Rheumatoid arthritis treatment to control your pain

Rheumatoid arthritis treatment from your doctor

“There are so many effective treatments for rheumatoid arthritis these days,” says Dr Ann Nainan, family doctor and Healthily expert. “Whatever you might have seen or heard from friends and family members who have had to deal with RA in the past, the good news is that the outlook is much brighter than it was 20 years ago.”

The key things you need to know:

• don’t delay talking to your doctor about treatment – if you get treatment early enough, some drugs can slow down or even switch off the progression of RA, while others will help deal with symptoms such as pain and stiffness
• there are drugs designed to put RA into remission – and stop inflammation in the lining of your joints (synovitis) damaging them over the long term. “Ideally, you need to start your drug treatment as soon as possible after you’ve been diagnosed,” says Dr Ann
• there’s a window of opportunity early on – possibly only a few months – when RA responds best to treatments. Time to diagnosis is improving – in the UK, the National Institute for Health and Care Excellence (NICE) says that suspected RA should be treated as an urgent referral, meaning you should be seen within 3 weeks
• your treatment is personal to you – “giving your doctor as much information as you can about your symptoms, family history, and any concerns you have about remembering to take treatments or worries about side effects, will help you find the best treatment plan,” says Dr Ann. Treatment will be created based on how severe your symptoms are, how long you’ve had them for, test results, whether you have other health conditions, and your personal preferences
• no single treatment works for everyone – it’s likely that you’ll switch between a number of drugs during the course of your treatment, and/or be prescribed a combination of drugs

Disease-modifying antirheumatic drugs (DMARDs)

“Disease-modifying antirheumatic drugs (DMARDs) are essential for managing RA and they’re designed to reduce or prevent joint damage and to preserve your joint function,” says Dr Ann.

• there are 3 main types – traditional DMARDs, biologic DMARDs and JAK inhibitors (targeted synthetic DMARDs)
• stick with them – they can take several months to start working effectively
• your doctor may prescribe other drugs alongside them – such as non-steroidal anti-inflammatory drugs (NSAIDs) and steroids, to tackle swelling and pain while you wait for the DMARDs to work

Traditional DMARDs

“Also known as non-biologic DMARDs, these are very effective and can help prevent the pain and stiffness caused by joint damage,” says Dr Ann. “They calm down your body’s overactive immune system to stop it damaging your joints.”

• your doctor will usually start you on a lower dose and gradually increase it
• gradually increasing your dose helps manage the potential side effects – not everyone gets side effects, and for many people the benefits outweigh the risks, but you’ll decide this with your doctor
• you’ll need regular blood tests – to check your liver health and for toxicity, so you’ll need to fit these into your life
• they may become less effective over time – and you may have to move on to another type of drug

“Generally, they’re worth sticking with because they do control the disease,” says Dr Ann. “If you get symptoms you think might be side effects, keep a note of them and talk to your doctor to work out the best plan for you.”

Methotrexate

• this is an ‘immunosuppressant’ that slows down your body’s immune system and works to reduce inflammation
• it can reduce pain, stiffness, and long-term joint damage
• common side effects include a sore mouth and stomach upsets. These may affect up to 1 in 10 people, meaning 9 out of 10 people won’t get them
• you take it weekly (on the same day) as a pill, liquid, or prefilled methotrexate injection pens or syringes
• once your dose has been adjusted to full strength, it can take 3 months to feel the effects
• you can’t take it if you’re pregnant, and need to stop taking it 6 months before you try for a baby (as does your partner if he’s taking it)
• whether you can breastfeed while taking it depends on your dose, how you take it and if you’re taking other medicines
• you need regular blood tests for liver and kidney function. Initial tests are done every 1 to 2 weeks, and every 2 to 3 months when the dose is stabilized
• you may also need to take a folic acid supplement to help reduce side effects such as nausea, vomiting and diarrhea. This helps by protecting healthy cells

Sulfasalazine

• sulfasalazine works to reduce inflammation
• it can reduce redness and swelling, and is believed to aid healing
• potential side effects include nausea, vomiting, diarrhea, stomach pain and indigestion, which affect more than 1 in 100 people
• you take it daily as a pill, liquid or a medicine you insert into your bottom (suppository)
• it can take 1 to 3 months before your symptoms get better
• you can’t take it if you’ve had previous allergic reaction to sulfasalazine, aspirin or similar drugs
• you need regular blood tests to monitor your blood count

Hydroxychloroquine

• originally developed for treating malaria, it can be used in the early stages of RA because it’s thought to interfere with the way cells in your immune system communicate with each other
• it can reduce joint pain and swelling. It may also help prevent joint damage and long-term disability
• the most common side effects are nausea, stomach pain, loss of appetite, headache and skin rashes (these affect more than 1 in 100 people)
• it’s taken daily as 1 dose or 2 divided doses
• it can take 2 to 3 months to see the effects
• you can’t take it if you’ve had a previous allergic reaction, are pregnant, breastfeeding or trying to become pregnant, have eye problems related to the retina or have psoriasis
• your doctor will monitor you closely with regular blood test to check the number and type of cells in your blood, and also check on your muscle and tendon function

Leflunomide

• works by stopping your body’s production of inflammatory cells
• it can reduce the inflammation which causes pain, stiffness and swelling in your joints
• side effects can include skin rash, temporary hair loss, abnormal liver function, nausea, diarrhea, weight loss, abdominal pain and raised blood pressure – these may affect up to 1 in 10 people
• it’s taken daily as a pill
• it takes 4 to 6 weeks before you feel any effects, but may take 4 to 6 months before you get the full benefits
• you can’t take it if you’re pregnant, breastfeeding or trying to become pregnant, if you’ve had liver problems, are taking other medications or herbal remedies, have a weak immune system, kidney problems, nerve problems or history of tuberculosis (TB)
• you’ll need regular blood tests to check for liver damage and other toxicities
• it can be used on its own or with other DMARDs such as methotrexate injections

Azathioprine

• this is an immunosuppressant so it works by calming your immune system
• benefits include reducing inflammation which causes swelling and pain in your joints
• nausea and headaches are common side effects that affect more than 1 in 10 people
• it’s taken once or twice a day as a pill
• it can take up to 12 weeks to feel the benefits after you’ve found your ‘right’ dose
• you’ll need to have regular blood tests while taking it
• you can’t take it if you’re pregnant or trying to become pregnant, if you’ve had a previous allergic reaction to it, have an infection/high temperature or feel generally unwell, if you’ve ever had liver problems or have had cancer
• it’s used much less than it was in the past because more effective treatments are now available. Whether you’ll be prescribed it depends on which drugs are available, your health and if you get any side effects
• it’s usually used as an add-on treatment to a main DMARD to help reduce steroids being taken if you have severe active RA

Biologic drugs

Biologic DMARDs are also known as biologic agents, targeted biologic agents and targeted synthetic DMARDs.

They work by blocking the activity of specific chemicals, cells and proteins involved in inflammation, which cause joint swelling and other RA symptoms.

“Biologic drugs are usually the next stage of the treatment ladder, as they target specific aspects of the body’s immune response, rather than many,” explains Dr Ann.

“They still have side effects – they suppress your immune system and so increase your risk of infections.

“There are several different types of biologics and they tend to work much quicker than conventional DMARDs – some within 2 weeks, others within 4 to 6 weeks.”

Anti-TNF drugs

• they work by targeting a protein called tumor necrosis factor (TNF) which is involved in inflammation
• drugs in this group include adalimumab, certolizumab, etanercept, golimumab, infliximab
• they have an anti-inflammatory effect, reducing pain, swelling and stiffness in your joints
• common side effects that affect more than 1 in 10 people include headaches, injection site reactions, rash, anemia, cough, diarrhea, nausea and abdominal pain
• most of these drugs are given by shot or infusion – how often you have this depends on the specific drug you need
• they take between 2 and 12 weeks to take effect
• your doctor won’t prescribe adalimumab – 1 of the most widely used anti-TNFs – if your RA isn’t active, if you have an infection, or there are other treatments you could try first. It’s also not suitable if you have certain health conditions
• if you’re pregnant, planning to get pregnant or you want to breastfeed, discuss your medication with your doctor. Whether you should take these drugs during pregnancy or breastfeeding can vary
• you’ll need blood tests while you’re on anti-TNFs to monitor their effects

Rituximab

• this is a monoclonal antibody, a type of protein that can bind to B cells (a type of white blood cell) in your body. B cells make antibodies but they can also produce harmful autoantibodies which can attack the tissue surrounding your joints in RA
• rituximab attaches to a molecule on B cells which triggers your immune system to destroy the B cells, reducing the number of autoantibodies
• benefits include reduced pain, improved function and fewer flare-ups (this is when your symptoms get worse temporarily)
• it’s used to treat RA that hasn’t improved with other types of medication
• the most common side effects are infusion-related reactions (such as fever, chills, and shivering). Fewer than 1 in 100 have severe reactions
• it’s given as an IV infusion, initially 2 weeks apart. The infusions are repeated when your symptoms begin to return. This could be between 6 months to a few years later
• it can take 8-16 weeks to notice an improvement after starting treatment
• it’s generally recommended not to take rituximab if you’re pregnant, as it can cross your placenta and may affect your baby
• you shouldn’t breastfeed during rituximab treatment and for 12 months after
• If you’re pregnant or thinking about becoming pregnant or you’re planning to breastfeed, speak to your doctor
• you’ll need monitoring with monthly blood tests

Tocilizumab

• another type of monoclonal antibody and it targets a protein called IL-6 which can cause inflammation if you have too much of it
• tocilizumab blocks the action of IL-6 in your body reducing inflammation and damage
• common side effects include abdominal pain, anxiety, cough, diarrhea, dizziness, increased risk of infection, insomnia or nausea
• it can be given as an intravenous infusion every 4 weeks, or as a weekly shot
• it generally takes 3 to 6 months to feel the benefits, but some people feel them sooner – as early as 2 weeks
• you can’t take it if your RA isn’t active, if you have a severe infection or you haven’t tried other treatments first
• you should generally avoid it during pregnancy, as its effects on the baby are not yet known. Speak to your doctor if you’re pregnant or planning to get pregnant
• talk to your doctor if you’re thinking of breastfeeding as the research is limited
• you’ll need blood tests every 4 to 8 weeks while you’re taking it

Biosimilars

There’s also a new generation of biologic-related drugs called biosimilars. These are very similar to biologics, they have the same benefits and potential side effects, but they’re cheaper to produce.

JAK inhibitor drugs

Janus kinase (JAK) inhibitors are the newest class of drugs used to treat RA. Also known as kinase inhibitors or targeted synthetic DMARDs, they include tofacitinib, baricitinib, filgotinib and upadacitinib.

Here’s what you need to know:

• like biologic drugs, they’re ‘targeted’ medication – but they’re easier to take, as they can be taken as pills
• they work by reducing your immune system’s ability to make certain proteins that play a role in inflammation
• they can reduce pain and swelling in your joints, and improve your daily function
• common side effects that may affect up to 1 in 10 people – meaning at least 9 in 10 people won’t get them – include nose, throat and windpipe infections, lung infections, shingles, flu, cystitis, dizziness and nausea
• depending on which medication you take, you’ll usually take pills daily or twice daily
• they can work in as little as 2 weeks in some cases, but in most people it takes 3 to 6 months to feel the benefits
• these drugs should only be used if there are no alternatives if you’re over 65 years old, if you’re at increased risk of heart attack or stroke or you smoke. That’s because of the increased risk of serious side effects including heart attack, stroke, cancer, blood clots and death. Caution is also needed if you have risk factors for blood clots or cancer
• they aren’t suitable if you’re pregnant, planning to become pregnant or you’re breastfeeding. Talk to your doctor if this is you
• you need regular blood tests while on JAK inhibitors, including a full blood count, liver enzymes and kidney function

Prescription painkillers

Painkillers may ease some of your pain symptoms and minor inflammation, but they don’t work on RA itself and the joint damage it can cause, so they should never be your only treatment.

“Alongside your medication that helps reduce the underlying inflammation that causes stiffness and joint damage, your doctors can also prescribe drugs to help with pain,” says Dr Ann. “Acetaminophen (paracetamol) isn’t that helpful in RA, but there are other options.”

Non-steroidal anti-inflammatory drugs (NSAIDs)

• your doctor may prescribe a short course of NSAIDs, such as ibuprofen or naproxen, at the lowest possible dose to treat your pain
• NSAIDs can cause side effects, particularly stomach problems such as indigestion and ulcers, which can be more likely if you’re taking high doses for a long time. Read more about side effects of NSAIDs
• if you think you need to take NSAIDs long term, your doctor will need to assess the risks and benefits, and may prescribe medication called a proton pump inhibitor (PPI) to protect your stomach

Opioids

• opioids such as codeine, dihydrocodeine and tramadol can be prescribed for moderate to severe pain if other types of pain relief haven't worked for you
• they’re avoided for long-term pain though, as there’s a risk of addiction and overdose. If your doctor prescribes them, you’ll be monitored closely

Steroids

“Steroids are generally used for severe RA symptoms, as they work more quickly than DMARDs,” says Dr Ann.

“You might benefit from them when you’re first diagnosed, to reduce your symptoms while your DMARDs get to work. Or you might need them short-term if you have a flare-up of symptoms.”

• corticosteroids and glucocorticosteroids are copies of anti-inflammatory steroid hormones made naturally by your body
• they can be given as pills or shots
• they have strong anti-inflammatory effects, reducing swelling and redness, and they control your immune system
• lower doses can sometimes be prescribed as a long-term treatment alongside DMARDs to control severe symptoms
• they can cause side effects, which are more likely if you take them at high doses or for longer periods – read about side effects from steroids
• your doctor will aim to give you the lowest possible dose for the shortest period of time needed to control your symptoms

Rheumatoid arthritis flare-up treatment

With RA, you can get ‘flare-ups’ – where your symptoms temporarily get worse. If you have a bad flare-up, you might struggle to get out of bed and get on with your daily activities. Flare-ups can also affect your sleep and leave you feeling wiped out with fatigue.

Your doctor may recommend treating a flare-up by:

• increasing the dose of drugs you’re already taking
• changing your drugs
• adding additional drugs, such as steroids

Over time, you may start to recognize a pattern of what causes your flare-ups.

Read about self-care for rheumatoid arthritis for more tips on preventing and managing flare-ups.

Other treatments for rheumatoid arthritis

“As well as prescription drugs, your doctor may refer you for other treatments to help manage your symptoms,” says Dr Ann.

Physiotherapy

Living with a long-term pain condition can make you more likely to lose fitness, or mean that you struggle with everyday tasks. A physiotherapist is trained to help you improve your fitness and muscle strength, and make your joints more flexible.

They may be able to help you with:

• face-to-face exercise sessions – to strengthen joints that have been damaged, such as your hands or wrists. You can then practice the exercises at home
• assessments – to see if you need walking aids, insoles, splints or balance/posture training
• advice – about how to recognise a flare-up and how to handle it with self-care treatments
• referral to a hydrotherapy pool – so you can exercise while supported by water

Occupational therapy

These specialists can help you with strategies for managing everyday tasks, such as opening jars, turning on taps or fastening buttons, and give you advice about protecting your joints at home and work.

Podiatry

As RA can particularly affect the joints in your feet, a podiatrist may be able to help if you have problems with walking or pain.

They may be able to give you insoles to make walking more comfortable, or some other type of support for your joints.

Surgery

Sometimes, despite long-term treatments, your joints will be damaged by RA and you may need surgery to fix it or reduce pain.

Types of surgery may include:

• finger surgery to release tendons if your finger is abnormally bent
• carpal tunnel release surgery – where a ligament in the wrist is cut to relieve pressure on a nerve if you have persistent carpal tunnel syndrome
• keyhole surgery (arthroscopy) to remove inflamed joint tissue
• joint replacement surgery