Medical Treatment

Rheumatoid arthritis is a progressive inflammatory disease. This means that unless the inflammation is stopped or slowed, the condition will continue to get worse in most people. Although rheumatoid arthritis does occasionally go into remission without treatment, this is rare. Starting treatment soon after diagnosis of rheumatoid arthritis is strongly recommended. The best medical care combines medication and nondrug approaches.

Nondrug approaches include the following:

• Physical therapy helps preserve and improve range of motion, increase muscle strength, and reduce pain.



• Hydrotherapy involves exercising or relaxing in warm water. Being in water reduces the weight on your joints. The warmth relaxes your muscles and helps relieve pain.



• Relaxation therapy teaches techniques for releasing muscle tension, which helps relieve pain.



• Both heat and cold treatments can relieve pain and reduce inflammation. Some people's pain responds better to heat and other's to cold. Heat can be applied by ultrasound, microwaves, warm wax, or moist compresses. Most of these are done in the medical office, although moist compresses can be applied at home. Cold can be applied with ice packs at home.



• Occupational therapy teaches you ways to use your body efficiently to reduce stress on your joints. It also can help you learn to decrease tension on the joints through the use of specially designed splints. Your occupational therapist can help you develop strategies for coping with daily life by adapting to your environment and using different assistive devices.



• Prosorba column: This is not a drug but a medical device. It filters antibodies linked to rheumatoid arthritis out of the blood. This procedure is available only in some medical centers and generally is used only for very severe rheumatoid arthritis.



• In some cases, reconstructive surgery and/or joint replacement operations provide the best outcome.

Drug approaches include a variety of medications used alone or in combinations.

• Rheumatoid arthritis was traditionally treated in the past with a stepwise approach starting with nonsteroidal antiinflammatory drugs (NSAIDs) and progressing through more potent drugs such as glucocorticoids, disease-modifying antirheumatic drugs (DMARDs), and biologic response modifiers.



• In the past, DMARDs were avoided early in the disease because of their potentially serious side effects and because they did not often bring on remission. DMARDs were usually reserved for people who showed signs of joint damage.



• Over time, however, this strategy was recognized as being faulty, because people treated early with DMARDs have better long-term outcomes, with greater preservation of function, less work disability, and a smaller risk of premature death.



• The goal of drug treatment is to induce remission or at least eliminate evidence of disease activity.



• Early use of DMARDs not only controls inflammation better than less potent drugs but also helps prevent joint damage. Newer DMARDs work better than the older ones in long-term prevention of joint damage.



• The current approach, therefore, is to treat rheumatoid arthritis aggressively with DMARDs soon after diagnosis. Treating rheumatoid arthritis early, within three to 12 months after symptoms begin, is the best way to stop or slow progression of the disease and bring about remission.



• Ongoing (long-term) treatment with combinations of medications may offer the best control of rheumatoid arthritis for the majority of people.



• Combinations of these agents do not usually have more severe adverse effects than one agent alone.

Disease-modifying antirheumatic drugs (DMARDs)

• This is a key type of drug treatment in rheumatoid arthritis. This is not one type of drug but several different types whose main similarity is that they all help to stop the joint damage of rheumatoid arthritis.



• DMARDs can slow or stop the progression of rheumatoid arthritis and thus joint destruction and disability.



• Successful DMARD therapy may eliminate the need for other antiinflammatory or analgesic (pain-relieving) medications.



• These drugs do not work for everyone with rheumatoid arthritis, but they give substantial relief to many.



• DMARDs may not reach their full effect for two to three months. It is important to keep taking the medication for at least that long before deciding it is not working. Until the full action of your DMARD takes effect, your health-care professional may prescribe antiinflammatory or analgesic medications as bridging therapy to reduce pain and swelling.



• DMARDs may be given alone or in combination with other types of drugs.



• These drugs have been shown to improve signs and symptoms (as well as quality of life) in most people with rheumatoid arthritis.

Biologic response modifiers

• These agents are carefully designed to block the actions of substances naturally produced by the immune system, such as tumor necrosis factor or interleukin-1. These substances are involved in the abnormal immune reaction associated with rheumatoid arthritis. Therefore, blocking their action can slow down the underlying autoimmune reaction and thus relieve symptoms and improve your overall condition.



• There are several different forms of these agents, and in some people, rheumatoid arthritis will get better with one form and not another.



• These agents slow down rheumatoid arthritis in a significant proportion of people with the condition (40%-70%, depending on the form) and can lead to remission. They do not cure the disease, as symptoms often return if the drug is stopped.



• These agents are often used in combination with one or more DMARDs in order to more fully suppress joint inflammation and improve function.



• These agents are expensive and the long-term effects are still under study. For these reasons, these drugs are often not the first choice of treatment in rheumatoid arthritis.



• Although it may take as long as three months to see whether a biologic agent is working in a specific individual, many people start to feel better within a few weeks.



• You cannot take these agents if you have an infection (especially tuberculosis), cancer now or in the recent past, or certain types of nervous system disorders.



• These agents improve signs and symptoms and quality of life in many people with rheumatoid arthritis.

Glucocorticoids

• Glucocorticoids (steroids) are potent antiinflammatory drugs. They reduce symptoms, and they may stop or slow joint damage.



• These drugs can be given as pills by mouth, by intramuscular injection, or in some cases, they can be injected directly into a joint.



• These agents have many side effects. They can be safely given only for short periods -- a few weeks or months -- in most people and so are commonly used to bridge the gap while waiting for a DMARD to reach full effect.



• These agents are not for everyone. For example, they can aggravate diabetes. Your health-care professional will decide whether glucocorticoids are right for you on the basis of your overall medical condition.



• Typically, these drugs are started at a relatively low, safe dose. Occasionally, a high dose is given at first to have an immediate effect, and the dose is reduced gradually (tapered) over a few weeks or months.



• It is very important not to stop taking a glucocorticoid abruptly, as this can be dangerous. If you are having severe side effects, talk to your health-care professional before stopping the drug.

Nonsteroidal antiinflammatory drugs

• Nonsteroidal antiinflammatory agents, or NSAIDs, reduce swelling and pain in rheumatoid arthritis. They do not slow joint damage, however, and therefore are not considered adequate treatment on their own. Like glucocorticoids, they often are used as a bridge to successful DMARD therapy.



• Several dozen NSAIDs are available. They can be classified into different groups of compounds. Commonly used NSAIDs include ibuprofen, naproxen, ketoprofen, piroxicam, and diclofenac.



• The most common and potentially serious adverse effects of NSAIDs occur in the digestive tract: stomach upset, belly pain, and bleeding.



• Rare side effects include serious skin reactions. NSAIDs may increase risk of heart attack and stroke.



• A newer generation of these drugs is called the COX-2 inhibitors, such as celecoxib (Celebrex). These drugs are more expensive although much less likely to cause digestive system effects.

Analgesics

• Acetaminophen/paracetamol, tramadol, codeine, opioids, and a variety of other analgesic medications can be employed to reduce pain.



• These agents do not affect swelling or joint destruction.

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Rheumatoid Arthritis - Early Symptoms

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