Rheumatoid arthritis is an autoimmune disease that affects the joints. In some people, the immune system starts to see molecules and cells in the body as ‘foreign’ rather than ‘self’, and attacks them as if they were an invading bacteria or parasite. We do not yet understand exactly why or how this happens and although rheumatoid arthritis treatment has really advanced in the last few years, this is a chronic condition that must be managed rather than an illness that can be cured.
A wide range of rheumatoid arthritis treatments are now available, some of which help control symptoms such as joint swelling and pain, and others, known as disease modifying anti-rheumatic drugs (DMARDS), that are able to slow the underlying disease process. Disease modifying rheumatoid arthritis treatments can provide months or even years of remission from symptoms but they do need to be taken for several weeks before they take effect.
This article on rheumatoid arthritis treatment is by Kathryn Senior, a freelance journalist who writes health, medical, biological, and pharmaceutical articles for national and international journals, newsletters and web sites.
Treatment and symptom control
When you are first diagnosed, rheumatoid arthritis treatment will probably start with symptom control. This can help you to feel better while the medical team looking after you work with you to make decisions about long-term therapy. Even when this is started, you will probably need non-steroidal anti-inflammatory drugs and/or steroids to control the inflammation in your joints in the early weeks because of the time lag before DMARD treatment starts to work.
- Non-steroidal anti-inflammatory drugs (NSAIDS) have a double action when used as a rheumatoid arthritis treatment. They have an analgesic effect – they reduce pain – and they damp down inflammation. Years ago, aspirin was the most common NSAIDS but this produces problems, particularly with the stomach, and it is more usual today to take ibuprofen or naproxen. Other forms of NSAIDS are also available on prescription for rheumatoid arthritis treatment but are not available over the counter at the chemist.
- Corticosteroids also reduce inflammation but they have no effect on pain. Prednisone is often used as a rheumatoid arthritis treatment and can be taken in tablet form to reduce inflammation generally, or can be injected directly into a joint that is particularly swollen and painful.
Treatment to slow joint damage
The main problem with rheumatoid arthritis is that although it can go into remission naturally, it tends to get worse over time. Damage to joints is impossible to repair once it has gone past a certain stage. The most recently developed rheumatoid arthritis treatments include drugs that slow this disease process. These are disease-modifying because they do actually alter and decelerate the progress of joint damage. There are several types of DMARD, which can be used as long-term rheumatoid arthritis treatments:
- Methotrexate is the cheapest and fastest acting of all the DMARDs used in rheumatoid arthritis treatment. It starts working within 8 weeks and is considered a very effective drug. It helps symptoms and also slows down or even stops further joint damage, as assessed by X-days and other imaging methods. People who don’t respond as well as expected to methotrexate on its own can be treated with ‘triple therapy’, combining methotrexate with hydroxychloroquine and sulfasalazine.
- Inhibitors of tumour necrosis factor alpha have been developed as disease modifying rheumatoid arthritis treatments over the last 15 years or so. They include the monoclonal antibodies infliximab (Remicade®), adalimumab (Humira®), and the antibody fragment etanercept (Enbrel®). All of these block tumour necrosis factor alpha and reduce the impact of self-immunity.
- T cell blocking agents, such as abatacept (Orencia®) stop immune cells in the body interacting with each other and prevent some of the autoimmune damage in joints. A useful rheumatoid arthritis treatment in the early stages of the disease.
- B cell blocking agents such as rituximab (Rituxan®) actually depletes immune cells called B cells from the body of someone with rheumatoid arthritis, preventing them attacking tissues in the joints.
- Hydroxychloroquine is a drug originally developed to treat malaria but that is now available as a rheumatoid arthritis treatment due to its ability to prevent joint damage in mild cases. It is usually used as part of a ‘triple therapy’ with methotrexate and sulfasalazine.
- Sulfasalazine is a more potent rheumatoid arthritis treatment than hydroxychloroquine but not quite as good as methotrexate but it does help the action of the other two drugs when used in ‘triple therapy’.
- Interleukin 1 receptor antagonists such as anakinra (Kineret®) inhibit one of the interleukins that is known to play a part in the autoimmunity that leads to rheumatoid arthritis.
Gold was considered one of the best rheumatoid arthritis treatments in the 1900s but has since been overtaken by the DMARDS, particularly methotrexate. Intramuscular gold is still used but very rarely. In very severe cases more potent immunosuppression may be needed to reduce symptoms. Cyclosporine and cyclophosphamide, both commonly used for immunosuppression after organ transplants, as be used as rheumatoid arthritis treatments, but both are toxic and can have many side effects.
As in osteoarthritis, when joint damage has become very serious, the option of surgery to replace the affected joint is always available. Hip replacement, knee replacement, wrist or elbow replacement and even knuckle replacements are done very successful as part of a rheumatoid arthritis treatment plan.