Rheumatoid Arthritis Treatments: Finding the Right RA Treatment
Key takeaways:
Rheumatoid arthritis (RA) is a condition that causes inflammation in the joints. Experts recommend early treatment for the most effective way to relieve symptoms and prevent irreversible joint damage.
Treatment for RA typically starts with a conventional disease-modifying antirheumatic drug or DMARD (such as methotrexate). It adds on from there if the first medication doesn’t reduce your symptoms enough.
There isn’t a “best” treatment for everyone with RA. But there are several effective options, so it’s best to work with your rheumatologist on your personal treatment plan.
In addition to medication, experts recommend regular exercise, social support, mind-body therapies, and not smoking.
Table of contents
Rheumatoid arthritis (RA) is a specific type of arthritis, or joint inflammation. It can affect any joint in the body, but it most commonly affects the hands, wrists, and feet.
Initially the inflammation in the fluid and tissue around the joints causes pain and swelling. Without treatment, it damages the cartilage (the tissue that covers the bones) and the bones themselves. This damage — which is irreversible — leads to decreased motion, pain, and deformity of the joints. RA can also affect other organs, such as the heart and lungs.
While this may sound alarming, know that starting medication early can help prevent further damage. This is why early diagnosis and treatment of RA are so important. With early diagnosis, better treatment approaches, and newer, more effective medications, people with RA are doing better now than ever before.
With so many options and so many factors to consider (such as cost, side effects, and disease severity), knowing where to start can seem daunting. To help, here’s a guide to the most common RA treatments.
What is rheumatoid arthritis?
RA is an autoimmune condition. A problem with the immune system causes inflammation in the joints and other parts of the body. When RA affects a joint, it can cause:
Pain
Swelling
Stiffness
Warmth
Decreased motion
RA can also cause inflammation in other parts of the body. That means other symptoms can include:
Fatigue (extreme tiredness)
Eye inflammation, such as scleritis
Muscle aches
A general sense of not feeling well
Experts aren’t sure what causes the immune system to overreact in RA. The current theory is that some people are more likely to get it for genetic reasons, and then they’re exposed to certain things in the environment that trigger it.
Around 1.5 million people in the U.S. have RA, and about 70% of them are women. It usually begins between ages 30 and 50, but it can happen at any age.
What are the treatment options for rheumatoid arthritis?
There are several treatment options for RA, but they are not all equal. The American College of Rheumatology (ACR) guidelines for RA treatment help determine when a medication should be used. Here, we will break them down by category.
Conventional (nonbiologic) DMARDs
Disease-modifying antirheumatic drugs (DMARDs) treat many inflammatory diseases, including RA. “Conventional,” “traditional,” or “nonbiologic” DMARDs are so called to differentiate them from a newer type of DMARD called “biologics” (see below).
Examples include:
The treatment guidelines recommend starting a DMARD within 3 months of when symptoms begin. This is to try to slow RA down as much as possible and to prevent joint damage.
Methotrexate is recommended as the first DMARD in early RA treatment for many. This is because it typically works well, dosage can be changed easily, and it’s affordable. It has also been around for a long time, so there’s plenty of long-term data on its use. Data suggests that leflunomide is generally as effective as methotrexate.
Sulfasalazine and hydroxychloroquine are less effective. They are often prescribed for people with mild RA or those who can’t take the other traditional DMARDs for medical reasons (see below).
Methotrexate is taken once per week, as pills or an injection. Side effects are possible, although you can lessen them by taking folic acid supplements. Side effects include:
Nausea
Vomiting
Headache
Fatigue
Mouth sores
Methotrexate isn’t safe for anyone who:
Is pregnant or plans to become pregnant
Has liver, lung, or severe kidney disease
Drinks alcohol daily
Leflunomide isn’t safe for those who have liver disease (or drink alcohol daily) or pregnancy, but it’s safer than methotrexate for someone with kidney disease. Sulfasalazine is taken 2 to 3 times per day, which is less convenient. Both leflunomide and sulfasalazine can cause side effects, like upset stomach, headaches, and rashes. Hydroxychloroquine is safer for people with liver or kidney disease, but there’s a very small chance of eye problems with it. So yearly eye exams are necessary.
Biologic DMARDs
These medications also target inflammation, but in a more specific way. They are called “biologics” because they’re made using biotechnology, rather than the chemical process used to make most medications. These medications don’t have generics, but there are biosimilar versions for some biologics. Biosimilars are as effective and often more affordable than biologics.
Biologics generally work better in combination with conventional DMARDs, but they can also be given alone. There are a few types of biologics for RA, and each type targets one specific part of the inflammatory process.
Tumor necrosis factor inhibitors
Tumor necrosis factor (TNF) is a cytokine, or small protein, that’s part of the immune system and plays a role in inflammation. Medications that inhibit TNF are commonly prescribed for RA, but they’re also used in other inflammatory diseases, such as Crohn’s disease and plaque psoriasis.
Examples include:
Adalimumab (taken every other week)
Certolizumab pegol (every other week)
Etanercept (weekly)
Golimumab (monthly)
Infliximab (every 4 or 8 weeks)
TNF inhibitors are usually the first type of biologic DMARD prescribed. This is because they’ve been available for longer, which means rheumatologists have more experience with them.
TNF inhibitors are given as an injection or intravenously (IV), but infliximab is only in IV form.
TNF inhibitors are not recommended for people with multiple sclerosis or heart failure with low ejection fraction. Several side effects are possible with TNF inhibitors. Some examples include:
Upper respiratory infection
Serious infections (requiring hospitalization)
Injection or infusion reactions
Skin changes
Previously, experts thought treatment with TNF inhibitors might increase people’s risk of cancer. But research suggests the risk isn’t as high as previously thought.
Interestingly, some people who take TNF inhibitors might develop antibodies against the medication. These antibodies could make treatment less effective and increase the risk of hypersensitivity reactions. It’s difficult to tell exactly how common this is, but it appears to be different for each medication.
Interleukin-6 receptor antagonists
Interleukins, such as interleukin-6 (IL-6), are also cytokines that play a big role in autoimmune inflammation. Medications that target IL-6 have been shown to improve RA-related joint pain and damage.
Examples include:
Sometimes, they’re used when a TNF inhibitor hasn’t worked well, but an IL-6 inhibitor can be tried before a TNF inhibitor.
Tocilizumab can be given as an injection every 1-2 weeks or IV every 4 weeks, and sarilumab is given as an injection every 2 weeks.
IL-6 inhibitors shouldn’t be used by people with diverticulitis, due to the risk of intestinal damage. Serious infections are also possible. The most common side effects include:
Low white blood cell count and/or platelet count
High levels of liver enzymes and/or cholesterol
Upper respiratory infections
Headache
Other biologic DMARDs (abatacept and rituximab)
Abatacept inhibits activation of immune cells called T cells. It can be used with a traditional DMARD or alone for treatment of RA. It’s available as an injection (weekly) or IV infusion (monthly).
Common side effects include headache, upper respiratory tract infection, and nausea. Like with other biologics, there’s a risk of serious infections. Some data suggests that there’s a lower risk of infection with abatacept than with TNF inhibitors.
Rituximab targets B cells, which are important immune cells. It’s approved for RA treatment only with methotrexate and after trying at least one TNF inhibitor. Rituximab is given as an infusion every 6 months (after an initial dosage of 2 infusions 2 weeks apart).
Methotrexate side effects: Methotrexate is one of the most common medications for rheumatoid arthritis (RA). Knowing what side effects to expect can help you deal with them better.
Exercise is an important part of living with RA. Yoga is a great option that can improve joint mobility. Try these yoga poses to get started.
Tips for managing arthritis pain: Medications can help ease joint pain, but they’re not the only answer. Learn about other ways to deal with pain from RA from someone who has it.
A rare, life-threatening neurological condition called progressive multifocal leukoencephalopathy is possible with rituximab. Rituximab is recommended over TNF inhibitors for people with RA who have previously had leukemia or lymphoma.
Janus kinase inhibitors
Medications that target janus kinase (JAK), an important signaler in the immune response, are the newest type of RA treatment. Unlike biologic DMARDs, they don’t target a specific cell or cytokine, but a series of communications by the cytokines. You may hear them called “targeted synthetic DMARDs.”
Examples include:
JAK inhibitors are commonly used in combination with a conventional DMARD, similar to how TNF-inhibitors and IL-6 inhibitors are prescribed. They are unique in that they come as pills that are taken once or twice daily.
Side effects and risks of JAK inhibitors are similar to those of TNF inhibitors. Common side effects include upper respiratory infection, gastrointestinal problems, and headaches. They shouldn’t be used in people with anemia, at higher risk for blood clots, or with gastrointestinal problems. There’s also an increased risk of shingles, so experts recommend getting vaccinated before starting treatment.
Baricitinib and upadacitinib aren’t safe for people with liver or kidney disease. In 2021, the FDA issued a safety warning regarding tofacitinib, due to a possible increased risk of serious heart problems, blood clots, and cancer. More recent studies provide conflicting data, so it’s best for anyone with a higher risk for cardiovascular events to discuss this with their rheumatologist.
Steroids
Glucocorticoids (“steroids”) are powerful anti-inflammatory medications. Examples include prednisone and methylprednisolone. Your rheumatologist may prescribe them from time to time for flares (when RA symptoms get worse). They might also recommend them when treating early RA if symptoms are severe.
These medications are not meant to be used as regular or stand-alone treatment. This is because they have side effects when used long term, such as bone loss and sleep disturbances. They are commonly prescribed at low doses for a short time (less than 3 months).
Risks of rheumatoid arthritis treatments
As with any medication, there are some risks involved with RA medications. You will probably need some screening blood tests before you start a new RA medication. These tests provide a picture of your health before starting a medication, as a baseline for comparison.
Because most RA treatments affect how the immune system works, there’s an increased risk of infections. Your rheumatologist will discuss this in detail with you, depending on which medication you take. It will also be important for you to stay up-to-date on vaccinations, which may include:
Additionally, you can expect to get periodic blood work done while you’re taking medication for RA. This is to make sure it’s safe to continue the treatment.
In most cases, you’ll get tests done when you start a new medication, every 2 to 3 months thereafter, and after the dose is adjusted (if that happens).
Can rheumatoid arthritis be treated without prescription medications?
No. Medication is the most important part of RA treatment. That said, there are other options that can be helpful when added to medication. These include:
Education and support programs
Mind-body therapies, such as meditation, yoga, and mindfulness
These options shouldn’t take the place of medications (specifically, DMARDs). But they can help with the following:
Can exercise or physical therapy help prevent rheumatoid arthritis flare-ups?
You might be worried that being active might harm your joints if you have RA. But that’s not the case at all. Exercise is safe for people with RA, and in fact, experts recommend it. Exercise can:
Decrease inflammation and joint stiffness
Improve heart, lung, and emotional health
Improve muscle strength
Reduce fatigue
The idea of exercise can feel overwhelming at first, especially if you’re newly diagnosed with RA or don’t exercise much. The good news is that there are plenty of resources available, like this tip sheet.
You can also consider working with physical or occupational therapy to improve function and mobility. This can help you:
Learn which exercises are best for you and how to exercise safely (without hurting your joints)
Improve balance and mobility
Deal with muscle spasms that can happen around your affected joints
Experiment with bracing and orthotic devices, which can help with walking (when RA affects the feet) or daily tasks (when RA affects the hands and wrists)
How to choose a rheumatoid arthritis treatment plan
RA treatment guidelines can help you and your rheumatologist come up with a treatment plan together. Your treatment choice will depend on things like symptom severity, and how many joints are affected. Because there isn’t a huge difference in efficacy between medications, it might come down to your other health problems (if any).
Here’s a summary of what the guidelines suggest:
Treatment should begin with a DMARD.
If step 1 isn’t enough, another DMARD or other biologic can be added.
If step 2 doesn’t work well enough, switching classes is recommended. For example, switching from a TNF inhibitor to an IL-6 or JAK inhibitor.
Glucocorticoids should only be used for a short time when needed for flares.
What is the goal of RA treatment?
As mentioned above, the goal is to diagnose and treat RA early to prevent as much damage as possible. As part of those guidelines, a “treat to target” (T2T) approach is recommended.
What does “treat to target” mean?
T2T is a term that describes treating a condition with frequent monitoring while keeping very specific goals in mind. In other words, it’s a methodical way to make decisions regarding treatment over time. It involves a few steps:
Choosing a target, or goal, for treatment (for example, having fewer affected joints)
Deciding how and when to assess whether the goal is achieved
Making a change to treatment if the target/goal isn’t met
T2T starts with shared decision-making, meaning you and your rheumatologist will work together to come up with a plan. It will include your goal(s) for treatment, what medication to start, when to follow up, how to decide if it’s working, and what to do if it’s not.
How do I know if a treatment method is working?
When you follow up with your rheumatologist, you’ll determine whether you’ve met your goal(s). This mostly depends on your physical examination and how you’re feeling. Blood tests don’t accurately reflect how well your treatment is working.
If you’ve met your goal, you may decide to stay the course. If not, it could be time to try a new medication. Know that it’s best to give a new medication at least 3 months to do its job before you decide whether it’s working.
T2T is an effective strategy. Studies show it improves outcomes in many respects, including improving function and symptoms and slowing joint damage seen on X-rays.
What lifestyle changes can help rheumatoid arthritis symptoms?
In addition to the other treatment options above, there are a few other ways to improve your RA symptoms and overall health:
Keep your body moving. As mentioned, regular physical activity can make a big difference.
Maintain a balanced and comfortable weight. It’s hard for your joints to carry extra weight, so many people find that keeping a balanced and comfortable body weight improves symptoms. Also, people with excess body weight don’t respond to some medications as well.
Quit smoking. If you smoke, quitting can improve your health greatly. Research shows it reduces RA disease activity, which can help you feel better, and it decreases your risk of cardiovascular events. Studies also suggest that people who smoke are more likely to have a weaker response to treatment with certain biologics, and RA-related effects in other parts of the body, such as the lungs, skin, and eyes.
Frequently asked questions
There isn’t a “safest” medication for RA. This is because it depends on your other medical conditions, and how you respond to each medication.
A type of cancer treatment called immunotherapy affects the immune system. Immunotherapy can cause inflammatory side effects like joint pain, similar to RA. These effects can go away when treatment stops, but not always. But more research is needed to understand this relationship better.
Sometimes surgery is needed for joints that are severely damaged despite medical treatment. These surgeries are performed by specialists called orthopedic surgeons. These procedures can involve fixing tendons, removing inflamed joint tissue, or joint replacement. The good news is that treatment of RA has improved so much over recent decades that the need for joint-replacement surgery has decreased.
The bottom line
The good news is that, when RA is diagnosed and treated early, remission is possible. With medications, it’s possible to control the inflammation to the point of having no symptoms. Everyone responds to these medications differently, so it’s important to work closely with your rheumatologist for the best treatment plan. Other ways to improve your RA symptoms and overall health include quitting smoking, if you smoke, and staying active.
Why trust our experts?
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