reduce pain and slow or prevent additional changes in joint structure and function.
Patients with end-stage RA may have pain due to joint damage rather than from inflammation. In this case, a clinician may recommend surgery to replace a damaged joint. (See "Patient information: Total hip replacement (arthroplasty)" and see "Patient information: Total knee replacement (arthroplasty)").
However, some joints cannot be successfully replaced. For such joints, a surgical fusion may be recommended to limit movements that cause pain.
Pregnancy — Treatment of rheumatoid arthritis during pregnancy is discussed in detail in a separate topic review. (See "Patient information: Rheumatoid arthritis and pregnancy").
CLINICAL TRIALS — Researchers are continually conducting clinical trials of rheumatoid arthritis treatments to find better ways of treating the disease. A clinical trial is a carefully controlled way to study the effectiveness of new treatments or new combinations of known therapies. For more information about clinical trials, visit http://clinicaltrials.gov/
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.
(www.nlm.nih.gov/medlineplus/healthtopics.html)
(301) 496-8188
(www.nih.gov/niams)
(404) 633-3777
(www.rheumatology.org)
(800) 283-7800
(www.arthritis.org)
[5-9]
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Here is the page link:
Good post!
Thanks, Lev for posting this.Last literature review version 17.1: January 2009 | This topic last updated: February 11, 2008 (More)
INTRODUCTION — Rheumatoid arthritis (RA) is a chronic inflammatory condition. The condition can affect many tissues throughout the body, but the joints are usually most severely affected. The specific causes of rheumatoid arthritis are unknown.
Rheumatoid arthritis symptoms develop gradually, and it is not always possible to know when it first developed. Many people have symptoms that are present continuously, some have symptoms which completely resolve, and others have alternating periods of bothersome symptoms and complete resolution. The onset, severity, and specific symptoms of this condition can vary greatly from person to person.
Treatment plays a key role in controlling the inflammation of rheumatoid arthritis and minimizing joint damage. Treatment usually entails a combination of drug therapy and other non-drug therapies. In some cases, treatment may also involve surgery.
The treatment of rheumatoid arthritis in a particular individual must be tailored to their particular case, including the severity of the condition, the effectiveness of specific therapies, and the occurrence of any side effects. Treatment choices may be different for a person with rheumatoid arthritis who has other illnesses, especially those of the liver or kidneys. It is important to work with a healthcare provider to create an effective and acceptable plan for treating rheumatoid arthritis.
This topic review discusses the traditional medical treatments that are used for patients with rheumatoid arthritis. A number of other topics about rheumatoid arthritis are available separately. (See "Patient information: Rheumatoid arthritis symptoms and diagnosis" and see "Patient information: Disease modifying antirheumatic drugs (DMARDs)" and see "Patient information: Rheumatoid arthritis and pregnancy" and see "Patient information: Complementary therapies for rheumatoid arthritis").
GENERAL PRINCIPLES OF TREATMENT — The aim of RA treatment is to control a patient's signs and symptoms, and to maintain their quality of life and ability to function [1]. Joint damage caused by RA generally occurs within the first two years of diagnosis, and it is difficult to predict which individuals will develop long-term complications. Therefore, the initial treatment of RA aims to eliminate or minimize inflammation. However, the risk of side effects from treatment must be weighed against the benefits. Treatments that can potentially stop joint damage are generally recommended for all patients with RA.
Long-term medical care with regularly scheduled visits is essential for the successful treatment of rheumatoid arthritis. This care often entails medical visits and tests to assess the effectiveness of treatment and monitor for side effects.
NONPHARMACOLOGIC THERAPIES — Nonpharmacologic therapies include treatments other than medications, and are the foundation of treatment for all people with RA. There are a wide variety of nonpharmacologic therapies available.
Education and counseling — Education and counseling can help a person better understand the nature of rheumatoid arthritis and cope with the challenges of this condition. People with RA and their healthcare providers can work together to formulate a long-term treatment plan, define reasonable expectations, and evaluate both standard and alternative treatment options.
Nonpharmacologic measures such as biofeedback and cognitive behavioral therapy can be very effective for controlling the symptoms of RA. These measures can reduce pain and disability and improve self-esteem. Programs on topics such as self-management skills, social support, biofeedback, and psychotherapy are offered by the Arthritis Foundation and by many hospitals and clinics (www.arthritis.org/communities/Chapters/ChapDirectory.asp). These programs have been shown to reduce pain, depression, and disability in people with arthritis and to allow them to gain some control over their illness.
Rest — Fatigue is a common symptom of RA. Resting inflamed joints by taking naps often helps restore energy. Rest can often be alternated with exercise.
Exercise — Pain and stiffness often prompt people with RA to become inactive. Unfortunately, inactivity can lead to a loss of joint motion, contractions, and a loss of muscle strength. Weakness, in turn, decreases joint stability and further increases fatigue.
Regular exercise can help prevent and reverse these effects [2]. Several different kinds of exercises can be beneficial, including range of motion exercises to preserve and restore joint motion, exercises to increase strength (isometric, isotonic, and isokinetic exercises), and exercises to increase endurance (walking, swimming, and cycling).
One study suggests that, in the short term, regular aerobic exercise improves muscle function, joint stability, aerobic capacity, physical function, and pain control without worsening arthritis; additional studies are needed to determine if the benefits persist in the long term. Another study suggests that aerobic weight-bearing exercise helps prevent the bone loss associated with steroid treatment and does not worsen rheumatoid arthritis.
Exercise programs for people with rheumatoid arthritis should be designed by a physical therapist and tailored to the severity of the condition, a person's body build, and their former activity level. A separate topic review is available that discusses exercise and arthritis. (See "Patient information: Arthritis and exercise").
Physical therapy — Physical therapy can relieve pain, reduce inflammation, and help preserve joint structure and function for patients with RA.
Specific types of physical therapy are used to address specific effects of RA:
Physical therapy may also include a consultation with a podiatrist who can make foot orthotics (devices that ensure correct position of the foot) and supportive footwear.
Nutrition and dietary therapy — People with active RA may lose their appetite or be unable to eat an adequate amount of food. Dietary therapy helps to ensure that a person consumes an adequate amount of calories and nutrients. However, weight loss may be recommended for overweight and obese people to reduce stress on inflamed joints. (See "Patient information: Weight loss treatments").
People with RA have a higher risk of developing coronary artery disease. High blood cholesterol is one risk factor for coronary disease that can respond to changes in diet. A nutritionist can recommend specific foods to eat or avoid to try to achieve a desirable cholesterol level. (See "Patient information: High cholesterol and lipids (hyperlipidemia)").
Changes in diet have been investigated as treatments for rheumatoid arthritis. The addition of fish oils and some plant oils, such as borage seed oil, have resulted in modest improvement in arthritis pain and in joint swelling [3]. However, there is no diet that can cure rheumatoid arthritis. No herbal or nutritional supplements, such as cartilage and collagen, can cure RA; these treatments can be dangerous in some cases and are not recommended. (See "Patient information: Complementary therapies for rheumatoid arthritis").
Measures to reduce bone loss — Rheumatoid arthritis causes bone loss, which can lead to osteoporosis. Bone loss is more likely with an increasing level of disability and a decreasing level of weight-bearing activity. The use of prednisone or other steroid drugs further accelerates bone loss, especially in postmenopausal women. (See "Patient information: Osteoporosis causes, diagnosis, and screening").
Several measures can minimize the bone loss associated with steroid therapy [4]:
DRUG THERAPY — Drug therapy is the cornerstone of treatment for active RA. Drug therapy is appropriate for anyone with RA, with the exception of selected people who are in remission. The goals of drug therapy are to achieve remission and prevent further damage of the joints and loss of function, without causing permanent or unacceptable side effects.
The type and intensity of drug therapy depends upon the severity of RA, the presence of factors associated with a better or worse prognosis, the effectiveness of previous treatments, and potential drug side effects. In most cases, the dose of drug therapy is increased until inflammation is suppressed or drug side effects become unacceptable.
The challenge of drug therapy is to balance the side effects against the need to control inflammation. All patients with RA who use medications need regular medical care and blood tests to monitor for complications. The frequency and type of testing is determined by the type of medication used. If side effects occur, they can often be minimized or eliminated by reducing the dose or switching to a different drug.
Several classes of drugs are used to treat rheumatoid arthritis: Non-steroidal antiinflammatory drugs (NSAIDs), disease modifying antirheumatic drugs (DMARDs), biologic response modifiers, steroids, and if needed, analgesics.
Nonsteroidal anti-inflammatory drugs — Nonsteroidal anti-inflammatory drugs (NSAIDs) may be recommended to relieve pain and reduce minor inflammation. However, NSAIDs do not reduce the long term damaging effects of rheumatoid arthritis on the joints. NSAIDs must be taken continuously and at a specific dose to have an anti-inflammatory effect (show table 1). Even at the correct doses, NSAIDs must usually be taken for two to four weeks before their effectiveness is known. If the initial dose of NSAIDs does not improve symptoms, a clinician may recommend increasing the dose gradually or switching to another NSAID. People taking an NSAID should not take a second NSAID at the same time.
Many NSAIDS have significant side effects, including gastrointestinal bleeding, fluid retention, and an increased risk of heart disease. The risks need to weighed carefully against the benefit when taking these drugs.
More detailed information about NSAIDs is available in a separate topic review. (See "Patient information: Nonsteroidal antiinflammatory drugs (NSAIDs)").
Disease-modifying antirheumatic drugs — Disease-modifying antirheumatic drugs (DMARDs) can substantially reduce the inflammation of RA, although they act slowly. However, DMARDs can help to reduce the dose of steroids that is necessary to control pain and inflammation. Studies suggest that DMARDs can reduce or prevent joint damage, preserve joint structure and function, and enable a person to continue his or her daily activities.
Drugs in this class include hydroxychloroquine (Plaquenil®), methotrexate (Rheumatrex®), gold salts (Ridaura®, Solganal®), D-penicillamine (Depen®, Cuprimine®), sulfasalazine (Azulfidine®), azathioprine (Imuran®), leflunomide (Arava®), and cyclosporine (Sandimmune®, Neoral®). Detailed information about these medications is available in a separate topic review. (See "Patient information: Disease modifying antirheumatic drugs (DMARDs)").
Several weeks to months of treatment are often necessary before the effects of DMARDs become evident. An improvement in symptoms may require four to six weeks of treatment with methotrexate, one to two months of treatment with sulfasalazine, and two to three months of treatment with hydroxychloroquine. Even longer durations of treatment may be needed to derive the full benefits of these drugs.
Minocycline — In some people with early RA, taking an antibiotic (minocycline) may have some benefit. This treatment may be a reasonable alternative to hydroxychloroquine and sulfasalazine.
Biologic response modifiers — Biologic response modifiers, also known as biologics, are medications that were designed to prevent or reduce the inflammation that damages joints. Biologics target molecules on cells of the immune system, joint, and the products that are secreted in the joint, all of which can cause inflammation and joint destruction. There are several types of biologics, each of which targets a specific type of molecule involved in this process (tumor necrosis factor, interleukin-1, and cell surface molecules on T and B lymphocytes).
Unlike DMARDs, which can take a month or more to begin working, biologics work rapidly, within two weeks for some medications (Enbrel®, Humira®, Remicade®) and within four to six weeks for others (Rituxan®, Orencia®). Biologics may be used alone or in combination with other DMARDs (eg, methotrexate), NSAIDs, and/or steroids.
Because of their cost (generally more than ,000 per year in the United States), biologics are often reserved for people who have not completely responded to DMARDs and for those who cannot tolerate DMARDs in doses large enough to control inflammation.
All biologic response modifiers must be injected. Humira®, Enbrel®, and Kineret® are injected under the skin by the patient, a family member, or nurse. Remicade®, Orencia® and Rituxan® must be injected into a vein, which is typically done in a doctor's office or clinic; this takes between one and three hours to complete.
Side effects — Biologic response modifiers interfere with the immune system's ability to fight infection and should not be used in people with serious infections.
Testing for tuberculosis is necessary before starting anti-TNF therapy. People who have evidence of prior TB infection should be treated because there is an increased risk of developing active TB while receiving anti-TNF therapy. (See "Patient information: Tuberculosis").
TNF-inhibitors are not recommended for people who have lymphoma or have been treated for lymphoma in the past; people with RA, especially those with severe disease, have an increased risk of lymphoma regardless of what treatment is used. TNF-inhibitors have been associated with a further increase in the risk of lymphoma in some studies; more research is needed to define this risk.
Steroids (glucocorticoids) — Steroids have strong anti-inflammatory effects. Drugs in this class include prednisone and prednisolone. Steroids may be taken by mouth, injected into a vein, or injected directly into a joint. Steroids quickly improve symptoms of rheumatoid arthritis such as pain and stiffness, and also decrease joint swelling and tenderness.
However, when used alone, steroids only modestly reduce damage to cartilage and bone caused by RA. Steroids are generally used to treat RA that severely limits a person's ability to fu