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The treatment of rheumatoid arthritis

Updated: Monday, Mar 16,2009, 9:54:54 AM
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Treatment aim 1 - to reduce pain and stiffness

Non-steroidal anti-inflammatory painkillers
These are sometimes just called 'anti-inflammatories' and are good at easing pain and stiffness. There are many types and brands. Each is slightly different to the others, and side-effects may vary between brands. To decide on the right brand to use, a doctor has to balance how powerful the effect is against possible side-effects and other factors. Usually one can be found to suit. However, it is not unusual to try two or more brands before finding one that suits you best.

During a flare-up of inflammation, if you rest the affected joint(s) it helps to ease pain. Special wrist splints, footwear, gentle massage, or applying heat may also help. Medication is also helpful. Medicines which may be advised by your doctor to ease pain and stiffness include the following.

The leaflet which comes with the tablets gives a full list of possible side-effects. The most common side-effect is stomach pain (dyspepsia). An uncommon but serious side-effect is bleeding from the stomach. Your doctor may prescribe another medicine to 'protect the stomach' from these possible problems. If you develop abdominal (stomach) pains, pass blood or black stools, or vomit blood whilst taking anti-inflammatory painkillers, stop taking the tablets and see a doctor soon.

A course of steroid tablets such as prednisolone is sometimes used. Steroids are good at reducing inflammation. They may be prescribed to treat a flare-up which has not been helped much by non-steroidal anti-inflammatory painkillers. An injection of steroid directly into a joint is sometimes used to treat a bad flare-up in one particular joint.

Paracetamol often helps. This does not have any anti-inflammatory action, but is useful for pain relief in addition to, or instead of, an anti-inflammatory painkiller. Codeine is another painkiller that is sometimes used.

The problem with steroids is their side-effects. A short course every 'now and then' for a severe flare-up is usually fine. However, serious side-effects may occur if you take steroids for more than a few weeks, or if you have injections frequently. Side-effects include: thinning of the bones (osteoporosis), thinning of the skin, weight gain, muscle wasting, and other problems.

One possible option is to take a low dose of steroid each day for a long period. However, this is controversial and not commonly advised. The steroid may help to keep inflammation down, and the low dose may mean that side-effects are less likely. However, even a low dose of steroids taken regularly may lead to some serious side-effects.

Note: non-steroidal anti-inflammatory painkillers, ordinary painkillers, and steroids ease the symptoms of RA. However, they do not alter the progression of the disease or prevent joint damage. You do not need to take them if symptoms settle between flare-ups. (However, never suddenly stop a long course of steroids without consulting a doctor.)

Treatment aim 2 - to prevent joint damage as much as possible


Disease-modifying drugs
There are a number of drugs called 'disease-modifying antirheumatic drugs' (DMARDs). These are drugs that ease symptoms but also reduce the damaging effect of the disease on the joints. They work by blocking the effects of chemicals involved in causing joint inflammation. They include: sulfasalazine, methotrexate, gold injections, gold tablets, penicillamine, leflunomide and hydroxychloroquine. It is these drugs which have improved the outlook (prognosis) in recent years for many people with RA.

It is usual to start a DMARD as soon as possible after RA has been diagnosed. This is to try and limit the disease process as much as possible. In general, the earlier you start one, the more effective it is likely to be.

DMARDs have no immediate effect on pains or inflammation. It can take up to 4-6 months before you notice any effect. Therefore, it is important to keep taking a DMARD as prescribed, even if it does not seem to be working at first. After starting a DMARD, many people continue to take an anti-inflammatory tablet or steroid tablets for several weeks until the DMARD starts to work. Once a DMARD is found to help, the dose of the anti-inflammatory tablet or steroid can be reduced or even stopped. It is then usual to take a DMARD indefinitely.

Other DMARDs include azathioprine, cyclosporin, and cyclophosphamide. These are usually reserved for people who do not respond well to the more commonly used DMARDs, due to the risk of serious side-effects.

Each of the DMARDs has different possible side-effects. If one does not suit, a different one may well be fine. Some people try two or three DMARDs before one is found to suit. (Some side-effects can be serious. These are rare, but it is usual to have regular tests - usually blood tests - whilst you take a DMARD. The tests look for possible side-effects before they become serious.)

Newer disease modifying drugs
Drugs which have recently been developed include etanercept, infliximab, adalimumab, and anakinra. They show promise but their long-term benefits are still being evaluated. One problem with these drugs is that they need to be given by injection. One may be tried if there has been little success when using other DMARDs.

Treatment aim 3 - to minimise disability as much as possible

As far as possible, try to keep active. The muscles around the joints will become weak if they are not used. Regular exercise may also help to reduce pain and improve joint function. Swimming is a good way to exercise many muscles without straining joints too much. A physiotherapist can advise on exercises to keep muscles around joints as mobile and strong as possible. They may also advise on splints to help rest a joint if needed.
If such things as your grip or mobility become poor, an occupational therapist may advise on adaptations to the home to make daily tasks easier.
If you develop a joint deformity then surgery to correct it is sometimes an option. If severe damage occurs to a joint, operations such as knee or hip replacements are an option.
Treatment aim 4 - to reduce the risk of developing associated diseases

As mentioned, if you have RA you have an increased risk of developing diseases such as heart disease, stroke, osteoporosis, and certain cancers. Therefore, you should consider doing what you can to reduce the risk of these conditions by other means. For example, if possible:

Eat a good healthy diet and exercise regularly.
Lose weight if you are overweight.
Do not smoke. (In addition to increasing the risk of cancer, heart disease and stroke, smoking may also make symptoms of RA worse.)
If you have high blood pressure, diabetes, or a high cholesterol level, they should be well controlled on treatment.
See leaflets called 'Preventing Heart Disease and Stroke' and 'Osteoporosis' for more details.

To prevent certain infections, you should have:

An annual 'flu jab if you are over the age of 65 years, or are taking immunosuppressive drugs, or are taking steroids equivalent to 20 mg or more of prednisolone each day for more than a month.
A 'one-off' pneumococcal immunisation if you are over the age of 75 years, or are taking immunosuppressive drugs, or are taking steroids equivalent to 20 mg or more of prednisolone each day for more than a month.
Other treatments

Some people try complementary therapies such as special diets, bracelets, acupuncture, etc. There is little research evidence to say how effective such treatments are for RA. In particular, beware of paying a lot of money to people who make extravagant claims of success. For advice on the value of any treatment it is best to consult a doctor, or contact one of the groups below.

What is the outlook (prognosis) for people with rheumatoid arthritis?

The outlook is perhaps better than many people imagine.

About 2 in 10 people with RA have a relatively mild form of the disease, and can continue to do most normal activities for many years after the condition first starts.
About 1 in 10 people with RA become severely disabled.
About 7 in 10 fall somewhere in between with varying degrees of difficulties and disability. Most will have to modify their lifestyle to some extent, but can expect to lead a full life.
In recent years, disease modifying drugs have improved the outlook as regards disability. However, because of the increased risk of developing 'associated diseases' (see above), the average life expectancy of people with RA is a little reduced compared to the general population.

In summary

Rheumatoid arthritis can range from relatively mild to severe.
The outlook cannot be predicted for an individual when the disease starts.
Treatment usually includes:
A disease-modifying drug which reduces joint damage. You should take this all the time. It may take up to 4-6 months to begin working.
An anti-inflammatory painkiller to ease pain. This helps symptoms but does not affect the progress of the disease. You do not need to take this if symptoms settle.
A painkiller such as paracetamol or codeine may be added for extra pain relief.
A short course of a steroids may be advised now and then to relieve a severe flare-up of symptoms.
Other treatments such as physiotherapy, occupational therapy, and surgery may also be advised, depending on the severity of the disease and other factors.
If possible, leading a healthy lifestyle such as not smoking, eating healthily, taking regular exercise, etc, can help to reduce the chance of developing associated diseases such as heart disease, stroke, osteoporosis, and certain cancers.

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