Rheumatoid Arthritis Treatment Options: Drugs and Alternatives

Rheumatoid arthritis (RA) treatment includes numerous options, from medications and physical therapy to alternative therapies and lifestyle changes supporting your joints. Seeking early RA treatment is crucial because medications can reduce inflammation, prevent permanent joint damage, and help put the disease in remission.

RA is an inflammatory arthritis that usually affects multiple joints, often beginning with pain and stiffness in the small joints of your fingers and feet. The disease can also spread from your joints to cause inflammatory conditions throughout your body, making it all the more imperative to get RA treatment at the first sign of symptoms.

RA Treatment With Medications 

Medications are the first line of treatment for rheumatoid arthritis because today’s advanced options reduce inflammation, stopping it from progressing to damage the bones and cause deformities.

The treat-to-target approach used for RA is backed by good evidence. With this approach, healthcare providers decide on a goal and adjust medications and other treatments until the goal is achieved. Treatment aims to lower disease activity, put RA into remission, and improve your quality of life.

Medication options are numerous for treating RA. They include over-the-counter (OTC) and prescription anti-inflammatory medications and pain relievers, corticosteroids, non-biologic DMARDs, biologic DMARDs, and JAK inhibitors. Your healthcare provider can recommend the best options for managing RA.

OTC Pain Relief

Most healthcare providers recommend nonsteroidal anti-inflammatory drugs (NSAIDs) for reducing RA pain and inflammation. These are sold over the counter (without a prescription) under different brand names, including Advil, Motrin (ibuprofen), and Aleve (naproxen). Tylenol (acetaminophen) can help with mild joint pain but does not reduce inflammation, which is essential for RA.

You can also use OTC topical pain relievers to manage RA pain. These are applied over painful joints and have fewer side effects than oral pain relievers. A few topical RA treatment options include salicylates, NSAIDs, lidocaine, menthol/camphor, capsaicin, and newer cannabidiol (CBD) options.

Always follow the manufacturer’s instructions for safe and effective use. Inform your healthcare provider if you experience side effects, including skin irritation.

Prescription Pain Relief

Your healthcare provider can prescribe more potent versions of oral OTC pain relievers. They can also prescribe others unavailable over the counter, such as Celebrex (celecoxib) and Mobic (meloxicam), and prescription-strength topical pain relievers, including Pennsaid (2% diclofenac) and lidocaine patches. A less-potent version of diclofenac, sold under brand names such as Voltaren, is available without a prescription. 

Corticosteroids 

Corticosteroids like betamethasone, cortisone, methylprednisolone, and prednisone help reduce inflammation and pain. They are available as oral medicines and injections.

These medicines are typically not recommended for long-term use. Prolonged use can cause side effects, including stomach ulcers, high blood sugar, high blood pressure, mood changes, eye problems, and osteoporosis.

However, your healthcare provider may prescribe low-dose corticosteroids with other RA medications for an extended time if needed to improve your symptoms.

Non-Biologic DMARDs

DMARDs decrease inflammation and slow down the progression of RA. As a result, you experience fewer symptoms and less damage over time.

Some of the most common non-biologic DMARDs used to treat RA include:

Biologic DMARDs

Biologics, another type of DMARD, target specific molecules that promote inflammation. These drugs work quicker than non-biologic ones and might have fewer side effects.

Biologics are given as injections and infusion treatments. Biologic DMARD classes include tumor necrosis factor (TNF) and B-cell, T-cell, and interleukin-6 (IL-6) inhibitors.

Some of the most common biologic DMARDs used to treat RA include:

• B-cell inhibitor: Rituxan (rituximab)
• IL-6 inhibitors: Actemra (tocilizumab) and Kevzara (sarilumab)
• T-cell inhibitor: Orencia (abatacept)
• TNF inhibitors: Humira (adalimumab), Cimzia (certolizumab pegol), Enbrel (etanercept), Remicade (infliximab), Simponi (golimumab)

JAK Inhibitors 

Your healthcare provider may prescribe a JAK inhibitor when non-biologic and biologic DMARDs aren’t helping to manage RA symptoms. These medicines suppress the immune response, preventing inflammation, and stopping joint and tissue damage.

Currently, three JAK inhibitors are available to treat RA. These include:

• Olumiant (baricitinib)
• Rinvoq (upadacitinib)
• Xeljanz, Xeljanz XR (tofacitinib)

Nondrug RA Treatment Options

Treating RA with medications is crucial, but to achieve optimal health, drugs are combined with a wide range of therapies to support your joints. 

Physical Therapy

According to the American College of Rheumatology (ACR), physical therapy is vital to managing RA. Research from the ACR shows people with RA who engage in physical therapy see improvement in pain levels and physical function.

Physical therapy combines exercise, hands-on care, and patient education. A physical therapist can examine you and develop a treatment plan that improves movement, restores function, prevents disability, and manages pain.

Joint Protection

For people with RA, occupational therapy services can include managing daily activities, joint protection, activity pacing, fatigue management, work simplification, splints, orthotics (custom-made shoe inserts), use of assistive devices, stress management, and more.

Assistive devices can help take the stress off inflamed joints and protect them from injury. For example, orthotics and braces can ease the pain of RA in your feet. If RA spreads to your knees or hips, using a cane or walker reduces stress on the joint and improves mobility. 

Many assistive devices are available to help you function when joint movement is limited. You might consider pens, toothbrushes, and cooking utensils that are easier to hold for people or a tool for reaching items on high shelves. 

Exercise

Exercise is an integral part of your RA treatment plan and is most effective when done every day. However, you should limit exercise and choose gentle options like water (aquatic) exercises when your RA symptoms flare up. Physical activity includes aerobic, aquatic, and resistance exercise:

• Aerobic exercise improves cardiorespiratory fitness and muscular endurance. Examples include cycling, running, hiking, walking, and aerobic workouts.
• Resistance exercises increase muscle strength and include free weights, resistance bands, and Pilates.
• Aquatic exercises provide both aerobic and resistance benefits. They include activities like swimming, water walking, and water aerobics. 

Rest

RA is a disease that goes through periods of flare-ups in which symptoms become worse and periods of remission in which symptoms improve. Getting plenty of rest when your RA flares up can help reduce joint inflammation and pain, as well as improve fatigue. 

Hot and Cold Therapy

Ice packs and heating pads relieve local pain, swelling, and stiffness. Cold therapy can bring down inflammation to reduce pain. Heat therapy increases blood flow to ease joint stiffness and cramping in the muscles around the joints. You can alternate between cold and hot therapy options as needed.

The ACR also recommends heat and cold therapy as medical treatment. Examples of heat and cold therapy in the medical setting include cryotherapy, therapeutic ultrasound, infrared sauna, paraffin therapy, and cold laser therapy.

Diet

A healthy diet helps to protect overall well-being, improves energy, manages weight, keeps the immune system strong, and boosts mental health. While diet alone can’t treat RA, eating a healthy and balanced diet can go a long way in helping you to feel better.

The ACR recommends following an anti-inflammatory diet like the Mediterranean-style diet. This diet promotes eating vegetables, fruits, whole grains, nuts, seeds, and olive oil, with moderate amounts of low-fat dairy and fish.

The Mediterranean diet also limits sugars, sodium, processed foods, refined carbs, and saturated fats—all believed to increase inflammation. 

Stress Management

Stress can make RA symptoms worse. Although researchers are not entirely sure about the direct link between RA and stress, they believe that the body’s stress response increases pain by contributing to inflammation. The stress response may also disrupt your sleep, lower your mood, and affect nearly every part of your body.

Many of the RA treatment options included in this list—such as exercise, diet, and complementary and integrative therapies—can help lower stress. Other stress management options include talking to a friend, taking breaks, and relaxing with a cup of chamomile tea.

Stopping Smoking

Studies have shown that smoking can worsen RA and reduce the effects of medications used to treat the condition. RA is also a risk factor for heart disease, and smoking further increases your risk.

If you are having a hard time quitting, let your healthcare provider know. They can give you information about programs and products to help you stop smoking.

Complementary and Alternative Medicine (CAM)

CAM therapies are nontraditional therapies typically used in addition to your RA treatments to better manage your symptoms.

Your CAM options for managing RA might include:

If you want to try CAM or alternative treatments to improve your RA symptoms, ask your healthcare provider if they’re safe for you to try. Herbs and supplements can interact with over-the-counter and prescription medications.

Integrative Approach

Integrative medicine draws from many therapies to provide the diverse treatments needed to ease your pain and help you enjoy an active life while managing RA. Medications, physical therapy, dietary changes, and all the treatments and CAM options mentioned here are part of an integrative approach.

Also, consider mental health treatments, such as talk therapy. Therapies like cognitive behavioral therapy (CBT), can help you overcome anxiety, stress, and depression caused by living with a chronic disease. Therapy also teaches techniques that can ease pain and improve daily life.

Surgery

Surgery is a last-resort treatment for RA that has progressed to cause significant joint damage. Your healthcare provider may recommend one of the following:

Tendon repair

The ongoing joint inflammation caused by RA can damage all the tissues in the joint, including the tendons. Over time, the tendons weaken, wear down, and can eventually tear. Though the damage usually can’t be repaired, your healthcare provider may recommend replacing it with a healthy tendon removed from elsewhere in your body.

Synovectomy

Synovectomy is surgery to remove the inflamed synovial tissues lining the joint. Though this procedure relieves your symptoms, the tissues can regrow. Then, RA can cause inflammation and pain in the new lining.

Arthrodesis (Bone Fusion)

A bone fusion may be a treatment option for the small joints in your fingers. Your surgeon removes the damaged cartilage, reshapes the bones, and inserts pins, screws, or plates to hold the two bones together. As new bone grows, the two fuse into one bone, eliminating the painful joint.

Arthroplasty (Joint Replacement)

Severe joint damage can only be repaired by removing the damaged bone and cartilage and replacing them with an artificial joint.

RA Treatment Effectiveness 

Guidelines for treating RA come from the ACR and get updated every few years. Updates usually occur as new treatments are released, older drugs are reassessed, and new evidence emerges regarding nondrug treatments.

Many medications used to treat RA are potent and can produce side effects, but are used because the evidence suggests that the benefits outweigh the risks.

Each person’s treatment approaches for RA are based on disease severity as the condition progresses through stages. Disease severity is typically classified as early to moderate, severe, and end-stage. 

Early to Moderate RA

In stage 1, or early RA, you will experience the earliest symptoms of RA, including morning stiffness and pain in the small joints of the hands and feet. Symptoms during this stage are subtle, which may make it harder for a healthcare provider to make a diagnosis.

If you are diagnosed early on and start treating the condition, there is a better chance of disease remission. Treatment options in early RA include NSAIDs, methotrexate, other non-biologic DMARDs, and low-dose steroids.

In stage 2, or moderate RA, inflammation of the joint linings may cause damage, and you will experience pain and limited motion in affected joints. Inflammation may affect other body tissues, especially the skin and eyes.

Most people get a diagnosis during stage 2, and treatment can reduce further damage and get symptoms under control. Your healthcare provider may add a biologic drug or JAK inhibitor to your treatment plan at this stage. 

Severe RA

By the time RA progresses to stage 3, it is considered severe. There might be more pain and swelling. Some people may also have muscle weakness, mobility loss, and bone and joint damage. If biologics and JAK inhibitors fail to manage symptoms, your healthcare provider will recommend another biologic or a different class biologic.

Stage 4, or end-stage RA means that affected joints no longer work, and symptoms include severe pain, swelling, stiffness, and loss of function. Progression to the stage can take years or decades, and with effective treatment, most people never make it to stage 4.

Does RA Progression Affect Life Expectancy? 

RA is generally not a fatal condition, but disease progression and complications of the condition might affect life expectancy. Mortality risk in people with RA can increase over time and seems to peak 20 years after diagnosis. Respiratory conditions and cardiovascular diseases are significant risk factors for premature death.

Fortunately, newer, more aggressive RA treatments have reduced such complications and increased the potential for disease remission, which means people with RA are living longer. 

How to Manage RA During Flares

People with RA have periods in which the disease flares up, and inflammation levels and disease activity are high. The most common symptoms of a flare-up are severe joint pain, swelling, stiffness, and fatigue. A flare-up can last for a few days, or it can last for weeks or months.

Specific events can trigger RA flares. You may keep RA in remission longer by avoiding common triggers such as:

• Diet
• Stress
• Illness or infection
• Weather changes
• Overdoing activities
• Missing medicine doses
• Smoking

Getting enough rest is important during a flare but you should still try to move your joints. Consider activities that are easy on the joints, such as stretching, walking, and swimming.

Keep stress levels down while recovering. Try massage, warm baths, and OTC oral and topical pain relievers to manage pain and reduce inflammation. If you haven’t already adjusted your diet, a flare is a good time to add anti-inflammatory and eliminate pro-inflammatory foods.

Contact your healthcare provider if your flare-up lasts longer than a few days or worsens. They can prescribe a corticosteroid or other treatments to quickly reduce inflammation and manage symptoms, including pain.

RA Treatment Advancements 

RA is a chronic condition without a cure. Fortunately, you have plenty of options for treating it, and therapies for treating RA continue to increase. As researchers develop and improve treatments, your healthcare provider might change your treatment plan to manage your disease better. 

Some of the newest treatment options available and in testing include:

• Biosimilars: These drugs are very close in structure and function to biological drugs. Biosimilars offer a more affordable option for some people with RA.
• IL-inhibitors: These agents inhibit the action of interleukins, which are proteins that promote inflammation.
• Targeted synthetic DMARDs, including JAK inhibitors: These target specific parts of the immune system to halt inflammation and inflammatory processes.

Talk to your healthcare provider to learn more about the latest available treatment options. They can share all the potential benefits and risks of changes to your treatment plan. They can also recommend lifestyle changes and the best ways to improve your outcomes. 

Summary 

Rheumatoid arthritis is a chronic disease without a cure. However, today’s advanced RA treatments improve your quality of life by helping to reduce inflammation, put the disease in remission, and minimize joint damage.

Treating RA involves an integrated approach combining nondrug and drug options. Non-drug options include physical and occupational therapies, lifestyle changes, and CAM therapies. Drug treatments include anti-inflammatory drugs, pain relievers, non-biologic and biologic DMARDs, corticosteroids, and JAK inhibitors. Surgery is a last resort for treating severe joint damage due to advanced RA.