How Rheumatoid Arthritis Is Treated

A Holistic Approach From Self-Care to Surgery

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While there is no cure for rheumatoid arthritis, there is an ever-increasing range of treatments able to alleviate the pain and swelling of this chronic inflammatory disorder. They include self-care remedies, diet, over-the-counter and prescription pain relievers, physical therapy, and newer generation disease-modifying drugs (DMARDs). Severe cases may require in-office procedures like arthrocentesis or surgeries to either repair or replace the damaged joint.

Home Remedies and Lifestyle

Rheumatoid arthritis is a chronic, progressive disease that needs to be managed as part of your life. Rather than just treating the disease with drugs, you need to take a holistic approach aimed at improving your overall health and mitigating the risk factors that place you in harm's way.

It's all about embracing healthy behaviors and changing how you respond to acute attacks.

Diet

Even if only your hands are affected, being overweight or obese triggers inflammation due to the release of inflammatory proteins (called cytokines) from fat cells. This only serves to aggravate the symptoms of rheumatoid arthritis and add needless stress to the joints of the lower extremities.

While there is no specific a diet for people with rheumatoid arthritis, many doctors endorse a Mediterranean diet which provides a healthy balance of proteins, fats, and carbohydrates while encouraging an increased intake of fish (rich in anti-inflammatory omega-C fatty acids), whole grains, vegetables, fruit, and healthy oils (like olive oil).

Exercise

Rheumatoid arthritis is also characterized by stiffness due to the progressive damage of synovial tissues in the joint space. By embarking on an informed workout plan, you can lose weight and sustain the range of motion of an affected joint. A sedentary lifestyle, by contrast, allows joint tissues to "tether"—effectively bond together like glue—leading to the permanent restriction of movement.

Exercise can also ensure that your bones remain strong and fight the symptoms of osteoporosis common in people with rheumatoid arthritis.

Smoking

We all know that smoking is not good for us, but it can be especially bad if you have rheumatoid arthritis. Cigarette smoke does insidious things to your body, not only triggering inflammation but causing the constriction of blood vessels to a point where circulation can be altogether stopped in certain parts of the body.

This can promote the development of rheumatoid vasculitis, a common disease complication characterized by chronic fatigue, skin ulcers and rashes, fever, weight loss, and muscle and joint pain. Moreover, research has shown that smoking can even increase your risk of getting rheumatoid arthritis, in some cases by as much as 300 percent.

While quitting cigarette can be tough, the benefits to your (joint and general) health can be enormous. Speak with your doctor about treatment options. Drugs like Zyban (bupropion) and Chantix (varenicline) can be effective in some smokers and will not interfere with your rheumatoid arthritis drugs.

Over-the-Counter (OTC) Remedies

As part of your first-line treatment plan, your doctor will typically recommend an over-the-counter (OTC) nonsteroidal anti-inflammatory drugs (NSAID) to alleviate mild to moderate pain and swelling.

These include such popular OTC brands as Aleve (naproxen) or Advil (ibuprofen). In addition to having anti-inflammatory properties, NSAIDs are also analgesic and antipyretic (meaning that they can relieve pain and fever, respectively).

NSAIDs do not slow the progression of the disease. If symptoms worsen, your doctor may prescribe stronger NSAIDs such as Celebrex (celecoxib) or Voltaren (diclofenac). NSAID side effects include stomach upset, high blood pressure, ringing in your ears, gastric ulcers, and liver toxicity.

Prescriptions

If you have been diagnosed with rheumatoid arthritis, your doctor will commonly prescribe a combination of medications, some of which treat the symptoms and others that address the underlying autoimmune disorder.

These include oral and injected corticosteroids, disease-modifying antirheumatic drugs (DMARDs), and newer-generation biologic drugs.

Corticosteroids

Corticosteroids are highly-effective but potent drugs that can reduce inflammation and help moderate autoimmune activity. Corticosteroids work by mimicking cortisol, the adrenal hormone that helps regulate inflammation, metabolism, memory, and blood sugar.

They are often prescribed as part of a multi-drug therapy and are delivered either orally (in pill form), by injection (into a muscle or joint space), or intravenously (into a vein). Prednisone is the drug most commonly used for rheumatoid arthritis.

Corticosteroids are only prescribed for short-term use due to the increased risk of side effects, including osteoporosis, weight gain, easy bruising, cataracts, glaucoma, and diabetes. When taken orally, they are prescribed in low doses and usually taken in the morning. Injections are reserved for acute attacks and used no more than three or four times a year.

DMARDs

Disease-modifying antirheumatic drugs (DMARDs) work by tempering the overall immune response. As an autoimmune disease, rheumatoid arthritis is caused by a malfunction of the immune system in which normals cell are targeted for attack. The role of DMARDs is to suppress the immune system as a whole.

DMARDs work most effectively when they are taken as soon as possible after the disease is diagnosed. There are literally dozens of DMARDs approved for the treatment, which include older generation drugs like Plaquenil (hydroxychloroquine) and newer ones like Arava (leflunomide). Most are taken orally.

By far, the most commonly prescribed DMARD is methotrexate. Methotrexate has been around for more than 50 years and continues to be the backbone of rheumatoid arthritis treatment. Among its many advantages, methotrexate can be taken safely for long periods of time, usually requires once-weekly dosing, and can even be used in children.

On the downside, methotrexate can cause liver toxicity and bone marrow suppression. Periodic blood tests are needed to avoid these complications. Other side effects include fatigue, nausea, stomach upset, rash, diarrhea, mouth sores, and easy bruising. Taking a daily folic acid supplement may help reduce some of these drug-related side effects.

Avoid methotrexate if you are pregnant or trying to get pregnant as it may cause birth defects.

Biologic Response Modifiers

Biologic response modifiers are a newer type of DMARD which targets specific parts of the immune system rather than the whole. They are considered biologic because they are not man-made but are derived from human or animal proteins.

While biological drugs used to treat rheumatoid arthritis have different mechanisms of action, they all work by blocking a specific immune target: either tumor necrosis factor (TNF) (whose role it is to signal inflammation), interleukin (which regulates the immune response), and T-cells (which target and attack suspected pathogens).

Commonly prescribed biologic drugs include:

Biologics are delivered either by injection or intravenously and are generally prescribed for people who have not responded to other treatments.

Because biologics interfere with the immune processes, people on treatment may be at greater risk of infection. As such, any cut, sore, or sign of infection be should be treated by a doctor. Common side effects include injection site pain, respiratory infections, and flu-like symptoms.

JAK Inhibitors

Janus kinase (JAK) inhibitors are a newer class of non-biologic DMARD that work by blocking the inflammatory process inside of a cell. Jafaki (ruxolitinib) and Xeljanz (tofacitinib) are the first JAK inhibitors approved for use in the U.S. Both are taken orally and prescribed to people who have either not responded adequately to methotrexate or have failed on biologics.

JAK inhibitors are used in combination with methotrexate and taken twice daily. Side effects include headache, fatigue, stomach irritation, flu-like symptoms, diarrhea, high cholesterol, and an increased risk of infection.

Physical Therapy

In addition to medication, your doctor may refer you to a rehabilitative specialist who can work with you to restore joint function and mobility. These include physical therapists and occupational therapists.

Physical therapy focuses on building strength and improving mobility. People with moderate to severe rheumatoid arthritis tend to work with a physical therapist on an ongoing basis and may be exposed different techniques based on their symptoms or limitations.

The therapies may include:

Occupational therapy aims to support your independence and improve your quality of life by helping you overcome physical limitations, often with the use of assistive tools and devices.

Examples include:

  • Installing larger doorknobs or handles that are easier to grip
  • Finding ergonomic chairs that allow you sit without discomfort
  • Choosing canes, walkers or other mobility devices appropriate to your need
  • Rearranging cabinets and shelves so items are easier to reach
  • Replacing light switches with sliders
  • Using voice-command rather than keypad controls

Other specialists, including podiatrists, massage therapists, and psychologists, may be sought to overcome other physical and emotional barriers.

Pre-Surgical Options

Surgery is always considered a last option if you have rheumatoid arthritis. Prior to even considering surgery, your doctor may want to explore minimally invasive, in-office techniques, especially if you are young and in otherwise good health.

Among the options is a procedure known as arthrocentesis in which fluid is extracted from a joint space with a needle to relieve pressure. It is often used as a mean of diagnosis but can be just as effective in cases where fluid build-up is causing significant pain.

An arthrocentesis may be performed on its own or prior to administering a corticosteroid shot. Other intra-articular injections involved the use of hyaluronic acid to lubricate the joint space or platelet-rich plasma (PRP) derived from the person's own blood to stimulate the production of cartilage in heavily damaged joints.

However, there will be times when arthrocentesis will not provide the expected relief, and surgery is the only option.

Surgery

If your joint pain has become unbearable, your doctor may recommend surgery to either repair the damaged joint or replace it. By and large, surgery is only considered if all other options have been exhausted and you are considered a reasonable candidate for the procedure.

Joint Repair

As rheumatoid arthritis progresses, joint tissues can become tethered. while the erosion of cartilage and bone will cause the joint to lose it alignment and shape, resulting in joint deformity. Particularly in the smaller joints where replacement is not an option, surgeons will use different techniques to help restore motion and alleviate pain.

Among the repair options:

  • Arthrodesis, also known as bone and joint fusion, is used to relieve intractable joint pain by bonding bones together to prevent intra-articular movement.
  • Arthroscopy is a procedure in which a lighted scope (called an arthroscope) is inserted into a joint space so that bits of bone and cartilage can be located and removed.
  • Carpal tunnel release, also called nerve release, is a surgery in which the carpal tunnel ligament of the hand is severed to make more space for nerves and tendons.
  • Synovectomy involves the removal of the joint lining, called the synovium, when it becomes chronically inflamed and interferes with the articulation of a joint.

Joint Replacement

Joint replacement surgery, also known as arthroplasty, has been increasingly common in people with rheumatoid arthritis. The decision to explore joint replacement would be based on a review of physical symptoms, treatment history, and findings from imaging tests.

Moreover, your age would play a huge part in the decision given that joint prostheses tend to last anywhere from 15 to 20 years. As such, most surgeons will want to delay the procedure for as long as reasonably possible, typically until you are somewhere in your 50s.

(With that being said, most people with rheumatoid arthritis are having replacements done their early 60s due to the increased effectiveness of newer DMARDs.)

Since DMARDs work by suppressing the immune system, you would need to stop treatment well before and well after surgery to reduce the risk of a potentially serious post-operative infection.

Today, knee and hip replacements have become incredibly safe and effective with a greater than 90 percent success rate. Post-operative complications in people with rheumatoid arthritis are pretty much the same as in anyone else and may include nerve damage, infection, blood clots, and joint dislocation.

Complementary Alternative Medicine (CAM)

In dealing with a chronic, lifelong disorder, people with rheumatoid arthritis will commonly embrace complementary therapies to support their traditional medical treatment.

While many such therapies offer benefits, both real and perceived, it is important to speak with your doctor about any supplement, herb, or traditional medicine you may be taking. This may prevent drug interactions that can undermine your therapy or side effects and toxicities that can make you ill.

Among the remedies considered beneficial to rheumatoid arthritis treatment:

  • Fish oil supplement contains high amounts of two omega-3 fatty acids which the body uses to reduce inflammation. Most studies have shown that a three-gram daily supplement can provide modest relief of mild arthritis pain and stiffness. However, fish oil supplements should be avoided in people who use blood thinners like warfarin as they may increase the risk of bleeding.
  • Borage, evening primrose, and black currant oils, available in gel-cap and liquid formulations, are great sources omega-6 fatty acids which also have anti-inflammatory properties beneficial to people with rheumatoid arthritis. Overuse should be avoided as borage may cause liver damage at high doses, while evening primrose can interfere with phenothiazine drugs used in psychiatric therapies.

Other popularly used complementary remedies such as glucosamine, chondroitin, acupuncture, and magnetic therapy have not been shown to be particularly useful in treating rheumatoid arthritis.

Sources:

National Center for Complementary and Alternative Medicine. "Research Report: Rheumatoid Arthritis and Complementary and Alternative Medicine." Bethesda, Maryland; updated May 4, 2016.

Nikiphorou, E.; Konan, S.; MacGregor, A. et al. "The surgical treatment of rheumatoid arthritis; A new era?" Bone Joint J. 2014; 96-B:1287-9. DOI: 10.1302/0301-620X.96B.34506.

Singh, J.; Saag, K.; Bridges, L. et al. "2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis." Arthritis Care Res. 2016: 68(1);1-25. DOI: 10.1002/acr.22783.

Smolen, J.; Aletaha, D.; and McInnes, I. “Rheumatoid arthritis.Lancet. 2017; 388(10055):2023-38. DOI: 10.1016/So140-6736(16)30173-8.

Sugiyama, D.; Nishimura, K.; Tamaki, K. et al. “Impact of smoking as a risk factor for developing rheumatoid arthritis: a meta-analysis of observational studies.Annals Rheum Dis. 2010; 69(1):70-81. DOI: 10.1136/ard.2008.096487.