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arthritis health center/arthritis a-z list/rheumatoid arthritis article


RHEUMATOID ARTHRITIS (RA)

 * Medical Author: William C. Shiel Jr., MD, FACP, FACR
 * Medical Editor: Melissa Conrad Stöppler, MD

Medically Reviewed on 11/20/2023
 * Introduction
   * What is rheumatoid arthritis (RA)?
 * Causes
   * What causes rheumatoid arthritis?
 * Symptoms
   * What are the symptoms of rheumatoid arthritis?
 * Diagnosis
   * Diagnosis of rheumatoid arthritis
 * Stages
   * What are the four stages of rheumatoid arthritis?
 * Treatment
   * What are the treatments for rheumatoid arthritis?
 * Medications
   * What are types of rheumatoid arthritis medications?
 * Prognosis
   * What is the prognosis for rheumatoid arthritis? Is there a cure for RA?
 * Complications
   * What are the complications of rheumatoid arthritis?
 * Prevention
   * Is it possible to prevent rheumatoid arthritis?
 * Diet, Exercise, and Alternative Therapy
   * Rheumatoid arthritis diet, exercise, therapy, home remedies, and
     alternative therapy


WHAT IS RHEUMATOID ARTHRITIS (RA)?




Understand how your rheumatoid arthritis, as well as the effects and side
effects of its treatment, will be monitored.

Rheumatoid arthritis (RA) is an autoimmune disease that causes chronic
inflammation of the joints. Autoimmune diseases are illnesses that develop when
the body's immune system attacks its tissues. The immune system contains a
complex organization of cells and antibodies designed normally to "seek and
destroy" invaders of the body, particularly infections. People with autoimmune
diseases have antibodies and immune cells in their blood that target their body
tissues, which can be associated with inflammation. It is not known what
triggers the onset of rheumatoid arthritis. Regardless of the exact trigger, the
result is an immune system that is geared up to promote inflammation in the
joints and occasionally other tissues of the body. Immune cells, called
lymphocytes, are activated and chemical messengers (cytokines, such as tumor
necrosis factor/TNF, interleukin-1/IL-1, and interleukin-6/IL-6) are expressed
in the inflamed areas.

While joint tissue inflammation and inflammatory arthritis are classic RA
features, the disease can also cause extra-articular inflammation and injury in
other organs.

Because it can affect multiple other organs of the body, RA is known as a
systemic illness and is sometimes called rheumatoid disease.

Rheumatoid arthritis that begins in people under 16 years of age is referred to
as juvenile idiopathic arthritis or JIA (formerly juvenile rheumatoid arthritis
or JRA).

Osteoarthritis is a noninflammatory joint disease whereby the cartilage of the
joint thins, typically asymmetrically -- so only one knee or hand may be
affected.


WHAT CAUSES RHEUMATOID ARTHRITIS?




Certain factors increase the risk of RA. The common risk factors are as follows:
sex, age, family history, obesity, smoking, and environmental exposures to
asbestos or silica.

The cause of the autoimmune reaction in rheumatoid arthritis is unknown. Even
though infectious agents such as viruses, bacteria, and fungi have long been
suspected, none has been proven as the cause. The cause of rheumatoid arthritis
is a very active area of worldwide research.

Does rheumatoid arthritis run in families?

 * It is believed that the tendency to develop rheumatoid arthritis may be
   genetically inherited (hereditary).
 * Certain genes have been identified that increase the risk for rheumatoid
   arthritis.
 * It is also suspected that certain infections or factors in the environment
   might trigger the activation of the immune system in susceptible individuals.

What are 5 common risk factors of rheumatoid arthritis?

 * Sex: Women are at a higher risk of RA than men. The incidence is four to five
   times higher in women younger than 50 years of age. However, between 60 and
   70 years, the female/male ratio is only about 2.
 * Age: RA most commonly begins in middle age. In some cases, RA may begin in
   teens younger than 16 years (juvenile RA) of age.
 * Family history: A positive family history increases the risk of RA.
 * Obesity: Women younger than 55 years of age with obesity are at a higher risk
   of RA than men.
 * Smoking and other environmental exposures: Environmental exposure to asbestos
   or silica and smoking are common risk factors for RA.

QUESTION

The term arthritis refers to stiffness in the joints. See Answer



WHAT ARE THE SYMPTOMS OF RHEUMATOID ARTHRITIS?




Picture of rheumatoid arthritis joint deformity in the feet; Image provided by
Getty Images

RA symptoms come and go, depending on the degree of tissue inflammation. When
body tissues are inflamed, the disease is active. When tissue inflammation
subsides, the disease is inactive (in remission).

Remissions can occur spontaneously or with treatment and can last weeks, months,
or years. During remissions, symptoms of the disease disappear, and people
generally feel well. When the disease becomes active again (relapse), symptoms
return. The return of disease activity and symptoms is called a flare.

The course of rheumatoid arthritis varies among affected individuals, and
periods of flares and remissions are typical.

WHAT DOES RHEUMATOID ARTHRITIS FEEL LIKE?

When the disease is active, RA symptoms and signs can include:

 * fatigue,
 * loss of energy,
 * lack of appetite,
 * low-grade fever,
 * muscle and joint pain,
 * joint redness,
 * joint swelling,
 * joint tenderness,
 * joint warmth,
 * joint deformity,
 * rheumatoid nodules,
 * stiffness,
 * loss of joint range of motion,
 * loss of joint function, and
 * limping.

People with active inflammation of joints from RA can also experience:

 * depression,
 * anemia
 * frustration, and
 * social withdrawal.

Muscle and joint stiffness are usually most notable in the morning and after
periods of inactivity. This is referred to as morning stiffness and
post-sedentary stiffness. Arthritis is common during disease flares. Also,
during flares, joints frequently become warm, red, swollen, painful, and tender.
This occurs because the lining tissue of the joint (synovium) becomes inflamed,
resulting in the production of excessive joint fluid (synovial fluid). The
synovium also thickens with inflammation (synovitis).

How serious is rheumatoid arthritis?

Rheumatoid arthritis usually inflames multiple joints and affects both sides of
the body. In its most common form, therefore, it is referred to as asymmetric
polyarthritis.

 * Early rheumatoid arthritis symptoms may be subtle.
 * The small joints of both the hands and wrists are often involved.
 * Early symptoms of RA can be painful and prolonged stiffness of joints,
   particularly in the morning.
 * Symptoms in the hands with rheumatoid arthritis include difficulty with
   simple tasks of daily living, such as turning doorknobs and opening jars.
 * The small joints of the feet are also commonly involved, which can lead to
   painful walking, especially in the morning after arising from bed.
 * Occasionally, only one joint is inflamed. When only one joint is involved,
   arthritis can mimic the joint inflammation caused by other forms of
   arthritis, such as gout or joint infection.
 * Chronic inflammation can cause damage to body tissues, including cartilage
   and bone. This leads to a loss of cartilage and erosion and weakness of the
   bones as well as the muscles, resulting in joint deformity, loss of range of
   motion, destruction, and loss of function.
 * Rarely, rheumatoid arthritis can even affect the joint that is responsible
   for the tightening of our vocal cords to change the tone of our voice, the
   cricoarytenoid joint. When this joint is inflamed, it can cause hoarseness of
   the voice.
 * Symptoms in children with rheumatoid arthritis include limping, irritability,
   crying, and poor appetite.


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DIAGNOSIS OF RHEUMATOID ARTHRITIS



There is no singular test for diagnosing rheumatoid arthritis. The diagnosis is
based on the clinical presentation.

What are the diagnostic criteria for rheumatoid arthritis?

 * Presentation of the joints involved
 * Characteristic joint swelling and stiffness in the morning
 * The presence of blood rheumatoid factor (RF blood test or RA test) and
   citrulline antibody
 * The presence of rheumatoid nodules and radiographic changes (X-ray testing)

Understand that many forms of joint disease mimic rheumatoid arthritis.

 * The first step in the diagnosis of rheumatoid arthritis is a meeting between
   the doctor and the patient. The doctor reviews the history of symptoms. Then
   the doctor checks the joints for inflammation, tenderness, swelling, and
   deformity and looks for rheumatoid skin nodules. Rheumatoid nodules are firm
   lumps or bumps under the skin, most commonly over the elbows or fingers). The
   doctor will also check other parts of the body for inflammation. Certain
   blood and X-ray tests are often obtained. The diagnosis will be based on the
   pattern of symptoms, the distribution of the inflamed joints, and the blood
   and X-ray findings. Several visits may be necessary before the doctor can be
   certain of the diagnosis. A doctor with special training in arthritis and
   related diseases is called a rheumatologist.
 * Joint inflammation helps to distinguish rheumatoid arthritis from common
   types of arthritis that are not inflammatory, such as osteoarthritis or
   degenerative arthritis. The distribution of joint inflammation is also
   important to the doctor in making a diagnosis. In rheumatoid arthritis, the
   small joints of the hands and fingers, wrists, feet, and knees are typically
   inflamed in a symmetrical distribution (affecting both sides of the body).
   When only one or two joints are inflamed, the diagnosis of rheumatoid
   arthritis becomes more difficult. The doctor may then perform other tests to
   exclude arthritis due to infection or gout. The detection of rheumatoid
   nodules (described above), most often around the elbows and fingers, can
   suggest the diagnosis.
 * Abnormal antibodies can be found in the blood of people with rheumatoid
   arthritis with simple blood testing. An antibody called "rheumatoid factor"
   (RF) can be found in 80% of patients with rheumatoid arthritis. Patients with
   rheumatoid arthritis and rheumatoid factor are referred to as having
   "seropositive rheumatoid arthritis." Patients who are felt to have rheumatoid
   arthritis and do not have positive rheumatoid factor testing are referred to
   as having "seronegative rheumatoid arthritis."
 * Citrulline antibody (also referred to as anti-citrulline antibody,
   anti-cyclic citrullinated peptide antibody, and anti-CCP antibody) is present
   in 50%-75% of people with rheumatoid arthritis. It is useful in the diagnosis
   of rheumatoid arthritis when evaluating cases of unexplained joint
   inflammation. A test for anti-citrullinated protein antibodies helps in
   looking for the cause of previously undiagnosed inflammatory arthritis when
   the rheumatoid factor is not present. Citrulline antibodies have been felt to
   represent the earlier stages of rheumatoid arthritis in this setting.
   Citrulline antibodies also have been associated with more aggressive forms of
   rheumatoid arthritis. Another antibody called the "antinuclear antibody"
   (ANA) is also frequently found in people with rheumatoid arthritis.
 * It should be noted that many forms of arthritis in childhood (juvenile
   inflammatory arthritis) are not associated with blood test positivity for
   rheumatoid factors. In this setting, juvenile rheumatoid arthritis must be
   distinguished from other types of joint inflammation. These include plant
   thorn arthritis, joint injury, arthritis of inflammatory bowel disease, and
   rarely joint tumors.
 * A blood test called the erythrocyte sedimentation rate (sed rate) is a crude
   measure of the inflammation of the joints. The sed rate measures how fast red
   blood cells fall to the bottom of a test tube. The sed rate is usually faster
   (high) during disease flares and slower (low) during remissions. Another
   blood test that is used to measure the degree of inflammation present in the
   body is the C-reactive protein (CRP). Blood testing may also reveal anemia,
   since anemia is common in rheumatoid arthritis, particularly because of
   chronic inflammation.
 * The rheumatoid factor, ANA, sed rate, and C-reactive protein (CRP) tests can
   also be abnormal in other systemic autoimmune and inflammatory medical
   conditions. Therefore, abnormalities in these blood tests alone are not
   sufficient for a firm diagnosis of rheumatoid arthritis.
 * Joint X-rays may be normal or only show swelling of soft tissues early in the
   disease. As the disease progresses, X-rays can reveal bony erosions typical
   of rheumatoid arthritis in the joints. Joint X-rays can also help monitor the
   progression of the disease and joint damage over time. Bone scanning, a
   procedure using a small amount of a radioactive substance, can also be used
   to show inflamed joints. MRI scanning can also be used to show joint damage.
 * The doctor may elect to perform an office procedure called arthrocentesis. In
   this procedure, a sterile needle and syringe are used to drain joint fluid
   out of the joint for study in the laboratory. Analysis of the joint fluid in
   the laboratory can help to exclude other causes of arthritis, such as
   infection and gout. Arthrocentesis can also help relieve joint swelling and
   pain. Occasionally, cortisone medicines are injected into the joint during
   arthrocentesis to rapidly relieve joint inflammation and further reduce
   symptoms.

Is there a genetic marker for rheumatoid arthritis?

Four known genetic markers associated with rheumatoid arthritis (RA) include:

 1. Human leukocyte antigens: The most common and significant genetic mutation
    associated with RA.
 2. Signal transducer and activator of transcription 4 (STAT4): Responsible for
    the regulation and activation of the immune system.
 3. Tumor necrosis factor receptor-associated factors (TRAF1/C5): Have a major
    role in chronic inflammation.
 4. Protein tyrosine phosphatase 22 (PTPN22) genes: Influence the progression
    and expression of RA.


WHAT SPECIALISTS TREAT RHEUMATOID ARTHRITIS?



The primary specialist for diagnosing, managing, and monitoring rheumatoid
arthritis is a rheumatologist. The rheumatologist works together with the
primary doctor and other specialists to maximize health outcomes and minimize
comorbid health conditions.

Other specialists involved in the care of RA patients include the following:

 * physiatrists
 * dermatologists
 * pulmonologists
 * cardiologists
 * nephrologists
 * radiologists
 * neurologists
 * endocrinologists
 * orthopedists
 * general surgeons

Ancillary health care providers who can be involved in the care of patients with
rheumatoid arthritis include physical therapists, occupational therapists, and
massage therapists.


WHAT ARE THE FOUR STAGES OF RHEUMATOID ARTHRITIS?



The American College of Rheumatology has developed a system for classifying
rheumatoid arthritis that is primarily based on the X-ray appearance of the
joints. This system helps medical professionals classify the severity of your
rheumatoid arthritis concerning cartilage, ligaments, and bone. The system
defines the four stages of RA as follows:

STAGE I (EARLY RA)

 * No damage was seen on X-rays, although there may be signs of bone thinning

STAGE II (MODERATE PROGRESSIVE)

 * On X-ray, evidence of bone thinning around a joint with or without slight
   bone damage
 * Slight cartilage damage is possible
 * Joint mobility may be limited; no joint deformities were observed
 * Atrophy of adjacent muscle
 * Abnormalities of soft tissue around the joint are possible

STAGE III (SEVERE PROGRESSION)

 * On X-ray, evidence of cartilage and bone damage and bone thinning around the
   joint
 * Joint deformity without permanent stiffening or fixation of the joint
 * Extensive muscle atrophy
 * Abnormalities of soft tissue around the joint are possible

STAGE IV (TERMINAL PROGRESSION)

 * On X-ray, evidence of cartilage and bone damage and osteoporosis around joint
 * Joint deformity with permanent fixation of the joint (referred to as
   ankylosis)
 * Extensive muscle atrophy
 * Abnormalities of soft tissue around the joint are possible

Rheumatologists also classify the functional status of people with rheumatoid
arthritis as follows:

 * Class I: completely able to perform usual activities of daily living
 * Class II: able to perform usual self-care and work activities but limited in
   activities outside of work (such as playing sports, and household chores)
 * Class III: able to perform usual self-care activities but limited in work and
   other activities
 * Class IV: limited in ability to perform usual self-care, work, and other
   activities


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WHAT ARE THE TREATMENTS FOR RHEUMATOID ARTHRITIS?



 * There is no known cure for rheumatoid arthritis.
 * To date, the goal of treatment in rheumatoid arthritis is to reduce joint
   inflammation and pain, maximize joint function, and prevent joint destruction
   and deformity.
 * Early medical intervention has been shown to be important in improving
   outcomes.
 * Aggressive management can improve function, stop damage to joints as
   monitored on X-rays and prevent work disability.
 * Optimal RA treatment involves a combination of medicines, rest,
   joint-strengthening exercises, joint protection, and patient (and family)
   education.
 * Treatment is customized according to many factors such as disease activity,
   types of joints involved, general health, age, and patient occupation.
 * RA treatment is most successful when there is close cooperation between the
   doctor, patient, and family members.


WHAT ARE TYPES OF RHEUMATOID ARTHRITIS MEDICATIONS?



Two classes of medicines are used in treating rheumatoid arthritis: fast-acting
"first-line drugs" and slow-acting "second-line drugs" (also referred to as
disease-modifying antirheumatic drugs or DMARDs).

 * The first-line drugs, such as non-steroidal anti-inflammatory medications
   like aspirin and cortisone (corticosteroids are used to reduce pain and
   inflammation).
 * The slow-acting second-line drugs promote disease remission and prevent
   progressive joint destruction.

The degree of the destructiveness of RA varies among affected individuals. Those
with less destructive RA or disease that has quieted after many active years can
manage their RA with rest plus pain control and anti-inflammatory drugs. Early
treatment with second-line drugs (DMARD) improves function and minimizes
disability and joint destruction, even within months of the diagnosis. Most
people require more aggressive second-line drugs, such as methotrexate, in
addition to anti-inflammatory agents. Sometimes these second-line drugs are used
in combination.

 * The areas of the body other than the joints that are affected by rheumatoid
   inflammation are treated individually. Sjögren's syndrome can be helped by
   artificial tears and humidifying rooms in the home or office. Medicated eye
   drops such as cyclosporine ophthalmic drops (Restasis) and lifitegrast
   ophthalmic drops (Xiidra) are also available to help the dry eyes in those
   affected. Regular eye checkups and early antibiotic treatment for infection
   of the eyes are important. Inflammation of the tendons (tendinitis), bursae
   (bursitis), and rheumatoid nodules can be injected with cortisone.
   Inflammation of the lining of the heart and/or lungs may require high doses
   of oral cortisone.
 * In some cases, with severe joint deformity, surgery may be recommended to
   restore joint mobility or repair damaged joints. Doctors who specialize in
   joint surgery are orthopedic surgeons. The types of joint surgery range from
   arthroscopy to partial and complete replacement of the joint. Arthroscopy is
   a surgical technique whereby a doctor inserts a tube-like instrument into the
   joint to see and repair abnormal tissues.
 * Total joint replacement is a surgical procedure whereby a destroyed joint is
   replaced with artificial materials. For example, the small joints of the hand
   can be replaced with plastic material. Large joints, such as the hips or
   knees, are replaced with metals.




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NON-STEROIDAL ANTI-INFLAMMATORY MEDICATIONS FOR RHEUMATOID ARTHRITIS



Acetylsalicylate (aspirin), naproxen (Naprosyn), ibuprofen (Advil, Medipren,
Motrin), etodolac (Lodine), and diclofenac (Voltaren) are examples of
non-steroidal anti-inflammatory drugs (NSAIDs).

 * NSAIDs are medicines that can reduce tissue inflammation, pain, and swelling.
 * NSAIDs are not cortisone. Aspirin, in doses higher than those used in
   treating headaches and fever, is an effective anti-inflammatory medication
   for rheumatoid arthritis.
 * Aspirin has been used for joint problems since the ancient Egyptian era.
 * The newer NSAIDs are just as effective as aspirin in reducing inflammation
   and pain and require fewer dosages per day.
 * Patients' responses to different NSAID medicines vary. Therefore, it is not
   unusual for a medical professional to try several NSAID drugs in order to
   identify the most effective agent with the fewest side effects.
 * The most common side effects of aspirin and other NSAIDs include stomach
   upset, abdominal pain, ulcers, and even gastrointestinal bleeding.
   * In order to reduce gastrointestinal side effects, NSAIDs are usually taken
     with food. Additional medicines are frequently recommended to protect the
     stomach from the ulcer effects of NSAIDs.
   * These medicines include antacids, sucralfate (Carafate), proton-pump
     inhibitors (Prevacid and others), and misoprostol (Cytotec).
   * Newer NSAIDs include selective Cox-2 inhibitors, such as celecoxib
     (Celebrex), which offer anti-inflammatory effects with less risk of stomach
     irritation and bleeding risk.

Corticosteroid medicines can be given orally or injected directly into joints
(intra-articular injections) and tissues. They are more potent than NSAIDs in
reducing inflammation and in restoring joint mobility and function.

 * Corticosteroids are useful for short periods during severe flares of disease
   activity or when the disease is not responding to NSAIDs.
 * However, corticosteroids can have serious side effects, especially when given
   in high doses for long periods of time.
   * These side effects include weight gain, facial puffiness, thinning of the
     skin and bone, easy bruising, cataracts, risk of infection, muscle wasting,
     and destruction of large joints, such as the hips.
 * Corticosteroids also carry an increased risk of contracting infections.
   * These side effects can be partially avoided by gradually tapering the doses
     of corticosteroids as the patient achieves improvement in symptoms.
 * Abruptly discontinuing corticosteroids can lead to flares of the disease or
   other symptoms of corticosteroid withdrawal and is discouraged.
   * Thinning of the bones due to osteoporosis may be prevented by calcium and
     vitamin D supplements.


SECOND-LINE (SLOW-ACTING) RHEUMATOID ARTHRITIS MEDICATIONS



While "first-line" medicines (NSAIDs and corticosteroids) can relieve joint
inflammation and pain, they do not necessarily prevent joint destruction or
deformity. Rheumatoid arthritis requires medicines other than NSAIDs and
corticosteroids to stop progressive damage to cartilage, bone, and adjacent soft
tissues.

 * The RA medicines needed for the ideal management of the disease are also
   referred to as disease-modifying antirheumatic drugs or DMARDs.
 * These "second-line" or "slow-acting" medicines may take weeks to months to
   become effective. They are used for long periods, even years, at varying
   doses.
 * If maximally effective, DMARDs can promote remission, thereby retarding the
   progression of joint destruction and deformity.
 * Sometimes several DMARD second-line medicines are used together as
   combination therapy.
 * As with the first-line medicines, the doctor may need to try different
   second-line medicines before treatment is optimal.

Hydroxychloroquine (Plaquenil) is related to quinine and has also been used in
the treatment of malaria. It is used over long periods for the treatment of
rheumatoid arthritis.

 * Possible side effects include upset stomach, skin rashes, muscle weakness,
   and vision changes. Even though vision changes are rare, people taking
   Plaquenil should be monitored by an eye doctor (ophthalmologist).

Sulfasalazine (Azulfidine) is an oral medication traditionally used in the
treatment of mild to moderately severe inflammatory bowel diseases, such as
ulcerative colitis and Crohn's colitis. Azulfidine is used to treat rheumatoid
arthritis in combination with anti-inflammatory medicines. Azulfidine is
generally well tolerated.

 * Common side effects include rash and upset stomach. Because Azulfidine is
   made up of sulfa and salicylate compounds, it should be avoided by people
   with known sulfa allergies.

Methotrexate (Rheumatrex, Trexall, Otrexup, Rasuvo) has gained popularity among
doctors as an initial second-line drug because of its effectiveness and
infrequent side effects.

 * It also has an advantage in dose flexibility (dosages can be adjusted
   according to needs).
 * Methotrexate is an immunosuppressive drug. It can affect the bone marrow and
   the liver, even rarely causing cirrhosis.
 * All people taking methotrexate require regular blood tests to monitor blood
   counts and liver function.
 * Taking folic acid as a supplement can reduce the risk of methotrexate side
   effects.

Gold salts were used to treat rheumatoid arthritis throughout most of the past
century. Gold the glucose (Solganal) and gold thiomalate (Myochrysine) are given
by injection, initially weekly, for months to years. Oral gold, auranofin
(Ridaura), was introduced in the 1980s.

 * Side effects of gold (oral and injectable) include skin rash, mouth sores,
   kidney damage with leakage of protein in the urine, and bone marrow damage
   with anemia and low white cell count.
 * Those receiving gold treatment are regularly monitored with blood and urine
   tests.
 * Oral gold can cause diarrhea.
 * These gold drugs have lost favor in the treatment of RA because of the
   availability of more effective treatments, particularly methotrexate.

Immunosuppressive medicines are powerful medicines that suppress the body's
immune system. Several immunosuppressive drugs are used to treat rheumatoid
arthritis. They include methotrexate as described above, azathioprine (Imuran),
and cyclophosphamide (Cytoxan). Immunosuppressive medicines can depress bone
marrow function and cause anemia, a low white cell count, and low platelet
counts. A low white count can increase the risk of infections, while a low
platelet count can increase the risk of bleeding. Methotrexate rarely can lead
to liver cirrhosis, as described above, and allergic reactions in the lung.
Because of potentially serious side effects, immunosuppressive medicines are
used in low doses, usually in combination with anti-inflammatory agents.

Leflunomide (Arava) is available to relieve the symptoms and halt the
progression of the disease. It seems to work by blocking the action of an
important enzyme that has a role in immune activation. Leflunomide can cause
liver disease, diarrhea, hair loss, and/or rash in some people. It should not be
taken just before or during pregnancy because of possible birth defects and is
generally avoided in women who might become pregnant.

Etanercept (Enbrel), infliximab (remicade), and adalimumab (Humira) are examples
of biologic drugs that intercept tumor necrosis factor (TNF) in the joints; TNF
promotes joint inflammation in RA. These TNF-blockers intercept TNF before it
can act on its natural receptor to "switch on" the process of inflammation. This
effectively blocks the TNF inflammation messenger from recruiting the cells of
inflammation. Symptoms can be significant, and often rapidly, improved in those
using these drugs.

Anakinra (Kineret) is another biologic DMARD treatment that is used to treat
moderate to severe rheumatoid arthritis. Anakinra works by binding to a cell
messenger protein (IL-1, a pro-inflammatory cytokine). Anakinra is injected
under the skin daily. Anakinra can be used alone or with other DMARDs.

Rituximab (Rituxan) is an antibody that was first used to treat lymphoma, a
cancer of the lymph nodes. Rituximab can be effective in treating autoimmune
diseases like RA because it depletes B-cells. These are important cells of
inflammation that produce abnormal antibodies that are common in these medical
conditions. Rituximab is used to treat moderate to severely active rheumatoid
arthritis in patients who have failed treatment with TNF-blocking biologics.

Tofacitinib (Xeljanz) is the first in a newer class of medicines used to treat
rheumatoid arthritis called JAK inhibitors. Baricitinib (Olumiant) and
upadacitinib (Rinvoq) are also JAK inhibitors. Tofacitinib, baricitinib, and
upadacitinib treat adults with moderately to severely active RA in which
methotrexate did not work well and who have failed a TNF-blocker biologic.


WHAT IS THE PROGNOSIS FOR RHEUMATOID ARTHRITIS? IS THERE A CURE FOR RA?



 * With early, aggressive treatment, the outlook for those affected by
   rheumatoid arthritis can be very good.
 * The overall attitude regarding the ability to control the disease has changed
   tremendously since the turn of the century. Doctors now strive to eradicate
   any signs of active disease while preventing flare-ups.
 * The disease can be controlled and a cooperative effort by the doctor and
   patient can lead to optimal health.
 * Rheumatoid arthritis causes disability and can increase mortality and
   decrease life expectancy leading to early death.
 * Patients have a less favorable outlook when they have deformity, disability,
   ongoing uncontrolled joint inflammation, and/or rheumatoid disease affecting
   other organs of the body.
 * Overall, rheumatoid arthritis tends to be potentially more damaging when
   rheumatoid factor or citrulline antibody is shown by blood testing. Life
   expectancy improves with earlier treatment and monitoring.
 * Finally, minimizing emotional stress can help improve the overall health of
   people with rheumatoid arthritis. Support and extracurricular groups provide
   those with rheumatoid arthritis time to discuss their problems with others
   and learn more about their illness.

Rheumatoid arthritis is not a curable disease at this time. As the science of
genetics and disease, as well as autoimmunity, evolve, it is very likely that
cures for rheumatoid arthritis will become available.


WHAT ARE THE COMPLICATIONS OF RHEUMATOID ARTHRITIS?




Nerves can become pinched in the wrists to cause carpal tunnel syndrome.

Since rheumatoid arthritis is a systemic disease, its inflammation can affect
organs and areas of the body other than the joints.

 * Arthritis-related inflammation of the glands of the eyes and mouth can cause
   dryness in these areas and is referred to as Sjögren's syndrome. Dryness of
   the eyes can lead to corneal abrasion.
 * Inflammation of the white parts of the eyes (the sclerae) is referred to as
   scleritis and can be very dangerous to the eye.
 * Rheumatoid inflammation of the lung lining (pleuritis) causes chest pain with
   deep breathing, shortness of breath, or coughing. The lung tissue itself can
   also become inflamed and scarred, and sometimes nodules of inflammation
   (rheumatoid nodules) develop within the lungs.
 * Inflammation of the tissue (pericardium) surrounding the heart, called
   pericarditis, can cause chest pain that typically changes in intensity when
   lying down or leaning forward.
 * Rheumatoid arthritis is associated with an increased risk of a heart attack.
 * The rheumatoid disease can reduce the number of red blood cells (anemia) and
   white blood cells.
 * Decreased white cells can be associated with an enlarged spleen (referred to
   as Felty's syndrome) and can increase the risk of infections.
 * The risk of lymph gland cancer (lymphoma) is higher in patients with
   rheumatoid arthritis, especially in those with sustained active joint
   inflammation.
 * Firm lumps or firm bumps under the skin (subcutaneous nodules called
   rheumatoid nodules) can occur around the elbows and fingers where there is
   frequent pressure. Even though these nodules usually do not cause symptoms,
   occasionally they can become infected.
 * Nerves can become pinched in the wrists to cause carpal tunnel syndrome.
 * A rare, serious complication, usually with longstanding rheumatoid disease,
   is blood vessel inflammation (vasculitis). Vasculitis can impair blood supply
   to tissues and lead to tissue death (necrosis). This is most often initially
   visible as tiny black areas around the nail beds or as leg ulcers.


IS IT POSSIBLE TO PREVENT RHEUMATOID ARTHRITIS?



Currently, there is no specific prevention of rheumatoid arthritis. Because
cigarette smoking, exposure to silica minerals, and chronic periodontal disease
all increase the risk for rheumatoid arthritis, these conditions should be
avoided.


RHEUMATOID ARTHRITIS DIET, EXERCISE, THERAPY, HOME REMEDIES, AND ALTERNATIVE
THERAPY



There is no special RA diet or diet "cure" for rheumatoid arthritis. However, it
is thought that a healthy diet is an important complement to medication in the
treatment of rheumatoid arthritis. Research is suggesting that the different
kinds of bacteria in our intestines (microbiome) have a big impact on rheumatoid
arthritis.

What foods worsen rheumatoid arthritis?

 * Dairy
 * Sugar
 * Meat
 * White flour-based products
 * Gluten
 * Alcohol
 * Artificial sweeteners
 * Artificial additives
 * Monosodium glutamate (MSG)
 * Saturated fats
 * Trans fats
 * Vegetable oil
 * Excess salt

What type of diet is recommended for people with rheumatoid arthritis?

Diets higher in fish, grains, and vegetables decrease the risk of developing RA.
The Western diet, defined as including more processed meats, increases the risk.
It is not certain whether this is because of a direct anti-inflammatory effect
of the fish, grains, and vegetables or because of changes in the natural
bacteria in the gut.

Some home remedies may be helpful, although these are not considered as potent
or effective as disease-modifying drugs. Fish oils, such as salmon, and omega-3
fatty acids supplements are beneficial in some short-term studies in rheumatoid
arthritis. This suggests that there may be benefits to adding more fish to the
diet, such as in the popular Mediterranean diet. The anti-inflammatory effects
of curcumin in dietary turmeric, an ingredient in curry, may be beneficial in
reducing symptoms of rheumatoid arthritis.

Diets and food recommendations for people with rheumatoid arthritis

 * Elimination diet
 * Anti-inflammatory diet
 * Mediterranean diet
 * Iron-rich foods
 * Calcium-rich foods
 * Oily fish

Supplements for rheumatoid arthritis

Supplements such as calcium and vitamin D prevent osteoporosis in patients with
rheumatoid arthritis. Folic acid is used as a supplement to prevent the side
effects of methotrexate treatment of rheumatoid arthritis. Alcohol is minimized
or avoided in rheumatoid arthritis patients taking methotrexate.

The benefits of cartilage preparations such as glucosamine and chondroitin for
rheumatoid arthritis remain unproven. Symptomatic pain relief can often be
achieved with oral acetaminophen (Tylenol) or over-the-counter topical
preparations, which are rubbed into the skin. Antibiotics, in particular the
tetracycline drug minocycline (Minocin), have been tried for rheumatoid
arthritis recently in clinical trials. Early results have shown mild to moderate
improvement in the symptoms of arthritis. Minocycline has been shown to impede
important mediator enzymes of tissue destruction, called metalloproteinases, in
the laboratory as well as in humans.

Exercises and home remedies for rheumatoid arthritis

Impact-loading joints can aggravate inflamed, active RA; it's also difficult
when joints have been injured in the past by the disease. So, it is important to
customize activities and exercise programs according to each individual's
capacity. Physical therapy can be helpful. Exercises that are less traumatic for
the joints, including yoga and tai chi, can be beneficial in maintaining
flexibility and strength. They also lead to an improved general sense of
well-being.

Regular exercise is vital in maintaining joint mobility and strengthening the
muscles around the joints. Swimming is particularly helpful because it allows
exercise with minimal stress on the joints. Physical and occupational therapists
are trained to provide specific exercise instructions and can offer splinting
supports. For example, wrist and finger splints can help reduce inflammation and
maintain joint alignment. Devices such as canes, toilet seat raisers, and jar
grippers can assist in the activities of daily living. Heat and cold
applications are modalities that can ease symptoms before and after exercise.

Medically Reviewed on 11/20/2023
References
Bossini-Castillo, L., et al. "A genome-wide association study of rheumatoid
arthritis without antibodies against citrullinated peptides." Annals of the
Rheumatic Diseases.

Crane, M.M., et al. "Epidemiology and Treatment of New-Onset and Established
Rheumatoid Arthritis in an Insured US Population." Arthritis Care Res (Hoboken).

Doran, M.F., C.S. Crowson, G.R. Pond, W.M. O'Fallon, and S.E. Gabriel.
"Predictors of Infection in Rheumatoid Arthritis." Arthritis Rheum.

Firestein, G.S., et al. Kelley's Textbook of Rheumatology. Philadelphia, Pa:
Saunders Elsevier.

Fraenkel, et al. "2021 American College of Rheumatology Guideline for the
Treatment of Rheumatoid Arthritis." Arthritis Care & Research.

Garfin, Steven R. "Rheumatoid Arthritis of the Cervical Spine Overview of
Rheumatoid Spondylitis."
https://emedicine.medscape.com/article/1266195-overview

Hedstrom, A.K., L. Klareskog, and L. Alfredsson. "Exposure to passive smoking
and rheumatoid arthritis risk: results from the Swedish EIRA study."Ann Rheum
Dis.

Kim, Kwangwoo, et al. "Imputing Variants in HLA-DR Beta Genes Reveals That
HLA-DRB1 Is Solely Associated with Rheumatoid Arthritis and Systemic Lupus
Erythematosus." PLoS ONE
https://doi.org/10.1371/journal.pone.0150283.

Koopman, William, et al., eds. Clinical Primer of Rheumatology. Philadelphia,
Pa: Lippincott Williams & Wilkins.

McInnes, Iain B., and Georg Schett. N Engl J Med.

Rech, J., et al. "Abatacept Reverses Subclinical Arthritis in Patients with
High-risk to Develop Rheumatoid Arthritis -results from the Randomized,
Placebo-controlled ARIAA Study in RA-at Risk Patients." American College of
Rheumatology Convergence 2021.

Seo, Philip, et al. Oxford American Handbook of Rheumatology. United States:
Oxford University Press.

Singh, J.A., et al. "American College of Rheumatology Guideline for the
Treatment of Rheumatoid Arthritis." Arthritis Rheumatol.

Viatte, Sebastien, et al. "Association of HLA-DRB1 Haplotypes With Rheumatoid
Arthritis Severity, Mortality, and Treatment Response." JAMA.

Weisman, Michael H., et al. Practical Rheumatology. Philadelphia, Pa: Mosby.

American College of Rheumatology. "Rheumatoid Arthritis."
https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Rheumatoid-Arthritis

England, Bryant R., and Ted R. Mikuls. "Epidemiology of, Risk Factors for, and
Possible Causes of Rheumatoid Arthritis." UpToDate.com.
https://www.uptodate.com/contents/epidemiology-of-risk-factors-for-and-possible-causes-of-rheumatoid-arthritis

Rheumatoid Arthritis, Cleveland Clinic:
https://my.clevelandclinic.org/health/diseases/4924-rheumatoid-arthritis

What is rheumatoid arthritis?, Versus Arthritis:
https://www.versusarthritis.org/about-arthritis/conditions/rheumatoid-arthritis/

Rheumatoid arthritis, Medline Plus:
https://medlineplus.gov/genetics/condition/rheumatoid-arthritis/#resources

NIH: Genetics of Rheumatoid Arthritis, A Comprehensive Review
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3655138/

Best Foods for Rheumatoid Arthritis.
https://www.arthritis.org/health-wellness/treatment/treatment-plan/tracking-your-health/foods-that-can-help-ra-symptoms

Managing Rheumatoid Arthritis with Dietary Interventions.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5682732/

Nutrition & Rheumatoid Arthritis.
https://www.hopkinsarthritis.org/patient-corner/disease-management/rheumatoid-arthrtis-nutrition/

Nutrition Interventions in Rheumatoid Arthritis: The Potential Use of
Plant-Based Diets. A Review.
https://www.frontiersin.org/articles/10.3389/fnut.2019.00141/full

6 Simple Diet Lessons from Nutritionists with Rheumatoid Arthritis.
https://creakyjoints.org/about-arthritis/rheumatoid-arthritis/ra-healthy-living/diet-for-rheumatoid-arthritis/


TOP RHEUMATOID ARTHRITIS RELATED ARTICLES

 * ARTHRITIS (JOINT INFLAMMATION)
   
   Arthritis is inflammation of one or more joints. When joints are inflamed
   they can develop stiffness, warmth, swelling, redness and pain. There are
   over 100 types of arthritis, including osteoarthritis, rheumatoid arthritis,
   ankylosing spondylitis, psoriatic arthritis, and gout.

 * C-REACTIVE PROTEIN (CRP) TEST
   
   What are the ranges and levels of C-Reactive protein (CRP) in the blood? The
   CRP blood test is a marker of inflammation in the body, and it is produced by
   the liver. Find out about high, low, and normal ranges, levels, and results.

 * SIGNS OF CHRONIC INFLAMMATION YOU MAY NOT EXPECT
   
   You may know already that inflammation can cause sore joints. But it’s also
   linked to less obvious issues like balance problems, memory problems, rashes,
   and fatigue.

 * CORTISONE INJECTION
   
   Cortisone injections are used to treat small areas of inflammation or
   widespread inflammation throughout the body. There is minimal pain from these
   injections, and relief from the pain of inflammation occurs rapidly.

 * FERRITIN BLOOD TEST
   
   Ferritin is a protein in the body that is used to store iron. The ferritin
   blood test can detect elevated or low levels of ferritin in the body, which
   may indicate disease such as hemochromatosis, rheumatoid arthritis, certain
   cancers, anemia, or iron deficiency.

 * FOOT PAIN
   
   Foot pain may be caused by many different diseases, deformities,
   biomechanical conditions, improper footwear, or injuries. Pain and tenderness
   may be accompanied by joint looseness, swelling, weakness, discoloration, and
   loss of function.

 * HEMATOCRIT RANGES (NORMAL, HIGH, LOW)
   
   Hematocrit in the blood is the proportion of the blood that consists of red
   blood cells, by volume. A low hematocrit level may signal anemia, or other
   conditions such as loss of blood, nutritional deficiency, bone marrow
   problems, and abnormal hematocrit. High hematocrit levels may be due to
   chronic smoking, living at high altitudes, dehydration, or other conditions
   and diseases.

 * RHEUMATOID ARTHRITIS: ALTERNATIVE RA THERAPIES
   
   Learn which alternative treatments show promise for rheumatoid arthritis.

 * RA SLIDESHOW
   
   What is rheumatoid arthritis (RA)? Learn about treatment, diagnosis, and the
   symptoms of juvenile rheumatoid arthritis. Discover rheumatoid arthritis (RA)
   causes and the best medication for RA and JRA.

 * RA QUIZ
   
   How is rheumatoid arthritis different from other forms of arthritis, such as
   osteoarthritis and gout? Take the Rheumatoid Arthritis (RA) Quiz to rest your
   RA IQ.

 * RHEUMATOID ARTHRITIS: RA FOOD MYTHS AND FACTS
   
   Is there really an RA diet? Learn the truth from WebMD about which foods can
   ease your symptoms and which you should avoid.

 * RHEUMATOID FACTOR
   
   Rheumatoid factor is often measured in blood tests for the diagnosis of
   rheumatoid arthritis. However, rheumatoid factor can also be present in
   individuals with other conditions such as lupus, infectious hepatitis,
   syphilis, mononucleosis, tuberculosis, liver disease, and sarcoidosis.

 * STEROID DRUG WITHDRAWAL
   
   Corticosteroid drugs such as prednisone and prednisolone are commonly used to
   treat asthma, allergic reactions, RA, and IBD. Steroids such as these do have
   serious drawbacks such as steroid withdrawal symptoms such as: fatigue,
   weakness, decreased appetite, weight loss, nausea, vomiting, abdominal pain,
   and diarrhea. Speak with your health care provider prior to tapering off
   steroid medications.

 * SWOLLEN LYMPH NODES (LYMPHADENOPATHY)
   
   Lymph nodes help the body's immune system fight infections. Causes of swollen
   lymph nodes (glands) may include infection (viral, bacterial, fungal,
   parasites). Symptoms of swollen lymph nodes vary greatly, but may include
   fever, night sweats, toothache, sore throat, or weight loss. Causes of
   swollen lymph nodes also vary, but may include cancer, the common cold, mono,
   chickenox, HIV, and herpes. The treatment of swollen lymph nodes depends upon
   the cause.

 * LUPUS (SYSTEMIC LUPUS ERYTHEMATOSUS OR SLE)
   
   Lupus is a condition characterized by chronic inflammation of body tissues
   caused by autoimmune disease. Lupus can cause disease of the skin, heart,
   lungs, kidneys, joints, and nervous system. When internal organs are
   involved, the condition is called systemic lupus erythematosus (SLE). When
   only the skin is involved, the condition is called discoid lupus.






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