Rheumatoid arthritis - Treating rheumatoid arthritis

Stopping the condition progressing

There are a number of medications available that can be used to help stop rheumatoid arthritis getting worse and reduce your risk of further problems.

These are often divided into two types of medication: 'disease-modifying anti-rheumatic drugs (DMARDs)' and 'biological treatments'.

Disease-modifying anti-rheumatic drugs (DMARDs)

If you have been diagnosed with rheumatoid arthritis, you will normally be offered a combination of DMARD tablets as part of your initial treatment, as these medications are particularly effective in easing symptoms of the condition and slowing down its progression.

DMARDs work by blocking the effects of the chemicals released when the immune system attacks the joints, which could otherwise cause further damage to nearby bones, tendons, ligaments and cartilage.

There are many different DMARDs that can be used, including , leflunomide, hydroxychloroquine and sulfasalazine.

Methotrexate is normally the first medicine given for rheumatoid arthritis, often alongside another DMARD and a short-course of corticosteroids to relieve any pain (see below). It may also be combined with the biological treatments mentioned below.

Common side effects of methotrexate include feeling sick, loss of appetite, a sore mouth, diarrhoea, headaches and hair loss. The medication can also sometimes have an effect on your blood count and your liver, so you will have regular blood tests to monitor this.

Less commonly, methotrexate can affect the lungs, so you will usually have a chest X-ray and possibly breathing tests when you start taking methotrexate, to provide a comparison if you develop shortness of breath or a persistent dry cough while taking it. However, most people tolerate methotrexate well.

It can take a few months to notice a DMARD working. It is important to keep taking the medication, even if you do not notice it working at first.

You may have to try two or three types of DMARD before you find the one that is most suitable for you. Once you and your doctor work out the most suitable DMARD, you will usually have to take the medicine in the long term.

Biological treatments

Biological treatments are a newer form of treatment for rheumatoid arthritis. They include etanercept, infliximab, adalimumab, certolizumab, golimumab, rituximab, abatacept and tocilizumab.

They are usually taken in combination with methotrexate or another DMARD and are normally only used if these medications alone have not been effective.

Biological medications are given by injection and they work by stopping particular chemicals in the blood from activating your immune system to attack your joints.

Side effects from biological treatments are usually mild and include skin reactions at the site of the injections, infections, feeling sick, a high temperature (fever) and headaches.

Some people may also be at risk of getting more serious problems, including the reactivation of infections such as tuberculosis (TB) in people who have had them in the past.

Want to know more?

National Rheumatoid Arthritis Society (NRAS): Treatment
Arthritis Care: Taking medication
NICE: Abatacept for treating rheumatoid arthritis
NICE: Golimumab for the treatment of rheumatoid arthritis
NICE: Certolizumab pegol for the treatment of rheumatoid arthritis
NICE: Tocilizumab for the treatment of rheumatoid arthritis
NICE: Adalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis

Relieving pain

In addition to the medications used to control the progression of rheumatoid arthritis, you may also need to take medication specifically to relieve pain.

Some of the different medicines that may be used to relieve pain are outlined below.

Painkillers

In some cases, you may be advised to use painkillers such as paracetamol, or a combination of paracetamol and codeine (co-codamol) to relieve the pain associated with rheumatoid arthritis.

These medications don't help treat the underlying inflammation of your joints, but they can sometimes be helpful in relieving pain. For example, they may be recommended while you are waiting to see a specialist or during periods where your symptoms are particularly bad (flare-ups).

Non-steroidal anti-inflammatory drugs (NSAIDs)

In addition to – or instead of – the painkillers mentioned above, your doctor may prescribe a non-steroidal anti-inflammatory drug (NSAID).

This may be a traditional NSAID (such as ibuprofen, naproxen or diclofenac) or an alternative type called a COX-2 inhibitor (such as celecoxib or etoricoxib).

These medications can help relieve pain while also reducing inflammation in the joints, although they will not stop rheumatoid arthritis getting worse over time.

Your doctor will discuss with you what type of NSAID you should take and the benefits and risks associated with each of them.

Although uncommon, taking an NSAID tablet can increase the risk of serious stomach problems – such as internal bleeding – because the medications can break down the lining that protects the stomach against damage from stomach acids.

If you are prescribed an NSAID tablet, you will often have to take another medicine, such as a proton pump inhibitor (PPI), as well. Taking a PPI reduces the amount of acid in your stomach, which greatly reduces the risk of damage to your stomach lining.

Corticosteroids

Corticosteroids are powerful medications that can help reduce pain, stiffness and inflammation.

They can be used as a tablet (for example, prednisolone), as an injection directly into a painful joint, or as an injection into the muscle (to help lots of joints).

They are usually used to provide short-term pain relief – for example, while you are waiting for DMARD medication to take effect or during a flare-up.

Corticosteroids are normally only used in this way because long-term use of corticosteroids can have serious side effects, such as weight gain, osteoporosis (thinning of the bones), easy bruising, muscle weakness and thinning of the skin.

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National Rheumatoid Arthritis Society (NRAS): Symptom control

Supportive treatments

Your doctor may also refer you to other services that might be able to help you with your rheumatoid arthritis symptoms.

Physiotherapy

A physiotherapist may help you improve your fitness and muscle strength, and make your joints more flexible.

They may also be able to help with pain relief using heat or ice packs, or transcutaneous electrical nerve stimulation (TENS). A TENS machine applies a small pulse of electricity to the affected joint, which numbs the nerve endings and can help ease the pain of rheumatoid arthritis.

Occupational therapy

If rheumatoid arthritis causes you problems with everyday tasks, occupational therapy may help.

An occupational therapist can provide training and advice that will help you to protect your joints, both while you are at home and at work.

Some type of support for your joints, such as a splint, may also be recommended, or devices that can help open jars or turn on taps.

Podiatry

If you have problems with your feet, a podiatrist may be able to help. You may also be offered some type of support for your joints or shoe insoles that can ease pain.

Want to know more?

Arthritis Care: Occupational therapy
Arthritis Research UK: Therapies
Arthritis Research UK: Rheumatology team
National Rheumatoid Arthritis Society (NRAS): Who can help me?

Surgery

Sometimes, despite medication, damage to your joints may occur. In such cases, you may need surgery to help restore your ability to use your joint.

Surgery may also be recommended to reduce pain or correct deformities.

Finger, hand and wrist surgery

There are different types of surgery to correct joint problems in the hand. Examples include:

carpal tunnel release (cutting a ligament in the wrist to relieve pressure on a nerve) – see treating carpal tunnel syndrome for more information
release of tendons in the fingers to treat abnormal bending
removal of inflamed tissue that lines the finger joints

Arthroscopy

Arthroscopy is a procedure to remove inflamed joint tissue.

During the operation, a thin tube with a light source and camera (arthroscope) is inserted into the joint through a small cut in the skin so that the surgeon can see the affected joint.

Special surgical instruments are inserted through other small cuts in the skin to remove the damaged tissue. You usually do not have to stay overnight in hospital for this kind of surgery, but the joint will need to be rested at home for several days.

Joint replacement

Some people with rheumatoid arthritis will need surgery to replace part or all of a joint, such as the hip, knee or shoulder joint. This is known as a joint replacement or arthroplasty.

Replacement of these joints is a major operation that involves several days in hospital followed by months of rehabilitation.

The latest joints have a limited lifespan of 10-20 years. They are not perfect and some function may not be restored after the damaged joint is replaced by a new one.

Read more about knee replacement and hip replacement.

Want to know more?

Arthritis Care: Surgery
Arthritis Research UK: Arthritis surgery
National Rheumatoid Arthritis Society (NRAS): Surgery

Complementary and alternative therapies

Many people with rheumatoid arthritis try complementary therapies, such as:

In most cases, there is little or no evidence these are effective in the long-term, although some people may experience a short-term benefit from them.

Nutritional supplements and dietary changes

There is no strong evidence to suggest that specific dietary changes can help improve rheumatoid arthritis, although some people with rheumatoid arthritis feel that their symptoms get worse after they have eaten certain foods.

If you think this may be the case for you, it may be useful to try avoiding problematic foods for a few weeks to see if your symptoms improve. However, it is important to ensure your overall diet is still healthy and balanced.

There is also little evidence supporting the use of supplements in rheumatoid arthritis, although some can be useful in preventing side effects of medications you may be taking. For example, calcium and vitamin D supplements may help prevent osteoporosis if you are taking steroids and folic acid supplements may help prevent some of the side effects of methotrexate.

However, there is some evidence to suggest that taking fish oil supplements may help reduce joint pain and stiffness caused by rheumatoid arthritis.

Want to know more?

Arthritis Care: Complementary therapy
Arthritis Research UK: Complementary and alternative medicines
National Rheumatoid Arthritis Society (NRAS): Diet