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Rheumatoid arthritis (RA) is an autoimmune disease that causes inflammation in joints by attacking the synovium. This tissue lies beneath the cartilage that covers the end of a bone, and produces synovial fluid to lubricate the joint.
When RA flares, white blood cells inflame the synovial tissue, causing it to thicken and swell. This results in joint pain and visible swelling; over time, it can lead to loss of motion and erosion of the bone.
RA can be a puzzling disease, says Padmanabhan Raghu, MD, a rheumatologist at Rush University Medical Center. Its symptoms and progression can vary widely from person to person, and can wax and wane over time. Here, Raghu explains what can happen at each stage of the disease:
In the early stages, RA often causes joint swelling, pain, stiffness and fatigue.
Treatment options: Controlling inflammation is key at every stage of RA, Raghu says, but controlling it early provides the best chance to prevent joint damage.
Often, the best control comes from a low-dose steroid combined with a low dose of a disease-modifying antirheumatic drug, or DMARD. The most common DMARD is methotrexate, a drug first developed to fight cancer, but now commonly used as a first-line therapy for RA.
What else might help? Smoking is a risk factor for RA, Raghu says, and can make treatment less effective. If you're a smoker, being diagnosed with RA is one more major reason to quit.
Maintaining a healthy weight is also important, since excess weight puts stress on joints.
The moderate stage of RA is when damage to cartilage can begin to appear, resulting in loss of mobility and range of motion. Fatigue can also become more of a problem.
Treatment options: Joints that aren't responding to treatment might benefit from steroid injections. This may also be the time to try biologic DMARDs: drugs such as Enbrel and Humira that use genetically engineered proteins to suppress part of the immune system. Biologics, which are given by injection or intravenously, can slow RA's progression but can also have significant side effects.
What else might help? "The reduced joint mobility caused by active RA can lead to muscle weakness, which we want to prevent," explains Raghu. "So once we have pain under reasonable control, physical exercise is an essential part of treatment. Some patients may need physical therapy before they begin muscle-strengthening aerobic exercises on their own."
RA's severe stage means that synovial inflammation has eroded the cartilage of the joint and has moved on to eroding the bone. This stage can mean more pain and swelling; less mobility and muscle strength; and the beginning of visible joint deformities.
Treatment options: "Treatment here is really case by case," Raghu says. "It can be difficult to tell how much pain is due to joint damage and how much is due to inflammation."
He may refer some patients to an orthopedic surgeon to discuss the possibility of joint replacement. Other surgical options might include arthrodesis (also known as joint fusion) and tendon reconstruction.
What else might help? Raghu says that a number of his patients with chronic pain have benefited from cognitive behavioral therapy, "which can help patients identify their triggers for pain flares, and can provide coping techniques to improve general quality of life."
It takes time and thorough examination to figure out the best treatment regimen for each patient, so close collaboration between patient and physician is essential.
The end stage of RA means that most of the tissue that was formerly inflamed has been destroyed, and bone erosion has occurred. The affected joints stop functioning and patients experience pain and severe loss of mobility.
Treatment options: "When there's a lot of joint damage, we focus on controlling pain," Raghu says.
Many of his patients see benefit from pain modulators such as gabapentin, muscle relaxers such as cyclobenzaprine, and low-dose antidepressants such as amitriptyline. Often, these drugs are used in combination.
Joint replacement can also restore mobility and reduce need for multiple pain medications. Raghu may refer patients to a joint replacement surgeon to see if this is a good treatment option.
What else might help? Check medical supply stores and online vendors for modifications and adapted tools that can make life with limited mobility easier and safer. For example, bathroom grab bars, a shower seat and a raised toilet seat can help you stay safe and independent, and simple rubber grips are available for everything from jars to pens to doorknobs.
Whichever stage you are in, your symptoms might remain the same for a long period. They could go into remission entirely, or could suddenly flare and worsen. Because no two people experience rheumatoid arthritis in the same way, there is no one-size-fits-all approach to treating it.
"It takes time and thorough examination to figure out the best treatment regimen for each patient," says Raghu, "so close collaboration between patient and physician is essential."
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