Treatment
Treating rheumatoid arthritis means, for the most part, relieving symptoms and slowing the disease's progress. Although there is no cure, you and your health care professional can develop strategies for managing the disease. You'll probably use a variety of approaches, but all have the same basic goals: relieve pain, reduce inflammation, slow (or even stop) joint damage and improve your ability to function.
In addition to the guidance of your primary health care professional, you may need care from a physical therapist, a rheumatologist (a physician who specializes in diagnosing and treating disorders that affect the joints, muscles, tendons, ligaments and bones) or an orthopedist.
When symptoms occur, you can take steps to lessen their severity. Protecting your joints from undue stress can help. You may find that using a splint around a painful joint (generally wrists and hands) helps reduce pain and swelling. The splint supports the joint and lets it rest. Your health care professional can help you obtain a properly fitting splint. You may want to talk to him or her about self-help devices that can reduce stress on the joints while you participate in everyday activities. Zipper pullers, long-handled shoehorns and products that help you get on and off chairs, toilet seats and beds can all ease the strain on your joints.
Most likely, your treatment plan will include medications to relieve pain and/or reduce inflammation. Although there is no cure, disease-modifying antirheumatic drugs (DMARDs) may slow or stop the course of the disease. In the past, health care professionals often hesitated to prescribe these strong drugs until the disease had become relatively advanced. However, this approach has changed, especially for those who suffer from severe, rapidly progressing rheumatoid arthritis. Many health care professionals believe that early treatment with more powerful drugs and the use of drug combinations is the best way to halt RA's progression and reduce or prevent joint damage.
The following are commonly used rheumatoid arthritis medications:
Analgesics. Analgesics are drugs that provide pain relief, and they can be used either orally or topically in people with RA. Topical analgesics include capsaicin (Capsagel) or diclofenac (Cataflam), and oral forms include acetaminophen (Tylenol), propoxyphene (Darvon), tramadol (Ultram), and the more potent opioids oxycodone (OxyContin) and hydrocodone (Vicodin). -
Nonsteroidal
anti-inflammatory drugs (NSAIDs). NSAIDs such as aspirin, ibuprofen, ketoprofen and naproxen help diminish pain, swelling and inflammation. However, each NSAID is a different chemical and can have different effects in the body.
NSAIDs can cause stomach irritation and affect kidney function. Plus, there is the potential for cardiovascular events associated with the use of NSAIDS. The longer you use NSAIDs, the more likely you are to have side effects, and the more serious those effects can be. Many other drugs cannot be taken with NSAIDs—in particular, the blood thinner warfarin (Coumadin)—and these medications are associated with serious gastrointestinal problems, including ulcers, bleeding and perforation. They should be used with caution in people over 65 and in those with any history of ulcers or gastrointestinal bleeding, congestive heart failure, renal insufficiency and hypertension. Even the nonprescription, over-the-counter forms of these medications have the same risks. It's important to ask your health care professional for safety information associated with pain relievers with your personal health history in mind.
A newer NSAID (called a COX-2 specific inhibitor) inhibits an enzyme (COX-2), which triggers pain and inflammation, while sparing an enzyme called COX-1, which helps maintain the normal stomach lining. The COX-2 inhibitor Celecoxib (Celebrex) is sometimes prescribed for rheumatoid arthritis, osteoarthritis and other pain-causing conditions, such as acute pain menstrual cramps. Celebrex is currently the only COX-2 inhibitor on the market. Celebrex can increase the risk of heart attack and stroke; discuss these risks with your health care professional. And if you are currently taking Celebrex and think you are having an allergic reaction or have other severe or unusual symptoms while taking any NSAID, call your health care professional immediately. For more information on the risks associated with Celebrex, visit www.fda.gov.
- Disease-modifying antirheumatic drugs (DMARDs), also called slow-acting antirheumatic drugs or second-line drugs, are used to alter the course of the disease and prevent joint and cartilage destruction. They can produce significant results, but no one is sure exactly how they work. You may need to wait weeks—even months—before seeing any effect, and you may use some or all of these, depending on the specifics of your condition. In some cases, one DMARD is used by itself. In other cases, more than one DMARD may be prescribed at the same time. Some patients have to try different medicines or combinations to find one that works best with the fewest side effects.
The most common DMARDs are: methotrexate (Rheumatrex), sulfasalazine (Azulfidine), hydroxychloroquine (Plaquenil), leflunomide (Arava) and cyclosporine (Sandimmune, Neoral). Less commonly used medications include gold salts (Solganal). Patients taking methotrexate and most other DMARDs need periodic monitoring to make sure that toxicity to the liver or bone marrow does not occur. Although there is clearly a potential for toxicity of a powerful drug like methotrexate, it actually has a remarkable safety profile in RA, and patients can take it continuously for many years. Side effects of sulfasalazine include changes in blood counts, nausea or vomiting, sensitivity to sunlight, skin rash, and headaches. Hydroxychloroquine, when taken in high doses for prolonged periods of time, may increase the risk of damage to the retina of the eye; therefore, an eye examination is recommended before starting treatment and every 6 to 12 months thereafter. Side effects of leflunomide include rash, temporary hair loss, liver damage, nausea, diarrhea, weight loss, and abdominal pain. Side effects of cyclosporine include high blood pressure, swelling, kidney damage, increased hair growth, nausea, diarrhea, and heartburn. If you take cyclosporine, you should have your blood pressure and kidney function checked every two to four weeks when starting the drug, and then once a month thereafter.
Pay attention to how your body responds to these drugs. Not only do you need to make sure the medications are effective (since efficacy can occasionally diminish over time), you also need to be alert to any problems arising from the drugs.
- Immunosuppressants (which technically include DMARDs) are used to restrain the overly active immune system that causes RA. This class of drugs includes azathioprine (Imuran) and cyclophosphamide (Cytoxan). These drugs can be effective, but they also can prove extremely toxic and often have severe side effects. For instance, azathioprine can result in blood abnormalities, low white blood cell count and a possible increased risk of cancer, while cyclophosphamide may lead to a low white-blood-cell count, other blood abnormalities and an increased cancer risk. Again, close monitoring and lab tests, including liver-function tests, are advisable.
Corticosteroids (also known as glucocorticoids), such as prednisone, prednisolone (Econopred Plus) dexamethasone (Decadron), and methylprednisolone (Medrol), have both anti-inflammatory and immunosuppressive properties. Since they can cause dramatic improvements in a very short time, health care professionals often use them while waiting for DMARDs to kick in. They may be an option if your RA doesn't respond to NSAIDs and DMARDs. These medications also have serious side effects, however, especially at high doses, including fragile, easily bruised skin, thinning of bones, weight gain, onset or worsening of diabetes, cataracts and a round face. Biologic response modifiers are proteins that must be administered by injection. They have demonstrated remarkable efficacy in some cases. The most commonly used agents block and inactivate a protein called tumor necrosis factor, or TNF-alpha, that is involved in the cascade of immune responses that cause inflammation in RA patients. There have been very rare reports of serious nervous system disorders such as multiple sclerosis, seizures or inflammation of the nerves of the eyes, and serious infections, including sepsis and tuberculosis, with the TNF-inhibitors (also called anticytokine therapies). The risk of tuberculosis has been greatly decreased with pre-therapy screening of TB skin tests and/or chest x-rays, and treating patients with anti-TB drugs if these tests are positive.
Additionally, there is some evidence that patients treated with TNF inhibitors might have a somewhat higher risk of lymphomas. Although patients need to be aware of these risks, it is equally important to recognize that the benefits can be substantial. The following TNF inhibitors have been approved for use in the United States:
Etanercept (Enbrel) is a genetically engineered protein that helps reduce symptoms and inhibits the progression of structural damage in adult patients with moderate to severe RA who have not responded well to other treatments. It can also be used in combination with methotrexate if methotrexate alone isn't doing the job. The usual side effects are injection site reactions that include redness, itching, bruising or pain, upper respiratory infections and allergic reactions. Infliximab (Remicade) is an antibody-based TNF therapeutic that is often used in combination with methotrexate. It is effective for the symptoms as well as for inhibiting the progression of structural damage in patients with moderately to severely active rheumatoid arthritis who have had an inadequate response to methotrexate. The drug is given intravenously at intervals of two to eight weeks. Side effects include allergic reactions, upper respiratory infections and reactivation of tuberculosis. Adalimumab (Humira) also reduces symptoms and inhibits the progression of structural damage in adult patients with moderately to severely active RA. Humira is administered every one to two weeks by subcutaneous injection and can be used as a single agent or with methotrexate. Side effects are similar to those associated with etanercept. Anakinra (Kineret) is another biological response modifier that blocks a key mediator of inflammation, reducing symptoms of moderately to severely active RA in adult patients who have not responded to one or more DMARDs. Kineret can be used alone or in combination with DMARDs other than TNF- blocking agents. Kineret blocks interleukin-1 (IL-1), a protein present in excess in RA patients instead of TNF. By blocking IL-1, Kineret modestly inhibits the inflammatory response in RA, reducing pain. Kineret is given as a daily self-administered injection under the skin. Potential side effects of the drug include decreased white blood cell count, an injection site reaction, headache and an increase in upper respiratory infections, especially in people who have asthma or chronic obstructive pulmonary disease. If you have an active infection, do not use Kineret.
If a patient on a biologic response modifier has an infection severe enough to require antibiotics, the biologic should not be given until the infection is gone.
Two immunosuppressant medications designed primarily to prevent transplant rejection have been be used to treat RA—cyclosporine (Neoral, Sandimmune) and mycophenolate mofetil (CellCept). Side effects of cyclosporine include high blood pressure, dizziness, coughing, flushing, headache, excess hair growth and gastrointestinal problems. Kidney dysfunction is a potentially serious side effect but often can be avoided by reducing the dose. Mycophenolate side effects include diarrhea, leukopenia, sepsis and vomiting. These drugs increase susceptibility to infection.
The cancer drug rituximab (Rituxan) is also approved for the treatment of RA. Rituxan works by targeting immune cells involved in inflammation known as CD20-positive B-cells, which are believed to contribute to rheumatoid arthritis. Rituxan is recommended for RA patients who haven't responded to TNF-inhibitors and is usually given along with methotrexate. Side effects include flu-like symptoms, such as fever, nausea, chills and infections.
In addition, another drug in the class of biologic response modifiers used in the treatment of RA is abatacept (Orencia, CTLA4-Ig). Abatacept works similarly to rituximab, but it targets T- cells instead of B-cells.
Patients using DMARDs or biologics should not receive live virus vaccinations. The flu and pneumonia vaccines are safe in these individuals.
Surgery may be an option if you have severe joint damage. In the right circumstance, it can help reduce pain, improve the affected joint's function and appearance and enhance your ability to perform daily activities. However, surgery is not right for everyone, and you and your health care professional need to discuss the best approach. Factors to consider include your overall health, the condition of the joint or tendon that will be operated on and cost of the surgery.
A common type of surgery prescribed for people with RA is joint
replacement, which replaces your damaged joint with an artificial one. One thing to consider is that the artificial joints can wear out, necessitating additional surgery.
Tendon
reconstruction, most frequently performed on the hands, is a surgery that reconstructs the damaged tendon by attaching an intact tendon to it. It can restore some hand function, particularly if it's done before the tendon ruptures.
In synovectomy,
the inflamed synovial tissue is removed. Synovectomy is performed if the lining around your joint (synovium) is inflamed and causing pain.
ClinicalTrials.gov, a service of the National Institute of Health, provides patients, family members, health care professionals and members of the public easy access to information on clinical trials for a wide range of diseases and conditions, including rheumatoid arthritis. The Web site is located at www.clinicaltrials.gov.
What You Can Do to Combat RA Symptoms
While health care professionals must be involved in your care, there are a number of lifestyle changes you can make to help manage RA. Experts suggest that eating a healthy diet can enhance your overall health and thus help you better manage your RA. Although drinking has no known impact on the disease itself, you may need to avoid alcoholic beverages, depending on the RA medications you are taking, especially the often-prescribed methotrexate. Check with your health care professional. Stress reduction is also important, since your stress level may affect the amount of pain you feel.
Rest and exercise—seemingly opposite ends of the spectrum—are important to your health. When your RA is active, you will want more rest. But exercise is critical to healthy muscles, joint mobility and flexibility. (Note: discuss any exercise program with your health care professional before starting.)
While exercise may seem unappealing if you're experiencing frequent pain, there are a number of techniques to help you get through a program:
- Moist heat supplied by warm towels, hot packs, a bath or a shower can be used at home for 15 to 20 minutes three times a day to relieve symptoms. Applying heat before exercise can be a good way to start. A health care professional can apply deep heat using short waves, microwaves and ultrasound to relieve pain.
- Cold supplied by a bag of ice or frozen vegetables wrapped in a towel helps stop pain and reduce swelling when used for 10 to 15 minutes at a time. This treatment often is recommended for acutely inflamed joints. Do not use cold treatments if you have numbness or poor circulation.
- Hydrotherapy (water therapy) can decrease pain and stiffness. Exercising in a large pool may be easier because water takes some weight off painful joints. Many community centers, YMCAs and YWCAs have water exercise classes developed for people with arthritis. Some patients also find relief from the heat and movement of a whirlpool.
- When performed by a trained professional, massage and manipulation (using the hands to restore normal movement to stiff joints) can help control pain and increase joint motion and muscle and tendon flexibility.
Although these physical therapy modalities can temporarily relieve symptoms, none have documented anti-inflammatory effects or affect the rate of joint damage that can occur in RA.
Alternative Therapies for RA Pain Relief
- Relaxation techniques: Deep breathing, guided imagery and visualization (where you focus on "seeing" pleasant pain-free scenes or activities in your mind) and stress reduction help provide some pain relief. Physical therapists can teach relaxation techniques. The Arthritis Foundation has a self-help course that includes relaxation therapy; find out more about the Arthritis Foundation Self-Help Program at www.arthritis.org/self-help-program.php.
- Acupuncture:
Acupuncture is an important component of traditional Chinese medicine that involves the insertion of thin needles at specific points, which are mostly along the body's nerve pathways, to improve health. According to the National Center for Complementary and Alternative Medicine at the National Institutes of Health, a handful of small studies have been conducted on the use of acupuncture in RA, and the findings do not clearly answer the question of whether or not it works. Individuals who want to use acupuncture should discuss their interest with their health care team and only a licensed acupuncturist should be used. There are no data demonstrating that acupuncture has an independent effect on the course of RA.
- Nutritional supplements: Few studies have carefully evaluated the role of nutritional supplements in RA. Therefore, products and reports about nutritional supplements claiming to provide pain relief should be viewed with caution. Discuss your interest or questions about such products and reports with your health care professional.
- Transcutaneous electrical nerve stimulation (TENS): TENS is the application of electrical stimulation from a small device to the skin for pain relief. TENS seems to work by blocking pain messages to the brain and by modifying pain perception. To relieve some arthritis-related pain, the TENS device is positioned to direct the mild electric pulses to nerve endings beneath the skin on or near the painful area affected by rheumatoid arthritis. A small number of studies have shown improvements in pain and joint function in people with rheumatoid arthritis, but better studies are needed to make a clear conclusion. TENS machines cost between $50 and $800. (The inexpensive units are fine.) You can wear them during the day and turn them off and on as needed for pain control-they may provide some pain relief.
- Biofeedback: Biofeedback is a way to enhance an awareness of your body so that you become focused on how your body functions; usually this enhanced focus is turned toward something—such as muscle control—that typically occurs at a subconscious level. During biofeedback, an electronic device provides information about a body function (such as heart rate) so that the person using biofeedback can learn to control that function. Biofeedback may help people with arthritis learn to relax their muscles. In this case, an electronic device amplifies the sound of a muscle contracting, so the arthritis patient knows that the muscle is not relaxed. The therapy is typically learned with the help of a health care professional and then may be practiced at home once the patient has mastered the technique, either with a biofeedback machine or without one.
- Some additional techniques under investigation include tai chi (a movement- based form of meditation) and cognitive behavioral therapy (a method of anticipating and preparing yourself for situations and bodily sensations that will cause pain).
With all of these treatments—lifestyle, medical and surgical—monitoring which treatments work and which don't and watching for side effects is critical. Monitoring can involve regular consultations with your health care professional as well as blood, urine and other laboratory tests and x-rays.
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Create Date: 3/1/02
Date Last Updated: 6/18/08
Review Date: 2/1/08
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