MEDICATIONS:

For the past 10 years, studies have shown that early, aggressive treatment for RA can delay the onset of joint destruction. In addition to rest, strengthening exercises, and anti-inflammatory agents, the current standard of care is to initiate aggressive therapy with disease-modifying anti-rheumatic drugs (DMARDs) once the diagnosis is confirmed.

Anti-inflammatory agents used to treat RA traditionally included aspirin and non-steroidal anti-inflammatory drugs (NSAIDS), such as ibuprofen (Motrin, Advil), fenoprofen, indomethacin, naproxen (Naprosyn), and others.

These are widely used medications that are effective in relieving pain and inflammation associated with RA. However, side effects associated with frequent use of many of these medications include life-threatening gastrointestinal bleeding.

Similar drugs, called Cox-2 inhibitors, are now a mainstay of anti-inflammatory therapy because the risk of gastrointestinal bleeding is significantly reduced with these drugs. Currently, there are two available -- rofecoxib (Vioxx) and celecoxib (Celebrex).

As mentioned, DMARDs alter the course of the disease. Included in this group are gold compounds, which can be injectible (Myochrysine and Solganal) or oral (auranofin/Ridaura). Methotrexate (Rheumatrex) is the most commonly used DMARD for rheumatoid arthritis with good proven effectiveness.

Antimalarial medications, such as Hydroxychloroquine (Plaquenil), as well as Sulfasalazine (Azulfidine), are also beneficial, usually in conjunction with Methotrexate.

The benefits from these medications may take weeks or months to be apparent. Because they are associated with toxic side effects, frequent monitoring of blood tests while on these medications is imperative.

In the last few years, new and exciting medications have been introduced. A promising medication that is fast becoming a first-line agent for the aggressive treatment of RA is called etanercept (Enbrel). Enbrel acts by inhibiting an inflammatory protein, called tumor necrosis factor (TNF).

Other new medications include infliximab (Remicade) that also blocks TNF and leflunomide (Arava), which blocks the growth of new cells. Anakinra is an even newer therapy that blocks the action of another inflammatory protein, interleukin-1. Anakinra and Etanercept are injectable medications, whereas Infliximab is given intravenously every 2 months.

Drugs that suppress the immune system, like azathioprine (Imuran) and cyclophosphamide (Cytoxan), may be used in people who have failed other therapies. These medications, which are associated with toxic side effects, are reserved for severe cases of RA.

Corticosteroids have been used to reduce inflammation in RA for greater than 40 years. However, because of potential long-term side effects, corticosteroid use is limited to short courses and low doses where possible.

Side effects may include bruising, psychosis, thinning of the bones (osteoporosis), cataracts, weight gain, susceptibility to infections, diabetes, and high blood pressure.  A number of medications can be administered in conjunction with steroids to minimize resultant osteoporosis.

Consult a health care provider before long-term use of any medication, including over-the-counter medications.

SURGERY:

Occasionally, surgery is indicated for severely affected joints. The most successful surgeries are those on the knees and hips. Usually, the first surgical treatment is removal of the synovium (synovectomy).

A later alternative is total joint replacement with a joint prosthesis. Surgeries can be expected to relieve joint pain, correct deformities, and modestly improve joint function. In extreme cases, total knee or hip replacement can mean the difference between being totally dependent on others and having an independent life at home.

LIFESTYLE CHANGES:

Range of motion exercises and individualized exercise programs prescribed by a physical therapist can delay the loss of joint function.

Joint protection techniques, heat and cold treatments, and splints or orthotic devices to support and align joints may be very helpful.

Frequent rest periods between activities, as well as 8 to 10 hours of sleep per night are recommended.

OTHER THERAPY:

Sometimes therapists will use special machines to apply deep heat or electrical stimulation to reduce pain and improve joint mobility.

Occupational therapists can construct splints for your hand and wrist and teach you how to best protect and use your joints when they are affected by arthritis. They also show people how to better cope with day-to-day tasks at work and at home, despite limitations caused by RA.

MONITORING:

Depending on the medications being taken, regular blood or urine tests should be done to monitor both progress and negative side effects.

Prognosis

Frequently, the disease can be controlled with a combination of treatments. Treatment may vary depending on the severity of the symptoms. Surgery may be needed, if medications fail.

The course of the disease varies between individuals. People with rheumatoid factor and/or subcutaneous nodules seem to have a more severe course of disease. People who develop RA at younger ages also have a more rapidly progressive course.

Remission is most likely to occur in the first year and the probability decreases as time progresses. By 10 to 15 years from diagnosis, about 20% of people will have had remission.

Between 50 - 70% will remain capable of full-time employment. After 15 to 20 years, only 10% of patients are severely disabled, and unable to perform simple activities of daily living (washing, toileting, dressing, eating).

However, the average life expectancy may be shortened by 3 to 7 years with this disease, and patients with severe forms of RA may die 10-15 years earlier than expected.

As treatment for rheumatoid arthritis improves, the occurence of severe disability and life threatening complications appears to be decreasing, so these figures may be overly pessimistic.

Complications

Rheumatoid arthritis is not solely a disease of joint destruction. It can involve almost all organ systems. The treatments for RA have also yielded serious side effects. Quality of life can be reduced, and mortality can increase.

As mentioned previously, the complications of RA can include joint destruction, gastrointestinal bleeding, heart failure, pericarditis, pleuritis, lung disease, anemia, low or high platelets, eye disease, cervical (neck) spine instability, neuropathy, and vasculitis. Fortunately, improved therapies appear to be reducing the occurence of these severe complications.

Call Your Health Care Provider If:

Call your health care provider if you think you have symptoms of rheumatoid arthritis.

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