Medication is the primary form of treatment for rheumatoid arthritis (RA), an inflammatory condition of the joints for which there is no cure.
Some drugs focus on merely treating symptoms, temporarily reducing the pain and inflammation of RA. But others, called disease-modifying anti-rheumatic drugs, or DMARDs, are able to change or slow the progression of the disease, helping to prevent severe joint damage and other complications from developing. (1)
Medication for rheumatoid arthritis typically falls into one of three categories:
- Disease-modifying anti-rheumatic drugs (DMARDs)
- Nonsteroidal anti-inflammatory drugs (NSAIDs) (2)
The medications your doctor prescribes will usually change over the course of treatment. If following the treat-to-target paradigm, your doctor will continually monitor your disease activity and explain the reasoning behind using specific therapies — and alter your medications to help you reach your disease target (high, moderate, or low disease activity or full remission, depending on what reasonably works best for you).
Be sure to start a conversation with your doctor about treat-to-target for RA. While treat-to-target yields superior outcomes versus standard RA care, it has not yet been widely adopted, according to a study published in January 2019 in the journal Nature Reviews Rheumatology. (3)
The Importance of Early Drug Treatment for Rheumatoid Arthritis
Rheumatoid arthritis may begin in a gradual and subtle way, but the disease ultimately causes joint damage in 85 percent of people with the disease, according to the Johns Hopkins Arthritis Center. (4)
Given that the majority of this irreversible damage occurs within the first two years of the disease,?early diagnosis and treatment is vital?to protecting the joints and preventing disability. (1,2,4)
Treatment with disease-modifying drugs can help stop disease activity, as well as joint and bone destruction. Along with medication, various lifestyle changes can help reduce RA-related joint and bone damage, including:
DMARDs for Treating Rheumatoid Arthritis
There is no cure for RA, but DMARDs are the gold standard of RA treatment.
Each conventional (nonbiologic) DMARD is different, but they all work by slowing the inflammatory process of the body, protecting the joints from further damage. These drugs are generally prescribed shortly after diagnosis. (5)
Which DMARD your doctor prescribes depends on numerous things, including the severity of the disease and the balance between possible side effects and the benefits of the DMARD. But for many people with RA, DMARDs lose their effectiveness over time, so?DMARDs are often combined with other drugs, according to the consumer health information company A.D.A.M. (6)
Methotrexate Is a Popular DMARD Used to Treat RA
The most frequently used DMARD for RA is?Trexall (methotrexate), which takes up to six weeks to start working, with the full effect not seen until after 12 weeks of treatment. Up to 90 percent of people with RA take methotrexate at some point during treatment, according to the Arthritis Foundation. (5)
About 20 percent of patients eventually stop taking methotrexate due to its side effects, which include upset stomach, sore mouth, muscle aches, and hair thinning due to a drop in folic acid levels from the drug. Patients are often given?folic acid supplements?to reduce these side effects.
Your doctor may prescribe other DMARDs along with methotrexate, including:
Biologic DMARDs for Treating Rheumatoid Arthritis
Biologic DMARDs work more quickly than conventional DMARDs — some in as little as two weeks — but must be injected by your doctor. These drugs interfere with the immune system's ability to launch the damaging inflammatory process by targeting specific steps in this process.
What Is Anti-TNF Therapy?
The first types of biologics that hit the market work by binding and inhibiting tumor necrosis factor alpha (TNF), a pro-inflammatory immune system substance. These drugs may be used in combination with methotrexate, though two biologics are never used in combination with each other. (8)
TNF inhibitors include:
- Enbrel (etanercept)
- Remicade (infliximab)
- Humira (adalimumab)
- Cimzia (certolizumab)
- Simponi (golimumab)?(6,7)
The Food and Drug Administration warns that TNF inhibitors may be associated with an increased risk of lymphomas (cancer of the lymph nodes). But research published in August 2017 in the journal?Annals of Rheumatic Diseases?suggests?these drugs don't affect lymphoma risk, which may actually be due to RA-related inflammation.?(9)
Other biologics target other immune system factors, such as interleukin-1 (IL-1), IL-6, CD20-positive B cells, and T cell activity. These drugs are usually only prescribed if you're unresponsive to treatments with methotrexate and a TNF inhibitor. (1,2,4,6)
These other biologics include:
JAK Inhibitors for Difficult-to-Treat RA
A drug called?tofacitinib (Xeljanz, Jakvinus)?is also available. It belongs to a new subclass of DMARDs called?JAK inhibitors, which work by blocking another part of the body's immune system response:?Janus kinase (JAK) pathways. This type of DMARD, like conventional DMARDs, can be taken orally. (10)
A study published in April 2019 in the journal Arthritis Research & Therapy found that tofacitinib remained effective for at least eight years and safe for at least nine and a half years. (11)
In June 2018, the Food and Drug Administration approved a drug called Olumiant (baricitinib).?It is typically used alongside conventional DMARDs and is for people who have shown poor responses to certain biologics.
Corticosteroids for Treating Rheumatoid Arthritis
These drugs are often used while waiting for DMARDs to take effect, and are sometimes also prescribed to enhance the effects of a DMARD. They can quickly reduce pain, stiffness, swelling, and tenderness of joints.
But corticosteroids are only used for short-term relief because they can cause a number of serious side effects in the long run, including:
NSAIDs for Treating Rheumatoid Arthritis
Over-the-counter NSAIDs include:
Prescription NSAIDs include:
Controlling RA Symptom Flare-Ups With Medication
Even with regular treatment, you may occasionally experience?flare-ups?— periods of increased disease activity that causes spikes in symptoms.
Mild flare-ups can sometimes be treated at home with NSAIDs, rest, hot or cold compresses, or gentle exercise. If these treatments don't work, your doctor may prescribe oral corticosteroids, which will help reduce the inflammation causing your symptoms, and possibly alter any conventional or biologic DMARDs you may be taking.
Importantly, it's best to try to treat your flare-up rather than take the wait-and-see approach to prevent further joint damage. (14)
Rheumatoid Arthritis Medications and Pregnancy
Research presented in September 2017 at the annual meeting of the American College of Rheumatology shows that as many as?half of women with RA stop taking their medication during pregnancy. But doing so can cause disease activity to increase, potentially impacting unborn babies. (15)
Many RA medicines are considered safe to take during pregnancy, including TNF inhibitors, oral steroids, and NSAIDs. Please discuss with your doctor, because not all drugs are created equal.
Women with RA who become pregnant should discuss their medication options with their rheumatologist before making changes to their medication usage.
Editorial Sources and Fact-Checking
- Combe?B,?Landewe?R,?Daien?CI, et al. 2016 Update of the?EULAR?Recommendations for the Management of Early Arthritis.?Annals of the Rheumatic Diseases. June 2017.
- Patient Education: Rheumatoid Arthritis Treatment (Beyond the Basics).?UpToDate. March 12, 2019.
- Van Vollenhoven?R. Treat-to-Target in Rheumatoid Arthritis — Are We There Yet??Nature Reviews?Rheumatology. January 2019.
- Rheumatoid Arthritis. John Hopkins Arthritis Center.
- Understanding?Methotrexate.?Arthritis Foundation.
- Rheumatoid Arthritis.?A.D.A.M. Education. April 23, 2018.
- Donahue KE, Gartlehner G, Schulman ER, et al. Drug Therapy for Early Rheumatoid Arthritis: A Systematic Review Update. Agency for Healthcare Research and Quality.?July 2018.
- Biologics Overview.?Arthritis Foundation.
- Mercer LK,?Regierer?AC,?Mariette?X, et al. Spectrum of Lymphomas Across Different Drug Treatment Groups in Rheumatoid Arthritis: A European Registries Collaborative Project.?Annals of the Rheumatic Diseases. December 2017.
- Kawalec?P,?Mikrut?A,?Wisniewska?N,?Pilc?A. The Effectiveness of?Tofacitinib, a Novel?Janus?Kinase?Inhibitor, in the Treatment of Rheumatoid Arthritis: A Systematic Review and Meta-Analysis.?Clinical?Rheumatology. 2013.
- Wollenhaupt?J, Lee E-B, Curtis J, et al. Safety and Efficacy of Tofacitinib for up to 9.5?Years in the Treatment of Rheumatoid Arthritis: Final Results of a Global, Open-Label, Long-Term Extension Study.?Arthritis Research & Therapy. April 2019.
- Combating High Disease Activity in Early RA.?Arthritis Foundation.
- NSAIDs Overview. Arthritis Foundation.
- Markusse?IM,?Dirven?L,?Gerards?AH, et al. Disease Flares in Rheumatoid Arthritis Are Associated With Joint Damage Progression and Disability: 10-Year Results From the?BeSt?Study.?Arthritis Research & Therapy. August?2015.
- Haroun?T,?Eudy?AM,?Jayasundara?M, et al. Tough Choices: Understanding the Medication Decision-Making Process for Women With Inflammatory Arthritis During Pregnancy and Lactation.?Arthritis & Rheumatology.?2017.
- National Institute of Arthritis and?Musculoskeletal?and Skin Diseases.
- Rheumatoid Arthritis: In Depth.?National Center for Complementary and Integrative Medicine. January 2019.
- Mother to Baby.