Rheumatoid arthritis

Rheumatoid arthritis is an ongoing, called chronic, condition that causes pain, swelling and irritation, called inflammation, in the joints. But it also can damage other parts of the body. These may include the skin, eyes, lungs, heart and blood vessels.

Rheumatoid arthritis happens when the immune system attacks its own body’s tissues by mistake. This is called an autoimmune condition.

Rheumatoid arthritis differs from the more common osteoarthritis. Some people have both. Osteoarthritis causes damage to joints from overuse. Rheumatoid arthritis affects the lining of the joints and eats away at the bone under them. This causes a painful swelling that can cause joints to bend out of shape over time, called deformity.

The inflammation of rheumatoid arthritis also can damage other parts of the body. New medicines have improved treatment choices greatly. But rheumatoid arthritis still can cause long-term damage and increase the risk of heart disease.

Symptoms of rheumatoid arthritis may include:

• Painful, warm, swollen joints.
• Joint stiffness that most often is worse in the mornings and after periods of rest. It can last for 45 minutes or longer.
• Tiredness, fever and not wanting to eat.

Rheumatoid arthritis may affect just a few joints at first. Most often, these are the small joints of the hands and the feet.

As the disease gets worse, symptoms may spread to more joints. These most often include the wrists, elbows, hips, knees and ankles. Most of the time, symptoms affect the same joints on both sides of the body.

Many people who have rheumatoid arthritis also have symptoms that affect more than the joints. Areas that may be affected include:

• Skin.
• Eyes.
• Lungs.
• Heart.
• Nerve tissue.
• Blood.

Rheumatoid arthritis symptoms may vary in how bad they are. They may come and go. Periods when the condition becomes more active, called flares, follow periods of less or no swelling and pain. This is called remission.

Over time, rheumatoid arthritis can cause joints to bend out of shape and shift out of place. The joints can be hard to use for daily activities at home or at work.

When to see a doctor

Make an appointment with your healthcare professional if you have ongoing pain and swelling in your joints that is not getting better after several weeks.

Experts don’t know the cause of rheumatoid arthritis. But it’s a condition in which the immune system attacks healthy joint tissue by mistake, called autoimmune.

The cause is likely a mix of genetic changes and factors from outside the body, called environmental. Hormones may play a role. An infection with certain viruses may start rheumatoid arthritis in people whose genes make them more likely to get it.

Factors that may increase your risk of rheumatoid arthritis include:

• Your sex. People assigned female at birth are more likely than those assigned male at birth to get rheumatoid arthritis.
• Age. Rheumatoid arthritis can happen at any age. But most often it begins in middle age. Children and young teens may get a related condition called juvenile idiopathic arthritis.
• Family history. Having a family member with rheumatoid arthritis or other autoimmune conditions may raise the risk of the condition.
• Smoking. Cigarette smoking over time raises the risk of getting rheumatoid arthritis. Smoking also seems to make the condition worse in people who keep smoking.
• Gum infection. A serious gum infection, called periodontal disease, can damage the soft tissue around teeth and raise the risk of getting rheumatoid arthritis.
• Excess weight. People who are overweight seem to be at a somewhat higher risk of getting rheumatoid arthritis.

Rheumatoid arthritis increases the risk of getting:

• Osteoporosis. Rheumatoid arthritis itself, and some medicines used to treat it, can increase the risk of this condition. Osteoporosis weakens bones and makes them more likely to break.
• Rheumatoid nodules. These firm bumps of tissue most often form around pressure points, such as the elbows. But these nodules can form anywhere in the body, including the heart and lungs.
• Dry eyes and mouth. People who have rheumatoid arthritis are much more likely to get a condition that lowers the amount of moisture in the eyes and mouth. This is called secondary Sjogren’s syndrome.
• Infections. Rheumatoid arthritis and many of the medicines used to treat it can harm the immune system. This can lead to more infections. Vaccinations can help prevent infections such as the flu, pneumonia, shingles and COVID-19.
• Carpal tunnel syndrome. If rheumatoid arthritis affects the wrists, the swelling can press on the nerve to the hand and fingers.
• Heart problems. Rheumatoid arthritis can raise the risk of hardened and blocked arteries. It also can raise the risk of swelling and irritation, called inflammation, of the sac around the heart.
• Lung disease. People with rheumatoid arthritis have a higher risk of swelling and irritation, called inflammation, of lung tissues. This can cause scarring and lead to shortness of breath that gets worse over time.
• Lymphoma. Rheumatoid arthritis raises the risk of a group of blood cancers that happen in the lymph system. This is called lymphoma. People with rheumatoid arthritis may have a higher risk of other cancers, as well.

Rheumatoid arthritis can be hard to diagnose in its early stages. That’s because the early symptoms can be like those of other common conditions.

During the physical exam, your healthcare professional checks your joints for swelling, redness and warmth. Your healthcare professional also may check your reflexes and muscle strength.

Blood tests

People with rheumatoid arthritis often have an elevated erythrocyte sedimentation rate (ESR), also called sed rate, or C-reactive protein (CRP) level. This may show a higher level of inflammation in the body. Other blood tests look for rheumatoid factor and anti-cyclic citrullinated peptide (anti-CCP) antibodies.

Imaging tests

You may have X-rays to track rheumatoid arthritis in your joints over time. MRI scans and ultrasound tests may help with diagnosis. They can show how bad the condition is.

There is no cure for rheumatoid arthritis. Joint damage can happen quickly without treatment. But clinical studies show that easing of symptoms, called remission, is more likely with early treatment with medicines called disease-modifying antirheumatic drugs (DMARDs).

Treatment of rheumatoid arthritis also involves regular follow-up with your healthcare team. This is to watch for joint damage, to see whether treatment is working and to look for possible side effects of treatment.

Medications

Your healthcare professional will suggest medicines based on how bad your symptoms are and how long you’ve had rheumatoid arthritis. You and your healthcare professional will decide on treatment. Medicines might include:

• NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve pain and ease swelling and irritation. NSAIDs you can get without a prescription include ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve).

  There also are stronger prescription NSAIDs. Side effects for all NSAIDs may include stomach upset, heart problems and kidney damage.

• Steroids. Corticosteroid medicines, such as prednisone (Rayos), ease inflammation and pain and slow joint damage. There can be serious side effects. The risk of side effects rises when taken at high doses over a long time. Side effects may include thinning of bones, fractures, easy bruising from skin thinning, weight gain, diabetes, cataracts and glaucoma, among others.

  Healthcare professionals often prescribe a corticosteroid for quick symptom relief. The goal is to taper off the medicine when the condition is under control.

• Conventional DMARDs. These drugs can slow the progression of rheumatoid arthritis and save the joints and other tissues from long-term damage. Common DMARDs include methotrexate (Trexall, Otrexup, others), leflunomide (Arava), hydroxychloroquine (Plaquenil, Sovuna) and sulfasalazine (Azulfidine). Side effects vary but may include liver damage and severe lung infections.

• Biologic agents. Also known as biologic response modifiers, this newer class of DMARDs includes abatacept (Orencia), adalimumab (Humira), anakinra (Kineret), certolizumab (Cimzia), etanercept (Enbrel), golimumab (Simponi), infliximab (Remicade), rituximab (Rituxan), sarilumab (Kevzara) and tocilizumab (Actemra).

  Biologic DMARDs most often work best when used with a conventional DMARD, such as methotrexate. Biologic agents also raise the risk of rare infections such as tuberculosis, also called TB, or fungal infections. If you take biologic agents, you need to be watched closely.

• Targeted synthetic DMARDs. Healthcare professionals may prescribe these human-made medicines if conventional DMARDs and biologics haven’t worked. They include baricitinib (Olumiant), tofacitinib (Xeljanz) and upadacitinib (Rinvoq).

  Higher doses of tofacitinib may raise the risk of blood clots in the lungs, serious heart-related events and cancer.

Therapy

A physical or occupational therapist can teach you exercises to help keep your joints moving. The therapist also may suggest ways to do daily tasks that are easier on your joints. For instance, you may pick up an object using your forearms instead of your hands.

Assistive devices can make it easier to keep from stressing painful joints. For instance, a kitchen knife with a hand grip helps protect finger and wrist joints. Certain tools, such as buttonhooks, can make it easier to get dressed. Look for ideas in medical supply brochures and stores.

Surgery

Better medicines to treat rheumatoid arthritis have lowered the need for surgery. But if medicines fail to prevent or slow joint damage, you and your healthcare professional may think about surgery for damaged joints.

Rheumatoid arthritis surgery may involve replacing or repairing a damaged joint. The type of surgery may depend on the joint involved. Surgery may help you use a joint again. It also can ease pain.

Self-care measures, when used with your rheumatoid arthritis medicines, can help you manage your symptoms:

• Exercise regularly. Gentle exercise can help strengthen the muscles around your joints. And it can help you feel less tired. Check with your healthcare team before you start exercising. Walking is a good way to begin. Don’t exercise tender, injured or inflamed joints.
• Apply heat or cold. Heat can help ease your pain and relax tense, painful muscles. Cold may dull pain. Cold also numbs and can ease swelling.
• Relax. Find ways to cope with pain by lowering your stress. Techniques such as guided imagery, deep breathing and muscle relaxation all can help control pain.
• Don’t smoke. Smoking can make rheumatoid arthritis worse. If you smoke, ask your healthcare team to help you quit.

Some common complementary and alternative treatments that have shown promise for rheumatoid arthritis include:

• Fish oil. Some studies have found that fish oil supplements may ease rheumatoid arthritis pain and stiffness. Side effects can include nausea, belching and a fishy taste in the mouth. Fish oil can get in the way of medicines you take. So check with your healthcare professional before trying it.
• Tai chi. This movement therapy involves gentle exercises and stretches and deep breathing. Many people use tai chi to relieve stress. Small studies have found that tai chi may improve mood and quality of life in people with rheumatoid arthritis. When led by a trained leader, tai chi is safe. But don’t do any moves that cause pain or make it worse.

Pain and not being able to move well because of rheumatoid arthritis can affect a person’s work and family life. Depression and worry are common. You also might feel helpless and feel bad about yourself.

How much rheumatoid arthritis affects your daily life depends in part on how well you cope with the condition. Talk with your healthcare team about ways to cope. With time, you’ll learn what works for you. In the meantime, try to:

• Take control. With your healthcare team, make a plan to manage your arthritis. This will help you feel in charge of your condition.
• Know your limits. Rest when you’re tired. Rheumatoid arthritis can make you very tired. Rest or take a short nap when you need to.

• Connect with others. Let people close to you know how you’re feeling. They may be worried about you but might not feel it’s OK to ask about your pain. Find someone you can talk to when your condition feels like it’s too much for you to handle.

  It also might help to connect with others who have rheumatoid arthritis. You can do this through a local support group or online.

• Take time for yourself. Find time to do what you like. Write in a journal, go for a walk or listen to music. These can help lower stress.

You might first see your main healthcare professional. Your healthcare professional may send you to a specialist in the treatment of arthritis and other inflammatory conditions, called a rheumatologist.

What you can do

Make a list of:

• Your symptoms and when they began.
• Medical issues you’ve had in the past.
• Your parents’ or siblings’ medical issues.
• All the medicines and dietary supplements you take and their doses.
• Questions to ask your healthcare team.

What to expect from your doctor

Your healthcare team may ask some of these questions:

• Have your symptoms changed over time?
• Which joints are affected?
• Does any activity make your symptoms better or worse?
• Are your symptoms getting in the way of daily tasks?