There is no cure for RA, but treatments can improve symptoms and slow the progression of the disease. Disease-modifying treatment has the best results when it is started early and aggressively. The results of a recent systematic review found that combination therapy with tumor necrosis factor (TNF) and non-TNF biologics plus methotrexate (MTX) resulted in improved disease control, Disease Activity Score (DAS)-defined remission, and functional capacity compared with a single treatment of either methotrexate or a biologic alone. The goals of treatment are to minimize symptoms such as pain and swelling, to prevent bone deformity (for example, bone erosions visible in X-rays), and to maintain day-to-day functioning. This is primarily addressed with
disease-modifying antirheumatic drugs (DMARDs); dosed physical activity; analgesics and
physical therapy may be used to help manage pain. The use of
benzodiazepines (such as
diazepam) to treat the pain is not recommended as it does not appear to help and is associated with risks.
Lifestyle Regular exercise is recommended as both safe and effective to maintain muscle strength and overall physical function. Physical activity is beneficial for people with rheumatoid arthritis who experience fatigue, although there was little to no evidence to suggest that exercise may have an impact on physical function in the long term, a study found that carefully dosed exercise has shown significant improvements in patients with RA. Physical activity increases the production of
synovial fluid, which lubricates the joints and reduces friction. Moderate effects have been found for aerobic exercises and resistance training on cardiovascular fitness and muscle strength in RA. Furthermore, physical activity had no detrimental side effects like increased disease activity in any exercise dimension. It is uncertain if eating or avoiding specific foods or other specific dietary measures help improve symptoms, but several studies have shown that high-vegetable diets improve RA symptoms, whereas high-meat diets make symptoms worse.
Occupational therapy has a positive role to play in improving functional ability in people with rheumatoid arthritis. Weak evidence supports the use of wax baths (
thermotherapy) to treat arthritis in the hands. Educational approaches that inform people about tools and strategies available to help them cope with rheumatoid arthritis may improve a person's psychological status and level of
depression in the short term. Educating patients who have rheumatoid arthritis has shown a positive effect on how patients engage in their plan of care; the patient will be aware of fatigue, activity limitations, and pain and know possible side effects of how to manage this pain. Lack of knowledge can often lead to fear and limit adherence. Intervention by physical therapists plays a key role in offering proper tools for self-management, motivation in activities of daily living, and any assistive device use if needed. Patients will be assisted in managing neurologic impairments and musculoskeletal stiffness to maximize strength and function. Encouraging patients to balance physical activity with their everyday living can prevent further joint damage and provide a sense of control. The use of extra-depth shoes and molded insoles may reduce pain during weight-bearing activities such as walking. Insoles may also prevent the progression of
bunions. The most commonly used agent is methotrexate, with other frequently used agents including sulfasalazine and leflunomide. Sulfasalazine also appears to be most effective in the short-term treatment of rheumatoid arthritis.
Hydroxychloroquine, in addition to its low toxicity profile, is considered effective for the treatment of moderate RA symptoms. Pharmacokinetic characteristics of Hydroxychloroquine are complex due to the large volume of distribution, significant tissue binding, and long terminal elimination half-life. Historically, terminal elimination half-lives were considered very long, 40–50 days for Hydroxychloroquine as compared to up to 60 days for Chloroquine. More recent studies suggest a shorter half-life of about 5 days. A long Hydroxychloroquine half-life is attributed to extensive tissue uptake rather than to an intrinsic inability to clear the drug. The expected delay in the attainment of steady-state concentrations (3–4 months) may be in part responsible for the slow therapeutic response observed with Hydroxychloroquine. Agents may be used in combination, however, people may experience greater side effects. Methotrexate is the most important and useful DMARD and is usually the first treatment. A combined approach with methotrexate and biologics improves ACR50, HAQ scores and RA remission rates. Adverse effects should be monitored regularly with toxicity including gastrointestinal, hematologic, pulmonary, and hepatic. Rituximab combined with methotrexate appears to be more effective in improving symptoms compared to methotrexate alone. Biological agents should generally be used only if methotrexate and other conventional agents are not effective after a trial of three months. Biological DMARD agents used to treat rheumatoid arthritis include:
tumor necrosis factor alpha inhibitors (TNF inhibitors) such as
infliximab;
interleukin 1 blockers such as
anakinra,
monoclonal antibodies against
B cells such as
rituximab,
interleukin 6 blockers such as tocilizumab, and
T cell co-stimulation blockers such as abatacept. They are often used in combination with either methotrexate or leflunomide. Abatacept should not be used at the same time as other biologics. In those who are well controlled (low disease activity) on TNF inhibitors, decreasing the dose does not appear to affect overall function. Discontinuation of TNF inhibitors (as opposed to gradually lowering the dose) by people with low disease activity may lead to increased disease activity and may affect remission, damage that is visible on an x-ray, and a person's function.
Golimumab is effective when used with methotraxate. TNF inhibitors may have equivalent effectiveness, with
etanercept appearing to be the safest. Injecting etanercept, in addition to methotrexate twice a week, may improve ACR50 and decrease radiographic progression for up to 3 years. Abatacept appears effective for RA with 20% more people improving with treatment than without but long term safety studies are yet unavailable.
Adalimumab slows the time for the radiographic progression when used for 52 weeks. However, there is a lack of evidence to distinguish between the biologics available for RA. Issues with the biologics include their high cost and association with infections, including
tuberculosis.
Gold and cyclosporin Sodium aurothiomalate,
auranofin, and
cyclosporin are less commonly used due to more common adverse effects.
Hydrogen Therapy Patients with RA given H2-water
hydrogen therapy for four weeks showed significant improvement of symptoms.
Anti-inflammatory and analgesic agents Glucocorticoids can be used in the short term and at the lowest dose possible for flare-ups and while waiting for slow-onset drugs to take effect. Combination of glucocorticoids and conventional therapy has shown a decrease in rate of erosion of bones. Steroids may be injected into affected joints during the initial period of RA, before the use of DMARDs or oral steroids. Non-
NSAID drugs to relieve pain, like
paracetamol may be used to help alleviate the pain symptoms; they do not change the underlying disease.
NSAIDs reduce both pain and stiffness in those with RA but do not affect the underlying disease and appear to have no effect on people's long term disease course and thus are no longer first line agents. NSAIDs should be used with caution in those with
gastrointestinal,
cardiovascular, or kidney problems. Use of methotrexate together with NSAIDs is safe, if adequate monitoring is done.
COX-2 inhibitors, such as
celecoxib, and NSAIDs are equally effective. A 2004 Cochrane review found that people preferred NSAIDs over paracetamol. However, it is yet to be clinically determined whether NSAIDs are more effective than paracetamol. Limited evidence suggests the use of weak oral opioids, but the adverse effects may outweigh the benefits. Alternatively, physical therapy has been tested and shown as an effective aid in reducing pain in patients with RA. As most RA is detected early and treated aggressively, physical therapy plays more of a preventative and compensatory role, aiding in pain management alongside regular rheumatic therapy.
Physiotherapy For people with RA,
physiotherapy may be used together with medical management. Although medications improve symptoms of RA, muscle function is not regained when disease activity is controlled. Physiotherapy promotes physical activity. In RA, physical activity like exercise in the appropriate dosage (frequency, intensity, time, type, volume, progression) and physical activity promotion is effective in improving cardiovascular fitness, muscle strength, and maintaining a long-term active lifestyle. Additionally, exercise can be useful for pain management in this population, specifically, conditioning exercise programs that include aerobic, isometric, and isotonic exercises. Due to the debilitating effects of the disease, people with RA can gain skills back through exercise because it increases the energy capacity of the muscles. The combination of aerobic activity and cryotherapy may be an innovative therapeutic strategy to improve the aerobic capacity in arthritis patients and consequently reduce their cardiovascular risk while minimizing pain and disease activity.
Compression gloves Compression gloves are
handwear designed to help prevent the occurrence of various medical disorders relating to blood circulation in the wrists and hands. They can be used to treat the symptoms of
arthritis, though the medical benefits may be limited.
Alternative medicine In general, there is not enough evidence to support any complementary health approaches for RA, with safety concerns for some of them. Some mind and body practices and dietary supplements may help people with symptoms and therefore may be beneficial additions to conventional treatments, but there is not enough evidence to draw conclusions. A
systematic review of
CAM modalities (excluding fish oil) found that " The available evidence does not support their current use in the management of RA." Studies showing beneficial effects in RA on a wide variety of CAM modalities are often affected by
publication bias and are generally not high quality evidence such as
randomized controlled trials (RCTs). A 2005 Cochrane review states that
low level laser therapy can be tried to improve pain and morning stiffness due to rheumatoid arthritis as there are few side-effects. There is limited evidence that
tai chi might improve the range of motion of a joint in persons with rheumatoid arthritis. The evidence for acupuncture is inconclusive with it appearing to be equivalent to sham acupuncture. A Cochrane review in 2002 showed some benefits of electrical stimulation as a rehabilitation intervention to improve the power of the hand grip and help to resist fatigue. D‐penicillamine may provide similar benefits as DMARDs, but it is also highly toxic. Low-quality evidence suggests the use of therapeutic ultrasound on arthritic hands. Potential benefits include increased grip strength, reduced morning stiffness and number of swollen joints. Acupuncture‐like TENS (AL-TENS) may decrease pain intensity and improve muscle power scores. This may include less discomfort and difficulty such as when using an eye drop device.
Dietary supplements Fatty acids There has been a growing interest in the role of long-chain
omega-3 polyunsaturated fatty acids to reduce inflammation and alleviate the symptoms of RA. Metabolism of omega-3 polyunsaturated fatty acids produces docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), which inhibit pro-inflammatory eicosanoids and cytokines (TNF-a, IL-1b, and IL-6), decreasing both lymphocyte proliferation and reactive oxygen species. These studies showed evidence for significant clinical improvements on RA in inflammatory status and articular index.
Gamma-linolenic acid, an omega-6 fatty acid, may reduce pain, tender joint count, and stiffness, and is generally safe. For omega-3 polyunsaturated fatty acids (found in fish oil, flax oil and hemp oil), a meta-analysis reported a favorable effect on pain, although confidence in the effect was considered moderate. The same review reported less inflammation but no difference in joint function. A review examined the effect of marine oil omega-3 fatty acids on pro-inflammatory eicosanoid concentrations;
leukotriene4 (LTB4) was lowered in people with rheumatoid arthritis but not in those with non-autoimmune chronic diseases. Fish consumption has no association with RA. A fourth review limited inclusion to trials in which people eat ≥2.7 g/day for more than three months. The use of pain relief medication was decreased, but improvements in tender or swollen joints, morning stiffness, and physical function were unchanged. Collectively, the current evidence is not strong enough to determine that supplementation with omega-3 fatty acids or regular consumption of fish are effective treatments for rheumatoid arthritis. Due to the false belief that herbal supplements are always safe, there is sometimes a hesitancy to report their use which may increase the risk of adverse reactions.
Vaccinations People with RA have an increased risk of infections and mortality, and recommended vaccinations can reduce these risks. The inactivated
influenza vaccine should be received annually. The
pneumococcal vaccine should be administered twice for people under the age 65 and once for those over 65. Lastly, the live-attenuated
zoster vaccine should be administered once after the age 60, but is not recommended in people on a
tumor necrosis factor alpha blocker. ==Prognosis==