There is no cure for rheumatoid arthritis, but there are lots of medicines that can help treat the symptoms of the disease and prevent it progressing. Lifestyle changes, physiotherapy and occupational therapy can also help. Occasionally, surgery may be necessary for badly damaged joints.

Symptomatic relief
Two types of medicine are used to relieve the pain and stiffness of rheumatoid arthritis: simple analgesics and non-steroidal anti-inflammatory drugs (NSAIDs).

Simple analgesics are pain killers such as paracetamol or codeine, given separately or as a combination called co-codamol. They provide short-term pain relief and are used in conjunction with other rheumatoid arthritis drugs that have longer-lasting effects. Codeine can cause constipation.

NSAIDs reduce pain, stiffness and inflammation. They work by inhibiting the action of an inflammatory enzyme called cyclo-oxygenase (COX). Examples include ibuprofen, naproxen and diclofenac. As well as their anti-inflammatory properties, NSAIDs can damage the lining of the stomach, so they are often given alongside acid-reducing drugs called proton-pump inhibitors. Newer, more selective NSAIDs called COX-2 inhibitors (e.g. celecoxib or etoricoxib) are less likely to damage the stomach but they are not suitable for people with heart disease.

Disease-modifying agents

Disease-modifying anti-rheumatic drugs (DMARDs) are medicines that reduce the disease process that occurs in rheumatoid arthritis, with the aim of slowing or stopping progressive joint damage. They do not provide immediate pain relief, but by improving the underlying disease, they have long-term benefits.

Many different DMARDs are used to treat rheumatoid arthritis, usually in combination with others. It takes several months for them to achieve their effects and they are usually continued for many years. All of them can have serious side effects and regular blood tests are required to monitor blood count, liver function and kidney function for patients taking most DMARDs. Different DMARDs suit different patients.

Immunosuppressants are drugs that suppress the activity of the immune system, leading to a reduction in the autoimmune process that causes rheumatoid arthritis.

Methotrexate is the most commonly used, and least toxic, of the immunosuppressants. It is taken by mouth.
Leflunomide is similar to methotrexate and is often used in combination with it for maximum benefits. It must not be taken by pregnant women or those trying to conceive because it can cause birth defects.

Azathioprine is slightly less effective but more toxic than methotrexate. It is usually used for patients who are unable to take methotrexate.

Ciclosporin is a second-choice DMARD for patients with severe disease.

Cyclophosphamide is usually only used for patients with severe systemic symptoms due to its toxicity.

Chloroquine and hydroxychloroquine were originally developed as antimalarial drugs but were also found to be effective in rheumatoid arthritis. They are thought to work by inhibiting the production of inflammatory chemicals and reducing the activity of destructive enzymes. They are less toxic than many DMARDs although they can cause eye damage. They are taken orally.

Sulfasalazine is an anti-inflammatory that was specifically developed for use in rheumatoid arthritis, although it is also used in other inflammatory diseases. It works by reducing the production of inflammatory chemicals. It is taken by mouth.

Penicillamine is related to penicillin but it is not an antibiotic. It binds to metal ions in the body and is thought to work in rheumatoid arthritis by reducing the activity of immune cells. It can be taken by people who are allergic to penicillin.
Gold has been used to treat rheumatoid arthritis since the 1930s but it is still not known how it works. It can be given either as a tablet or as an injection into the muscle, but the injection is more effective.

Biologic therapies

Biologic therapies are drugs that have been designed to target specific chemicals or proteins known to be involved in a disease process. They are produced using genetic engineering.

In rheumatoid arthritis, four main biologic therapies have been developed. They are effective at reducing symptoms and improving quality of life but they are very expensive and their long-term risks and benefits are still being evaluated. They are only prescribed for patients with severe, ongoing symptoms despite DMARD therapy and are used in combination with a DMARD (usually methotrexate). They are given by injection or intravenous drip.

• Anti-TNF therapies attack an inflammatory chemical called TNF (tumour necrosis factor), dampening down the inflammatory process. Examples include infliximab, etanercept and adalimumab.
• Anti-IL-1 therapies target a chemical called IL-1 (interleukin 1), which carries messages between immune cells. By blocking these messages, the immune response is reduced. Anakinra is an example of an anti-IL-1 therapy.
• Anti-B-cell therapies destroy a type of immune cell called a B-cell, which produces antibodies. These reduce the production of auto-antibodies and reduce the inflammatory process. Rituximab is an anti-B-cell therapy.
• Anti-T-cell therapies prevent the activation of a type of immune cell called a T-cell, reducing the inflammatory response. Abatacept is an example of an anti-T-cell therapy.

Corticosteroids

Corticosteroids, often just known as steroids, are anti-inflammatory drugs related to the natural hormone, cortisone. They work by increasing the body’s production of anti-inflammatory proteins.

In rheumatoid arthritis, corticosteroids are usually given as tablets or as injections directly into an affected joint. Although they are very effective at reducing inflammation, they have serious side effects such as osteoporosis if they are taken in the long-term so short-term use only is recommended. Steroids are used in combination with DMARDs to gain rapid control of inflammation in people who have been newly diagnosed with rheumatoid arthritis and to control inflammation during disease flare-ups. Examples include hydrocortisone, dexamethasone, betamethasone and prednisolone.

Lifestyle modification

Changes to a person’s lifestyle can improve the symptoms of rheumatoid arthritis. The most important is exercise. Gentle, regular exercise helps to strengthen the muscles around a joint, improving its stability. It also relieves stiffness. However, it is important to balance exercise and rest, to avoid harming the joints further. Badly swollen joints should not be exercised and it is important to avoid putting too much stress on any of the joints. Low impact exercises such as swimming or walking are the most beneficial.

Eating healthily is also important. Symptoms of rheumatoid arthritis can be worse in people who are overweight because this puts more strain on the joints. Eating a healthy diet that is high in fibre, low in fat and sugar and contains plenty of fruit and vegetables can help maintain a healthy weight and provides the body with the vitamins and minerals it needs. It is especially important for people with rheumatoid arthritis to take enough calcium (in milk, cheese and yoghurt) and vitamin D (from oily fish), which are essential for healthy bones. And also iron (found in red meat, oily fish, pulses and green, leafy vegetables) which combats anaemia. Vitamin and mineral supplements can be useful. Antioxidants found in fruit and vegetables help destroy inflammatory chemicals and may also improve the symptoms of rheumatoid arthritis.

Cold packs can help to reduce swelling in affected joints. Hot water bottles or heat pads can relieve pain and stiffness, but they are not suitable for very inflamed joints. Some people find TENS machines, which provide gentle electrical stimulation to the target area, helpful. They are available to buy or hire and are sometimes available on the NHS in the UK.

Therapy

A physiotherapist can provide advice on an appropriate exercise programme for a person with rheumatoid arthritis as well as setting a regime of specific exercises aimed at strengthening affected joints. Some physiotherapists offer acupuncture, hydrotherapy and massage therapy and can provide TENS machines for pain relief.

An occupational therapist (or OT) can offer advice on how to perform everyday activities, such as dressing or cooking, without straining the joints too much. Occupational therapists also assess activities that patients find particularly challenging and can provide physical aids to help. These include, for example: splints to support affected joints; risers to raise the height of a chair, making it easier to get up; jar grippers, which make it easier to open jars; handles that fit to bathroom taps, making them easier to turn on and off; or walking aids such as sticks or frames.

Podiatry, previously known as chiropody, may be helpful for people with rheumatoid arthritis affecting the feet. Podiatrists provide specialised footwear or insoles to reduce pain and prevent or reduce deformity of the foot joints.

Surgery

Surgery may be necessary for patients with severe rheumatoid arthritis that cannot be controlled by drug treatments. Surgery aims to relieve the pain of the affected joints, to restore mobility and to reduce deformity. Several types of surgery can be used in rheumatoid arthritis:

Arthroscopy
This is keyhole surgery that involves examining the inside of the joint with a tiny camera. Small repairs to the joint can be carried out at the same time, including a procedure known as a synovectomy, where the inflamed synovial membrane that is responsible for rheumatoid arthritis is removed. It can, however, grow back.

Joint replacement
This involves removing the damaged joint and replacing it with an artificial one made from metal or plastic. It is most common for large joints such as the knee and hip but it can also be carried out on the small joints of the hands and ankles. The joints will no longer cause any pain and will be able to move freely. Joint replacements generally last 10–15 years.

Joint fusion
Joint fusion, or arthrodesis, involves permanently fusing the bones of a joint together. The joint will no longer be painful and will be very stable but it will not be able to move at all. It may be suitable for small joints in the fingers and toes, and for joints in the neck, which can cause life-threatening nerve compression if they become unstable.

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