Rheumatoid arthritis – Treatment

By NHS Choices 9

Medication

Many different medicines are used to treat rheumatoid arthritis. Some aim to relieve symptoms and others help slow the progression of the condition. Everyone with rheumatoid arthritis experiences it differently, so it may take time to find the best combination of medicines for your needs. Some of the different medicines that you may be prescribed are outlined below.

Painkillers

Painkillers reduce pain rather than inflammation and are used to control the symptoms of rheumatoid arthritis. The most commonly prescribed painkiller is paracetamol, Codeine is another painkiller that is sometimes prescribed as a combined medicine with paracetamol (known as co-codamol).

Non-steroidal anti-inflammatory drugs (NSAIDs)

Your GP may prescribe a non-steroidal anti-inflammatory drug (NSAID) to relieve pain and swelling in your joints. There are two types of NSAIDs and they work in slightly different ways. These are traditional NSAIDs – such as ibuprofen, naproxen or diclofenac and COX-2 inhibitors (often called coxibs) – such as celecoxib or etoricoxib. NSAIDs help relieve pain and stiffness while also reducing inflammation. However, they will not slow down the progression of rheumatoid arthritis.

Your doctor will discuss with you what type of NSAID you should take and the benefits and risks associated with each of them. NSAID tablets may not be suitable if you have asthma, a peptic ulcer, angina or if you have had a heart attack or stroke. If you are taking low-dose aspirin, discuss with your GP whether you should use an NSAID.

Taking an NSAID tablet can increase the risk of serious stomach problems, such as bleeding internally. Taking an NSAID can break down the lining that protects against damage from acids in the stomach. While the risk is serious, it is not common. According to research, if between 2,000 and 3,000 people take NSAIDs, one person is likely to have a stomach bleed. The COX-2 agents have a lower risk of serious stomach problems, but carry a risk of heart attacks and strokes.

If you are prescribed an NSAID tablet, you will almost certainly have to take another medicine, such as a proton pump inhibitor (PPI), as well. Taking a PPI reduces the amount of acid in your stomach, which greatly reduces the risk of damage to your stomach lining caused by the NSAID.

Corticosteroids

Corticosteroids help reduce pain, stiffness and swelling. They can be used as a tablet (for example, prednisolone) or an injection into the muscle (to help lots of joints). They are usually used when NSAIDs fail to provide relief. If you have a single inflamed or swollen joint, your doctor may inject the steroid into the joint. Relief is rapid and the effect can last from a few weeks to several months, depending on the severity of your condition.

Corticosteroids are usually only used on a short-term basis, as long-term use of corticosteroids can have serious side effects. These can include weight gain, osteoporosis (thinning of the bones), easy bruising, muscle weakness and thinning of the skin. They can also make diabetes and glaucoma (an eye disease) worse.

Disease-modifying anti-rheumatic drugs (DMARDs)

DMARDs help to ease symptoms and slow down the progression of rheumatoid arthritis. When antibodies attack the tissue in the joints, they produce chemicals that can cause further damage to the bones, tendons, ligaments and cartilage. DMARDs work by blocking the effects of these chemicals. The earlier you start taking a DMARD, the more effective it will be.

There are many different conventional DMARDs including methotrexate, leflunomide, hydroxychloroquine and sulfasalazine.

Methotrexate is often the first drug given for rheumatoid arthritis. You may take it in combination with another DMARD. The most common side effects of methotrexate are sickness, diarrhoea, mouth ulcers, hair loss or hair thinning, and rashes on the skin. Sometimes, methotrexate can have an effect on your blood count and your liver, and you will have regular blood tests to monitor this. Less commonly, it can affect the lungs, so you will usually have a chest X-ray and possibly breathing tests when you start taking methotrexate, to provide a comparison if you develop shortness of breath or a persistent dry cough while taking it. However, most people tolerate methotrexate well and around half of those who start it will still be taking it five years later.

Methotrexate may also be combined with biological treatments (see below).

It can take four to six months to notice a DMARD working. Therefore, it is important to keep taking the medication, even if you do not notice it working at first. You may have to try two or three types of DMARD before you find the one that is most suitable for you. Once you and your doctor work out the most suitable DMARD, you will usually have to take the medicine in the long term.

Biological treatments

Biological treatments are a newer form of treatment for rheumatoid arthritis. They include TNF-alpha inhibitors (etanercept, infliximab, adalimumab and certolizumab), rituximab and tocilizumab.

They are usually taken in combination with methotrexate or sometimes with another DMARD. They work by stopping particular chemicals in the blood from activating your immune system to attack the lining of your joints.

Biological treatments are not suitable for use by everyone. 

TNF-alpha inhibitors are usually only available on the NHS if you have already tried methotrexate and another DMARD at standard doses and your rheumatoid arthritis is still quite active.

Rituximab and tocilizumab are recommended by NICE, in combination with methotrexate, for severe rheumatoid arthritis only if you’ve tried DMARDs and one of the TNF inhibitors and still have quite active rheumatoid arthritis.

Side effects from biological treatments are usually mild and include skin reactions at the site of injection, infections, nausea, fever and headaches. Some people may be at risk of getting more serious problems, including people who have had tuberculosis (TB), septicaemia or hepatitis B in the past. There is a slight risk that biological treatments can reactivate these conditions and, in rare cases, trigger new autoimmune problems.

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Surgery

Sometimes, despite medication, damage to your joints may occur. You may need surgery to help restore your ability to use your joint. Surgery may also reduce pain and correct deformities.

Finger and hand surgery to correct joint problems

There are different types of surgery to correct joint problems in the hand. Examples include: 

  • carpal tunnel release (cutting a ligament in the wrist to relieve pressure on a nerve)
  • release of tendons in the fingers to treat abnormal bending
  • removal of inflamed tissue that lines the finger joints

If surgery is needed on the wrist and fingers, the wrist is usually done first.

Arthroscopy

Arthroscopy removes inflamed joint tissue. A thin tube with a light source is inserted into the joint through a small cut in the skin so that the surgeon can see inside. Instruments are inserted through other small cuts in the skin to remove the damaged tissue. You usually do not have to stay overnight in hospital for this kind of surgery. The joint will need to be rested at home for several days.

Arthroplasty

Arthroplasty replaces part or all of a hip or knee joint, and may involve a long hospital stay. Depending on which joints are reshaped, it may take several weeks or months of rehabilitation to recover fully.

Joint replacement

Replacement of hip, knee or shoulder joints is a major operation that involves four to 10 days in hospital followed by months of rehabilitation. The new joints have a limited lifespan of 10-20 years. They are not perfect and some function may not be restored after the damaged joint is replaced by a new one.

Read more information about knee replacement and hip replacement.

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Supportive treatments

Your doctor may also refer you to other services that might be able to help you with your rheumatoid arthritis symptoms.

Physiotherapy

A physiotherapist may help you improve your fitness and muscle strength, and make your joints more flexible. They may also be able to help with pain relief using heat or ice packs, or trancutaneous electrical nerve stimulation (TENS). A TENS machine applies a small pulse of electricity to the affected joint, which numbs the nerve endings and can help ease the pain of rheumatoid arthritis.

Occupational therapy

If rheumatoid arthritis causes you problems with everyday tasks, or is making it difficult for you to move around, occupational therapy may help. An occupational therapist can provide training and advice that will help you to protect your joints, both while you are at home and at work. Some type of support for your joints, such as a splint, may also be recommended, or devices that can help open jars or turn on taps.

Read more information about occupational therapy.

Podiatry

If you have problems with your feet, a podiatrist may be able to help. You may also be offered some type of support for your joints or shoe insoles that can ease pain.

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Complementary and alternative therapies

Many people with rheumatoid arthritis try complementary therapies. In most cases, there is little or no evidence they are effective in the treatment of symptoms of rheumatoid arthritis. They include massage, acupuncture, osteopathy, chiropractic, hydrotherapy, electrotherapy and nutritional supplements including glucosamine sulphate, chondroitin and fish oil.

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