Rheumatoid Arthritis: Symptoms, Diagnosis & Treatment Options
Medically reviewed by Leigh Ann Anderson, PharmD. Last updated on Jan 3, 2019.
Rheumatoid arthritis is a long-term, autoimmune disease that causes joint swelling (inflammation), pain, redness, warmth, and stiffness. The wrists, fingers, knees, feet, and ankles are most commonly involved. The cause of rheumatoid arthritis is not known. Rheumatoid arthritis usually affects joints on both sides of the body equally, and develops slowly over time. It can also affect other organs in the body. Starting treatment at diagnosis can help to limit permanent joint destruction.
The course of rheumatoid arthritis differs from person to person.
- People with a positive rheumatoid factor test or subcutaneous nodules (lumps under the skin) seem to have a more severe form of the disease.
- People who develop rheumatoid arthritis at a younger age also have a more rapidly progressive course.
- Remission (a temporary lessening of symptoms) is most likely to occur in the first year. The probability decreases over time. By 10 to 15 years from diagnosis, only about 20% of people have a remission.
While the disease is chronic with the possibility of severe complications, the use of disease-modifying biologic medications have dramatically improved the outcomes of patients with rheumatoid arthritis in recent years.
Rheumatoid arthritis differs from osteoarthritis, the most common type of arthritis which is due to the wear-and-tear on the joints and cartilage over time. Osteoarthritis commonly occurs in your hands, knees, hips and spine.
- Learn More: Ways to Manage Rheumatoid Arthritis
While the cause is unknown, changes in environmental factors may be involved. More research is ongoing.
- Rheumatoid arthritis is considered an autoimmune disease.
- In an autoimmune disease, the body confuses healthy tissue for foreign substances. When this occurs the body mistakenly “attacks” its own tissues.
- The immune system normally fights off foreign invaders such as viruses or bacteria.
About 1%, or 1 out of every 100 individuals, has rheumatoid arthritis. It can occur at any age but it is usually seen in people between 25 and 55 years of age. Three times more women are affected than men.
Having a specific gene type (a variant of the human leukocyte antigen gene) may also elevate your risk of being diagnosed with this disease; however, it is not considered an inherited disease. Infection and hormones may also contribute to the development of the disease.
Cigarette smoking and stressful life events (such as trauma or grief) are also risk factors for the occurrence of rheumatoid arthritis. Continued smoking can increase the severity of the disease. If you smoke and have been diagnosed with rheumatoid arthritis, you should make a plan to quit smoking.
Rheumatoid arthritis symptoms usually begin gradually with:
- joint stiffness and pain (worse in the morning or after being stationary for a while)
- muscle aches
- red, hot, inflamed joint
- loss of appetite
- weight loss
- paresthesias (numbness or tingling in fingers or hands)
- low-grade fever
- trouble sleeping
The joints of the fingers, hands and toes are often affected first. Joint pain is often felt on both sides of the body. The wrists, elbows, shoulders, ankles, knees, hips and spine may be involved. Although joints are typically affected, other tissues or organs, such as the eyes, lungs, heart, or nerves, can become inflamed.
When the joint is not used for a while, it can become warm, tender, and stiff. When the lining of the joint (synovium) becomes inflamed, it gives off more fluid and the joint becomes swollen.
Symptoms can come and go or worsen over time. When symptoms fade this is called being in remission. The course is variable and unpredictable for most patients.
Joint destruction may occur within 1 to 2 years after the appearance of the disease. Deformities of hands and feet, a limited range-of-motion, and difficulties with the normal activities of daily living can occur.
Your doctor will do a physical exam looking for joint swelling and redness. Your joint strength, flexibility and reflexes may be examined. X-rays, MRIs or or other imaging tests may be ordered. It is often diagnosed by a rheumatologist
- Rheumatoid arthritis is diagnosed based on the results of joint x-rays and a rheumatoid factor test (which is positive in about 70% of people with symptoms). It may also be found in those without rheumatoid arthritis, so it usually is not used alone for a diagnosis.
- A more specific blood test known as the anti-cyclic citrullinated peptide (anti-CCP) may also be ordered. People who are positive for anti-CCP usually do have rheumatoid arthritis.
- The erythrocyte sedimentation rate (sed rate) may be elevated, which indicates an inflammatory process in the body. The complete blood count (CBC) may show low hematocrit (anemia) or abnormal platelet counts.
- A C-reactive protein test may also be positive for patients with no detectable rheumatoid factor. Synovial fluid analysis may be used to diagnose the cause of pain and swelling in joints.
There is no known way of preventing the development of rheumatoid arthritis. However, proper early treatment can prevent further damage of the joints.
Rheumatoid arthritis usually requires lifelong treatment with:
- physical therapy
- regular exercise
- possible surgery for end-stage disease
Rheumatoid arthritis is a disease with variable prognosis that can impair your quality of life. Therefore, early, aggressive treatment of rheumatoid arthritis can delay joint destruction and improve your daily activities. Treatment for rheumatoid arthritis has had many advanced in the last few decades.
Once a diagnosis of rheumatoid arthritis is confirmed, treatment should start as soon as possible, even if x-ray changes are not yet seen. In addition to rest, strengthening exercises and nonsteroidal anti-inflammatory drugs (NSAIDs) for pain, aggressive therapy with disease-modifying anti-rheumatic drugs (DMARDs) is the current standard of care.
The aim of treatment is to minimize joint damage, initiate disease remission, and enhance your quality of life. This approach has led to earlier use of DMARDs, both non-biologic and biologic agents. Treatment should allow you to keep up with your normal daily activities with the fewest possible drug side effects.
For a complete list of drug uses, doses and side effects, please refer to the individual drug monographs.
Disease Modifying Anti-Rheumatic Drugs (DMARDs)
- DMARDs decrease inflammation, lessen damage to the joint, and help to maintain your joint function. Non-biologic DMARDs (such as methotrexate) are commonly the first agent used for controlling rheumatoid arthritis, but they all have a slow onset of action. These drugs are produced using traditional manufacturing techniques.
- DMARDs are often initially combined with a drug from the NSAID (like ibuprofen) or glucocorticoid anti-inflammatory drug class (like prednisone) initially or for more severe RA symptoms to control your acute pain and inflammation. Once the DMARD takes effect, these additional agents may be tapered to lower doses.
- Patients taking DMARDs may not show a response for 6 to 12 weeks, or even longer. However, this is variable depending on the patient and drug. Improvement with MTX may be seen within 4 to 6 weeks, but up to 3 months with hydroxychloroquine.
- The dose of a DMARD is titrated up as far as side effects allow. An additional DMARD is added when the maximum dose is reached, or the initial DMARD is stopped and switched to another.
- Most DMARDs require lab monitoring (such as blood cell counts, liver function test, urea and electrolyte level test) to ensure drug safety and to monitor for effectiveness. Many DMARDs can cause bone marrow or liver toxicity.
- Regular blood or urine tests may be needed to determine how well your medications are working and to look for side effects. Side effects are variable but can include liver damage, bone marrow suppression and severe lung infections.
Table 1: Non-biologic DMARDs for Rheumatoid Arthritis
|Generic Name||Brand Name|
|auranofin (gold salts)||Ridaura|
|cyclosporine||Gengraf, Neoral, Sandimmune|
|methotrexate||Otrexup, Rheumatrex Dose Pack, Trexall, Xatmep|
|sulfasalazine||Azulfidine, Azulfidine EN-tabs|
Methotrexate is a first-line DMARD that is often used in conjunction with an anti-inflammatory NSAID, such as ibuprofen (Motrin, Advil) or naproxen (Aleve).
- Methotrexate is usually taken once per week by mouth (tablet or liquid) or as an injection. Its effects are to lower joint inflammation and preserve joint function.
- The maximum recommended weekly dose is 20 mg to limit toxicity, although the normal dose for RA is much lower at 7.5 mg weekly.
- It works by interfering with DNA synthesis to block rapid cell division. It blocks dihydrofolate reductase (DHFR), an enzyme needed for folic acid synthesis and eventual protein synthesis.
Methotrexate can be combined with another DMARD or a biologic if the effects are not optimal. A response may take 3 to 6 weeks, and improvement will continue over another 12 weeks. It is very affordable, costing roughly $15 to $25 per month in the generic tablet form.
Side effects can include:
- stomach upset
- mouth or lip sores
- low white blood cell count
- blurred vision
- feeling tired
- liver damage (especially if alcohol is consumed)
Methotrexate can reduce the production of certain blood cells (leading to anemia) and this may increase the risk for bleeding or bruising, fever, chills, infections, and swollen lymph nodes. Regular monitoring of blood tests may be ordered, and folic acid may be used to lessen the risk of certain side effects like low blood counts, mouth sores, and liver impairment.
Methotrexate should not be used in pregnancy or breastfeeding. Any woman with rheumatoid arthritis planning a pregnancy should consult with her doctor first.
Other oral (non-biologic) DMARDs include sulfasalazine, hydroxychloroquine, and leflunomide.
Sulfasalazine can be combined with other DMARDs.
- It can reduce symptoms and slow down the joint damage. It is taken 2 to 4 times a day as an oral tablet. It can be combined with other DMARDs if needed.
- Side effects include: changes in blood counts, nausea, vomiting, skin rash, headaches, and an orange-yellow discoloration of the urine or skin.
- Avoid this drug is you are allergic to sulfa medications.
Hydroxychloroquine, an antimalarial drug, is effective in the treatment of rheumatoid arthritis.
- It is usually used in combination with methotrexate and sulfasalazine for added benefits. It can also be combined with corticosteroids or NSAIDs.
- It is taken as an oral tablet one to two times per day.
- An eye exam is usually required before starting hydroxychloroquine, and may be needed annually while taking it, as it can lead to damage of the retina with high doses or over a long period of time.
Leflunomide shows similar effectiveness to methotrexate and can be used alone in patients who cannot take methotrexate.
- It is taken once daily by mouth.
- It can be also be used with MTX or a biologic.
- Common side effects include: rash, hair loss, weight loss, upset stomach, diarrhea,, and liver damage. Blood testing is needed.
- Pregnancy: DO NOT take leflunomide during pregnancy due to the potential for fetal harm. you will need to have a negative pregnancy test before starting this treatment. If you desire pregnancy after stopping leflunomide, you will need to undergo an accelerated drug elimination procedure to lower the concentrations of the drug, as it can take up to 2 years to eliminate the drug from the body. Do not use during breastfeeding.
Azathioprine and cyclosporine are generally reserved for patients who do not respond to other therapies. Penicillamine or gold are used much less frequently today because most experts find them not as effective or safe as other DMARD options.
Biologics, also known as biologic response modifiers, are a disease-modifying option for rheumatoid arthritis and are newer to the market compared to the non-biologic oral DMARDs. They are made using recombinant DNA processes.
There are several types of biologics that target different specific molecules to lower inflammation and help protect the joint. All of these medications are available by injection only, either given subcutaneously (under the skin) or in a vein (intravenously).
- Most providers will start with a nonbiologic DMARD such as methotrexate to gauge response and tolerability.
- TNF blockers can be added to oral nonbiologic DMARDs (like methotrexate) for patients with early but severe rheumatoid arthritis or who fail non-biologic DMARDs.
- Biologics can also be used with NSAIDs or glucocorticoids like prednisone. Use of biologics usually allow a lower dose of these drugs.
- In severe cases, a TNF inhibitor biologic might be used initially as a single therapy; however, biologic DMARDs are usually most effective when paired with a nonbiologic DMARD, such as methotrexate..
Kinase inhibitors or other biologics may be used when TNF blockers are not effective or tolerated.
Biologics tend to work more quickly than the oral nonbiologic DMARDs, usually within 2 to 6 weeks.
Table 2: Biologics for Rheumatoid Arthritis*
*Note: Orencia, Olumiant, Rituxan, Kineret, Kevzara, Actemra, Rinvoq and Xeljanz are non-TNF biologics and target other immune system molecules; they may be considered for therapy if TNF blocker therapy is not adequate. Rinvoq may be used if methotrexate not adequate. Xeljanz is not considered a true biologic, as it is made with traditional drug manufacturing techniques, but has side effects similar to the biologics.
Tumor necrosis factor (TNF) inhibitors
Tumor necrosis factor (TNF) inhibitors are a class of biologics used to treat autoimmune diseases like rheumatoid arthritis. Humira (adalimumab), one of the top-selling drugs in history, belongs to this class.
- Tumor necrosis factor alpha is produced by certain white blood cells, and acts on many cells in the joints and in other organs and body systems to cause inflammation and joint damage.
- By blocking TNF alpha, the inflammation process in the joint tissue is halted or slowed.
- Methotrexate can also be used with TNF inhibitors to increase the effectiveness of therapy in rheumatoid arthritis.
TNF inhibitors and other biologics suppress the immune system and may increase your risk of infection; report any signs of infection, such as a fever, to your doctor immediately. Do not use these drugs if you have a serious infection.
- Also report any night sweats or weight loss that occurs during treatment.
- TNF blockers not recommended for patients with a history of lymphoma (a type of blood cancer).
- You may need vaccinations prior to or during treatment with biologics. Tell your doctor if you have a history of congestive heart failure (CHF), cancer or hepatitis.
- You will also be tested for tuberculosis (TB) before starting certain biologic agents, like TNF blockers. There is an increased risk of developing TB with these drugs.
- abatacept (Orencia) decreases T cell proliferation and inhibits the production of the cytokines tumor necrosis factor (TNF) alpha, interferon-γ, and interleukin-2.
- rituximab (Rituxan) depletes the B cells, which have several functions in the immune response. Rituximab has reduced signs and symptoms of rheumatoid arthritis, and manages to slow down the joint destruction.
- anakinra (Kineret) is an interleukin-1 inhibitor, a synthetic protein that blocks the inflammatory agent interleukin-1. Anakinra injection is used to slow progression of moderate to severe active rheumatoid arthritis in patients who have not responded to one or more of the DMARDs.
- tocilizumab (Actemra) was the first biologic approved that blocks IL-6, an inflammatory cytokine. For the treatment of RA, tocilizumab may be used alone or in combination with methotrexate or other disease modifying anti-rheumatic drugs (DMARDs). It can be given as an intravenous infusion or as a subcutaneous injection.
- tofacitinib (Xeljanz, Xeljanz XR) is a first-in-class agent that blocks an enzyme involved in joint inflammation called Janus kinase (JAK). Tofacitinib is available as an oral agent compared to the biologics which are all injected.
- baricitinib (Olumiant): In June 2018, the FDA approved Olumiant (baricitinib), a once-daily oral medicine for adults with moderate-to-severe rheumatoid arthritis and an inadequate response to TNF inhibitors. Like Xeljanz (tofacitinib), Olumiant is a Janus kinase (JAK) inhibitor. The manufacturers have reported Olumiant will be 60% less expensive than the leading TNF inhibitor.
- sarilumab (Kevzara): In May 2017 the FDA approved Kevzara, an IL-6 inhibitor for the treatment of patients with moderate-to-severe rheumatoid arthritis who have had an inadequate response or cannot tolerate one or more DMARDs. Kevzara may be used as monotherapy or in combination with methotrexate (MTX) or other conventional DMARDs.
Several biosimilars are now approved for rheumatoid arthritis, as well.
A biosimilar is a biological product that is very similar to a reference biologic (such as Humira, for example) and for which there are no clinically meaningful differences in terms of safety, purity, and potency. Only minor differences in clinically inactive components are allowable in biosimilar products.
Table 3: Biosimilars Approved for Rheumatoid Arthritis
|Generic Name||Brand Name||Reference Product|
- Learn More: What Are Biosimilars? Top Facts You May Not Know
Biosimilars may be less expensive than the reference (original brand) biologic, but are still very expensive. They must be specifically prescribed by your doctor. For now, pharmacists cannot substitute a biosimilar for a reference product at the pharmacy unless directed to do so by your physician. According to the FDA, no products are interchangeable.
As with biologics, biosimilars are usually too expensive for the individual patient without adequate insurance. These drugs involve complicated development which boost their price. Most patients will need to acquire these medications through a specialty pharmacy, or enroll in a patient-assistance program with the manufacturer.
Glucocorticoids (also called steroids or corticosteroids) have been used to reduce inflammation in rheumatoid arthritis for decades. Common examples include triamcinolone and prednisone. They can be used in conjunction with other rheumatoid arthritis medications as a bridge while those medications take effect, and for pain control during periods of flare-ups.
Potential side effects limit the use of oral corticosteroids to short courses and low doses when possible. The goal is to eventually for the patient to taper off of corticosteroids.
Side effects may include:
- weight gain
- increased risk of infections
- susceptibility to diabetes
- high blood pressure
- thinning of the bones (bone loss and osteoporosis).
Calcium and vitamin D and use of certain medications that can reduce bone loss may be options to help reduce bone loss if you need to take glucocorticoids over the long-term.
Glucocorticoids are given by mouth or injected. Intra-articular steroid injections (directly into the joint space) can effectively relieve pain, reduce inflammation, increase mobility and reduce deformity in one or a few joints. If repeated injections are required then the dose of DMARDs should be increased.
Table 4: Corticosteroids Commonly Used for Rheumatoid Arthritis
|Generic Name||Common Brand Name(s)|
|prednisone||Rayos, Prednisone Intensol|
|triamcinolone||Aristospan, Kenalog-40, Triesence|
Acetaminophen (brand name: Tylenol and others) is useful for minor pain. It has a place both in the early stages of disease when beginning DMARD treatment, and regularly in the later stages of the disease.
Most people can take acetaminophen without serious side effects as long as they do not exceed the recommended dose (maximum of 3 to 4 grams in 24 hours). Alcohol consumption should be reduced to avoid liver toxicity, which is also a side of many DMARDs. It can help to reduce mild pain but does not help with inflammation or swelling.
Non Steroidal Anti-Inflammatory Drugs (NSAIDs)
Nonsteroidal anti-inflammatory agents (NSAIDs) are also used to treat rheumatoid arthritis. NSAIDs also includes cyclooxygenase-2 inhibitors (COX-2 Inhibitors). NSAIDs primarily work by inhibiting cyclooxygenase to lower the production of prostaglandins and thromboxanes that lead to inflammation.
NSAIDS can be bought over-the-counter, such as ibuprofen or naproxen, or may be prescribed. Prescription NSAIDs include medicines such as diclofenac, indomethacin, flurbiprofen, meloxicam, oxaprozin, sulindac, and others.
NSAIDs can relieve mild-to-moderate pain in rheumatoid arthritis; however, they do not change the course of disease or prevent joint destruction. NSAIDs are usually taken for several weeks to assess initial effectiveness.
- Learn More: Common Prescription and Over-the-Counter NSAIDs
There can be considerable variation in individual patient response and tolerance to different NSAIDs. If the first NSAID used does not adequately relieve pain, it may be recommended to increase the dose or switch to another NSAID.
While NSAIDs are effective for many people in reducing pain and inflammation, they are not without common and sometimes serious side effects. Their use should be weighed against the risk for adverse events.
- The most common side effect of NSAIDs is stomach irritation, such as heartburn, constipation, diarrhea, nausea, and vomiting. Ulceration or bleeding may occur and can be serious. NSAIDs may be taken with food to prevent or minimize stomach upset, but this does not decrease the risk of bleeding.
- Taking a combination of NSAIDs, or NSAIDs and aspirin together increases the risk of stomach ulcers or gastrointestinal bleeding. This can be an especially serious risk in the elderly. Do not use two NSAIDs at the same time, or take NSAIDs with aspirin.
- NSAID use can also lead to possible heart problems. In 2005 the FDA asked drug manufacturers of NSAIDs to include a warning label on their product that alerts users of an increased risk for cardiovascular events and gastrointestinal bleeding.
- NSAIDs may lead to decreased kidney function in some patients. This can result in salt and water retention, increased blood pressure, and altered levels of potassium in your blood. Liver damage is possible, too.
- Although many NSAIDs are taken every four to six hours, some come in long-acting or extended release forms, and can be taken once or twice a day.
Only use the lowest NSAID dose that effectively relieves your pain, and for the shortest time possible to lessen side effect risk.
- Learn More: Top 9 Things You Must Know About Naproxen
Combining an NSAID with a stomach protecting (gastroprotective) agent, such as a proton pump inhibitor (PPI) or misoprostol (Cytotec) can help to prevent or treat stomach side effects, such as irritation, ulceration or bleeding, which may be caused by NSAIDs. The PPIs include: esomeprazole, omeprazole, lansoprazole, pantoprazole and rabeprazole. Misoprostol is a synthetic prostaglandin E1 analog.
Some products are also commercially available in combination:
- diclofenac and misoprostol (Arthrotec)
- esomeprazole and naproxen (Vimovo)
- famotidine and ibuprofen (Duexis)
Celecoxib (Celebrex) is the only cyclo-oxygenase-2 (COX-2) inhibitor currently available in the U.S, following the withdrawal of rofecoxib (Vioxx) in 2004 and valdecoxib (Bextra) in 2005 due to an elevated risk of heart attack and stroke.
- Celecoxib is as effective at relieving pain and inflammation as other common NSAIDs like ibuprofen, naproxen, and diclofenac and may be safer for the stomach.
- Lower doses of celecoxib have been found not to increase the risk of heart attack or stroke above that of naproxen or ibuprofen.
- COX-2 Inhibitors, like other NSAIDs, don't delay progression of rheumatoid arthritis; they only provide symptomatic relief.
Celecoxib is now available as a generic formulation and is as affordable as many other prescription NSAIDs.
Use of opioids such as hydrocodone (Vicodin) or oxycodone (Oxycontin), even when combined with acetaminophen, is discouraged in most cases due to the chronic nature of rheumatoid arthritis and the risk for side effects, dependence and addiction. Chronic, long-term use should be monitored by a pain specialist.
- Learn More: Understanding Opioid (Narcotic) Pain Medications
Range of motion exercises and individualized exercise programs prescribed by a physical therapist can delay the loss of joint function. Joint protection techniques, heat and cold treatments, and splints or orthotic devices to support and align joints may also be very helpful.
Sometimes therapists will use special machines to apply gentle, deep heat (ultrasound) or electrical stimulation (transcutaneous electrical nerve stimulation, or TENS) to reduce pain and improve joint mobility.
Occupational therapists can also construct splints for your hand and wrist and teach you how to best protect and use your joints when they are affected by arthritis. They also show people how to better cope with day to day tasks at work and at home, despite limitations caused by rheumatoid arthritis.
Keeping your activity levels up will help improve daily function and quality of life. Rest periods between activities, as well as at least 8 hours of sleep per night, are recommended.
Occasionally, surgery is needed to correct severely affected joints in end-stage rheumatoid arthritis. Surgery can relieve joint pain, correct deformities, and modestly improve joint function. Discuss the benefits and risks of any surgical procedure with your doctor.
Examples of surgeries used in rheumatoid arthritis are:
- Synovectomy: Surgery to remove the synovium which is the lining of the joint. This type of surgery can be performed on knees, elbows, wrists, fingers and hips.
- Tendon repair: In rheumatoid arthritis, tendons around your joint to loosen or rupture and need repair.
- Joint replacement: A surgeon removes the damaged parts of your joint and inserts a prosthesis (artificial body part) made of metal and plastic. These may need to be replaced every 10 years, or so.
- Joint fusion: If joint replacement is not an option, fusing a joint surgically can stabilize a joint and allow pain relief when a joint replacement isn't an option.
Related Reading: A Joint Effort: A Provider's Guide To Orthopedic Pain Options
Extracorporeal immunoadsorption (ECI)
Extracorporeal immunoadsorption (ECI), also referred to as protein immuno-adsorption therapy or Prosorba Column (from Cypress Bioscience) is a device that removes inflammatory antibodies such as IgG and IgM complexes (rheumatoid factors), and circulating immune complexes. It is used for the treatment of moderate to severe rheumatoid arthritis in adults with long standing disease, who have not responded to, or are intolerant of, DMARDs. The procedure takes 2 to 3 hours and must be done once weekly for 12 weeks.
The Food and Drug Administration (FDA) has approved ECI for the treatment of rheumatoid arthritis (RA), but it is not used as first-line therapy. Studies have reported that worsening of rheumatoid arthritis slows down or stops in roughly one third of the people who receive this treatment. However, there is a flare up of joint pain for several days after the treatment.
Side effects of ECI include:
- low blood pressure
Rheumatoid arthritis is not solely a disease of joint destruction. It can involve almost all organs and lead to other complications.
- Instability of the cervical spine can be a life-threatening complication.
- Eye complications can occur so patients should have regular eye exams.
- If you smoke, it is important to stop to help prevent worsening of your symptoms.
- Rheumatoid vasculitis (inflammation of the blood vessels) is a serious, potentially life threatening complication of rheumatoid arthritis. It can lead to skin ulcerations an infections, bleeding stomach ulcers, and nerve problems. It can cause a stroke, heart attack or heart failure.
- Rheumatoid arthritis can cause the outer lining of the heart to swell (pericarditis) and cause heart complications. Inflammation of the heart muscle, called myocarditis can also develop. Pericarditis and myocarditis can lead to congestive heart failure.
- Osteoporosis or carpal tunnel syndrome may occur.
Self-care measures can be additive to the effects from drug therapy.
- Exercise program: Daily exercise and maintaining flexibility is a key component of treatment. Daily exercise can help with sleep, too. Walking is a convenient and easy exercise to engage in. Try non-weight bearing exercises like biking or swimming if walking is painful. Check with your doctor before starting any exercise program.
- Heat and cold applications: Heat can help ease pain and relax painful muscles and joints. Cold has a numbing effect and can relieve muscle spasms.
- Lower your stress: Use techniques to reduce stress and anxiety in your life. Mindfulness, yoga, tai chi, walking, guided imagery, and breathing patterns can lower daily stress and boost one's outlook.
- Self-help devices: The use of self-help devices, such as easy-open prescription bottles, compression garments, and walk-in tubs are options. Special tools to help in the kitchen, with dressing, and other activities of daily living are available. Visit the Arthritis Foundation website for more information.
- Purple Book: Lists of Licensed Biological Products with Reference Product Exclusivity and Biosimilarity or Interchangeability Evaluations. FDA. Accessed Jan 4, 2019 at https://www.fda.gov/drugs/developmentapprovalprocess/howdrugsaredevelopedandapproved/approvalapplications/therapeuticbiologicapplications/biosimilars/ucm411418.htm
- Schur P, Furst D, Romain P. Up to Date. Patient education: Disease-modifying antirheumatic drugs (DMARDs). Beyond the Basics.
- Methotrexate [Package Insert]. Revised 08/2018. West-Ward Pharmaceuticals Corp. Accessed Jan 4, 2019 at https://www.drugs.com/pro/methotrexate-injection.html
- TNF Inhibitors. American College of Rheumatology. Accessed Jan. 4, 2018 at https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Treatments/TNF-Inhibitors
- Extracorporeal Immunoadsorption (Prosorba Column). Aetna. Jan. 2018. Accessed Jan. 3, 2019 at http://www.aetna.com/cpb/medical/data/300_399/0355.html
- Felson DT, LaValley MP, Baldassare AR, et al. The Prosorba column for treatment of refractory rheumatoid arthritis. Arthritis Rheum. 1999;42(10):2153-2159.
- Supplement Guide: Capsaicin. Arthritis Foundation. Accessed Jan 3, 2019 at https://www.arthritis.org/living-with-arthritis/treatments/natural/supplements-herbs/guide/capsaicin.php
- FDA Approves Ixifi. Drugs.com. Dec. 13, 2017. Accessed Jan 21, 2018 at https://www.drugs.com/newdrugs/fda-approves-ixifi-infliximab-qbtx-biosimilar-remicade-4659.html
- FDA Approves Renflexis. Drugs.com. Accessed Jan. 2, 2019 at https://www.drugs.com/newdrugs/fda-approves-renflexis-infliximab-abda-biosimilar-remicade-4519.html
- Venables PJW, O'Dell JR, Romain P. Patient Education: Rheumatoid Arthritis treatment (Beyond the Basics). Up To Date. Accessed Jan 2, 2019 at https://www.uptodate.com/contents/rheumatoid-arthritis-treatment-beyond-the-basics
- Kevzara. Product Label. Regeneron. Accessed Jan 3, 2019 at https://www.regeneron.com/kevzara-injection
- FDA Approves Cyltezo. Drugs.com. Jan. 21, 2018. Accessed Jan. 2, 2019 at https://www.drugs.com/newdrugs/fda-approves-cyltezo-adalimumab-adbm-biosimilar-humira-4583.html
- FDA Approves Amjevita (adalimumab-atto), a Biosimilar to Humira. Drugs.com. Accessed Jan. 2, 2019 at https://www.drugs.com/newdrugs/fda-approves-amjevita-adalimumab-atto-biosimilar-humira-4434.html
- Singh JA, et al. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care & Research 2016;68:1-25. http://www.rheumatology.org/Portals/0/Files/ACR%202015%20RA%20Guideline.pdf
- Pfizer. Xeljanz XR Prescribing Information. Accessed Jan 2, 2019 at http://labeling.pfizer.com/ShowLabeling.aspx?id=959
- Ravinder M, Venables P, O'Dell J, et al. Patient Education: Rheumatoid arthritis symptoms and diagnosis (Beyond the Basics). Up To Date. Accessed Jan. 6, 2018 at https://www.uptodate.com/contents/rheumatoid-arthritis-symptoms-and-diagnosis-beyond-the-basics
Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.