Treatment Options

The goal of rheumatoid arthritis treatment is to:

1. Relieve pain
2. Control inflammation
3. Slow or prevent destruction of joints
4. Maintain the ability to perform normal day-to-day tasks
5. Prevent surgery
6. Maximize quality of life

Successful rheumatoid arthritis treatment is usually made up of a combination of medication, rest, exercise, physical therapy, psychological support, job and home support, proper diet and joint protection.

Attitude can help rheumatoid arthritis treatment

Rheumatoid arthritis (RA) brings with it much more than physical symptoms. Some people experience feelings of powerlessness and depression. Adopting positive strategies in your day-to-day routine may help you to better manage your RA. It may help you develop a more positive outlook and, finally, give you a feeling of greater control over your disease.

It may also be a good idea for people affected by RA to form close ties with their doctors and therapists in order to participate more actively in their own healthcare — both mental and physical.

Rheumatoid Arthritis Treatment Options

Pain relievers
Even with medications designed to minimize the progress of rheumatoid arthritis, pain-reducing medications are often also needed. These include Tylenol* (acetaminophen), codeine and oxycodone. There are also a variety of topical gels and creams available to help temporarily soothe pain. The majority of creams and gels use heat or cold to provide pain relief. Topical creams that contain the substance capsaicin can generate a warm feeling on the skin and may reach past surface pain to the molecular level, affecting pain impulses. Many pain relievers can be bought without a prescription, but you should always check first with your physician or pharmacist before taking any new medication.

Non-steroidal anti-inflammatory drugs (NSAIDs)
NSAIDs reduce joint pain and inflammation and are generally used first when rheumatoid arthritis is diagnosed. Because responses to NSAIDs may vary, it is not uncommon for a physician to try several different ones to find out which is the most effective for you and which has the fewest side effects. Non-prescription NSAIDs include Aspirin*, Motrin* IB and Advil*. Prescription NSAIDs include Naprosyn*, Voltaren*, Celebrex*, Arthrotec* and indomethacin. Possible side effects may include heartburn, ulcers and bleeding, and some people may need to take additional medication to help protect the stomach.

Note: This is not a complete list of side effects of these drugs. It is important for you to inform your doctor if you have side effects mentioned here, or any other side effects.

Corticosteroids
Corticosteroids (also known simply as steroids) are drugs that mimic the natural anti-inflammatory hormone cortisone. Steroids can help control inflammation, which may help to relieve pain. In some cases, this can lead to improved joint function and range of movement. Prednisone is the corticosteroid most commonly used in rheumatoid arthritis treatment today. Steroids can have potentially significant side effects (including cataracts, high blood pressure, sleep problems and osteoporosis, or weakening of the bones), and they should not be overused. Excessive use may also weaken cartilage. Corticosteroids are often taken in pill form. They can also be given intravenously (by IV) in hospital or at a clinic, or they can be injected by your doctor directly into the affected joints.

Note: This is not a complete list of side effects of these drugs. It is important for you to inform your doctor if you have side effects mentioned here, or any other side effects.

Disease-modifying anti-rheumatic drugs (DMARDs)
DMARDs reduce inflammation and can slow or stop your immune system from attacking your joints and tissues. It's not completely understood how all DMARDs work, but it's thought that they suppress the immune system. DMARDs may slow the progression of rheumatoid arthritis and may also improve the course of the disease.

DMARDs are used early on in rheumatoid arthritis treatment, often in combination with other drugs. Some examples of DMARDs are methotrexate, Plaquenil* (hydroxychloroquine), Arava* (leflunomide), Imuran* (azathioprine) and Myochrysine* (sodium aurothiomalate).

Methotrexate is used to treat severe, disabling rheumatoid arthritis when standard therapies haven't worked. Methotrexate is usually taken orally, but it can also be given by injection. Some of the more common side effects with methotrexate include elevated liver enzymes, nausea/vomiting, mouth sores, skin irritation, hair loss, diarrhea, fatigue, chills and fever, dizziness and decreased resistance to infection. Bone marrow suppression (i.e., where a person's body doesn't produce enough red blood cells, white blood cells and platelets) is possible. In rare cases, methotrexate can also cause inflammation of the lung.

Note: This is not a complete list of side effects of these drugs. It is important for you to inform your doctor if you have side effects mentioned here, or any other side effects.

Plaquenil* (hydroxychloroquine), which is taken by mouth, has a beneficial effect on rheumatoid arthritis. It's used in patients who haven't responded well enough to other therapies. Some of the side effects are nausea, diarrhea, stomach pain, stomach cramps, reduced appetite and rash. Rarely, skin changes (e.g., itching, changes in pigmentation, bleaching and/or loss of hair) can also happen in patients on hydroxychloroquine but usually disappear once treatment is stopped. Although rare, permanent damage to the retina can occur.

Note: This is not a complete list of side effects of these drugs. It is important for you to inform your doctor if you have side effects mentioned here, or any other side effects.

Arava* (leflunomide) is used to treat adult patients with active rheumatoid arthritis. It comes in tablet form and is taken by mouth. Leflunomide works by reducing or suppressing, to a certain extent, the abnormal activation and multiplication of cells responsible for inflammation. Hypertension, diarrhea, loss of appetite, nausea, vomiting, abdominal pain, weight loss (usually mild), headache, dizziness, weakness, respiratory infection, inflammation of a tendon sheath, skin rash and ulceration of the mouth are considered common side effects of leflunomide treatment. Leukopenia (a reduction in white blood cells) and hypersensitivity reactions may occur. Hepatotoxicity (liver damage) has been known to occur. Although usually mild and reversible, cases of severe, sometimes fatal liver disease — including acute hepatic necrosis — have been seen. Pancreatitis (inflammation of the pancreas), interstitial lung disease and infections including fatal sepsis (an infection of the blood) are rare, but possible.

Note: This is not a complete list of side effects of these drugs. It is important for you to inform your doctor if you have side effects mentioned here, or any other side effects.

Imuran* (azathioprine) is used to treat rheumatoid arthritis in adult patients with severe, active erosive disease not responsive to other treatments. It's available in tablets or as an injection. Side effects with azathioprine treatment include nausea, vomiting and leukopenia and/or thrombocytopenia (a reduction in certain types of blood cells). Other rare but more serious side effects include acute myeloid leukemia (cancer of certain types of blood cells) and myelodysplasia (abnormal or reduced production of certain blood cells). Azathioprine is mutagenic (can cause mutation) and carcinogenic (can cause cancer) and may increase a patient's risk of neoplasia (abnormal growth of cells/tissue), in particular lymphoma and skin cancer. It may also cause fetal harm when administered to a pregnant woman. The frequency and severity of side effects depend on how much azathioprine the patient is taking and for how long they've been taking it as well as the patients' underlying disease or concomitant therapies.

Note: This is not a complete list of side effects of these drugs. It is important for you to inform your doctor if you have side effects mentioned here, or any other side effects.

Myochrysine* (sodium aurothiomalate) is used to treat both adult and juvenile rheumatoid arthritis. Myochrysine* is given as an intramuscular injection only. The most frequent side effects of Myochrysine* are skin rash and mucous membrane ulcers. Some patients develop proteinuria (protein found in the urine). In rare cases, gold treatment can lead to bone marrow suppression, severe skin exfoliation, inflammation of the small and large intestines, liver failure and allergic reactions.

Note: This is not a complete list of side effects of these drugs. It is important for you to inform your doctor if you have side effects mentioned here, or any other side effects.

If a DMARD is prescribed for you, your doctor will likely order a number of clinical tests to make sure your body is handling the medication well.

Biologic response modifiers (biologics)

Most biologics work by blocking the action of proteins called cytokines, specifically one known as tumour necrosis factor (TNF). Another blocks the activity of an interleukin known as IL-1, which is associated with the overproduction of TNF. Excessive amounts of TNF can attack the lining of joints and tissues. Neutralizing TNF either directly or indirectly can help prevent and relieve inflammation, swelling and pain. Biologics are used for moderate-to-severe rheumatoid arthritis when other drugs (e.g., DMARDs or corticosteroids) are not working well enough.

Biologics currently available in Canada for the treatment of RA include Remicade* (infliximab), Rituxan* (rituximab) and Orencia* (abatacept) which are administered intravenously, as well as Simponi* (golimumab), Humira* (adalimumab), Kineret* (anakinra), Enbrel* (etanercept), and Cimzia* (certolizumab pegol) which are administered by subcutaneous (i.e., under the skin) self-injection. Your doctor will explain the differences in the way these medications are administered, should one be prescribed for you.

Remicade* (infliximab) is used along with methotrexate for reducing signs and symptoms, inhibiting the progression of structural damage and improving physical function in adult patients with moderately to severely active rheumatoid arthritis.

Rituxan* (rituximab) is used along with methotrexate to reduce signs and symptoms in adult patients with moderately to severely active rheumatoid arthritis. It's used in patients who've had an inadequate response or intolerance to one or more TNF blockers.

Orencia* (abatacept) is used for reducing signs and symptoms, inducing clinical responses, inhibiting the progression of structural damage, and improving physical function in adult patients with moderately to severely active rheumatoid arthritis. It's used in patients who've had an inadequate response to one or more DMARDs and/or to TNF blockers. Orencia* can be used alone or in combination with a DMARD.

Orencia* is also indicated for reducing signs and symptoms of moderately to severely active polyarticular juvenile idiopathic arthritis/juvenile rheumatoid arthritis in pediatric patients 6 years of age and older who've had an inadequate response to one or more DMARDs, such as MTX. Orencia* has not been studied in children less than 6 years of age.

Simponi* (golimumab) in combination with methotrexate (MTX) is used to reduce signs and symptoms in adult patients with moderately to severely active rheumatoid arthritis.

Humira* (adalimumab) is used for reducing signs and symptoms, inducing major clinical response and clinical remission, inhibiting the progression of structural damage and improving physical function in adult patients with moderately to severely active rheumatoid arthritis. It can be used alone or in combination with methotrexate or other DMARDs.

Kineret* (Anakinra) is used for:

• Reducing signs and symptoms of active RA in patients 18 years of age or older;
• Inhibiting the progression of structural damage by reducing erosions and cartilage degradation in patients with active RA despite treatment with stable doses of methotrexate.

Kineret* can be used alone or in combination with other DMARDs, particularly methotrexate.

Enbrel* (etanercept) is used for treatment of moderately to severely active RA in adults. Treatment is effective in reducing the signs and symptoms of RA, inducing major clinical response, inhibiting the progression of structural damage, and improving physical function. Enbrel* can be initiated in combination with methotrexate (MTX) in adult patients or used alone.

Cimzia* (certolizumab pegol) in combination with methotrexate (MTX) is used for the treatment of adult patients with moderately to severely active RA. Treatment is effective in reducing the signs and symptoms of RA, inducing major clinical response, and reducing the progression of joint damage as assessed by X-ray. Cimzia may be used alone for reducing signs and symptoms in adult patients with moderately to severely active RA who do not tolerate MTX.

Side effects of biologic treatment may include upper respiratory tract infections, rash and shortness of breath. Other infections like sepsis, invasive fungal infection and tuberculosis (TB) may also occur. So it is essential that you tell your doctor if you are prone to infections or if you have ever had, or tested positive for, TB at any time.

The risk of developing malignancies such as blood cancer (lymphoma) or certain other cancers while on biologics may increase. Discuss with your doctor the cancer screening measures and impact of lifestyle choices on the risk of developing cancer before you consider treatment with a biologic.

Note: This is not a complete list of side effects for the biologics. It is important for you to inform your doctor if you have side effects mentioned here, or any other side effects.

Surgery
If one of your joints becomes badly damaged, or if the pain becomes too much to bear, you and your doctor may consider surgery.

There are a variety of surgical procedures for rheumatoid arthritis, ranging from arthroscopic surgery (which uses a specialized scope that is introduced through a small incision to remove inflamed tissue or smooth away bone deformities) to full joint replacement.

Naturally, every case is unique, and the outcomes of surgery in rheumatoid arthritis, combined with complementary therapies such as medication, exercise, joint protection and rest, will differ from person to person.

* Medications have both common (generic) and brand names. The brand name is what a specific manufacturer calls the product (e.g., Tylenol*). The common name is the medical name for the medication (e.g., acetaminophen). For more information on brand names, speak with your doctor or pharmacist. All brand names mentioned are the property of their respective trademark and/or license holders.

Complementary rheumatoid arthritis therapies
In addition to medications, there are a number of other therapies that may help you manage the symptoms of rheumatoid arthritis and that can be used to complement your treatment plan. Make sure to tell your doctor if you are doing any additional things or taking any additional medications to manage your RA symptoms.

Exercise
Exercise can play an important role in helping to reduce symptoms of rheumatoid arthritis. It can contribute to pain relief and may even help prevent further joint damage. Exercise is also important in achieving or maintaining a healthy weight, which will result in less strain on certain joints. Different types of exercise provide different results. For example, range-of-motion exercises can help reduce stiffness; strengthening exercises can help you maintain or build up muscle strength; and activities like walking, swimming and cycling can help make your heart stronger, make you feel less fatigued and keep your weight in a healthy range. A physiotherapist can also suggest exercise techniques to help manage pain, improve joint flexibility and build muscle.

Heat and cold
Sore muscles and joint pain are often relieved by applying heat. A hot shower may help reduce pain and stiffness in the morning. Note that heat should not be applied to an already inflamed joint as this may make the symptoms worse. Applying ice or a cold pack reduces pain and swelling when a joint is inflamed.

Protecting your joints
Putting too much strain on a joint can cause problems. That's why it's advisable to take special care when carrying out day-to-day tasks. Pacing yourself by alternating difficult or repetitive tasks with easier ones can be one way, and be sure to rest your joints by taking breaks between activities. Try to avoid joint stress as much as possible by using your larger, stronger joints to carry heavier loads (using a back pack, for example, instead of a hand-held briefcase or purse). You may also consider using assistive devices such as canes or raised chairs, or even installing grab bars and reaching aids in your bathroom, for example.

Relaxation
Another way to help reduce joint pain is by relaxing the muscles surrounding the joint. Deep breathing exercises and listening to classical or ambient relaxation music can help. There are also mental techniques you can try, such as meditation and visualization.

If you are experiencing symptoms of rheumatoid arthritis or have been diagnosed with the disease, you may find it helpful to fill out the RA Self-Assessment Discussion Guide.

*All trademarks are the property of their respective owner(s).