musculoskeletal and connective tissue disorders
Rheumatoid Arthritis (RA)
Treatment of Rheumatoid Arthritis
Nonpharmacological measures: Smoking cessation, healthy, balanced nutrition, physical joint protective measures, quality sleep Pharmacological measures: Medications that modify disease progression and nonsteroidal anti-inflammatory drugs (NSAIDs) as needed for analgesia Treatment of rheumatoid arthritis involves a balance of rest and exercise, adequate nutrition, physical measures, drugs, and sometimes surgery. Early diagnosis and treatment in rheumatoid arthritis predict improved outcomes. A treat-to-target approach to achieve full disease remission or minimal disease activity has been recommended by the American College of Rheumatology (ACR) ( Treatment references ) and European League Against Rheumatism (EULAR) ( Complete bed rest is rarely indicated, even for a short time; however, a program including judicious rest should be encouraged. Quality sleep should be encouraged, because poor sleep increases pain. An ordinary nutritious diet is appropriate. Rarely, patients have food-associated exacerbations; no specific foods have reproducibly been shown to exacerbate or lessen the symptoms of rheumatoid arthritis. Substituting omega-3 fatty acids (in fish oils) for dietary omega-6 fatty acids (in meats) partially relieves symptoms in some patients by transiently decreasing production of inflammatory prostaglandins and possibly by modifying the gut microbiome. Smoking cessation can increase life expectancy. Food and diet misinformation targeting rheumatoid arthritis patients is common, and patients should be directed to reliable sources of information. Joint splinting reduces local inflammation and may relieve severe symptoms of pain or compressive neuropathies. Cold may be applied to reduce joint pain and swelling. Orthopedic or athletic shoes with good heel and arch support are frequently helpful; metatarsal supports placed posteriorly (proximal) to painful metatarsophalangeal joints decrease the pain of weight bearing. Molded shoes may be needed for severe deformities. Occupational therapy and self-help devices enable many patients with debilitating rheumatoid arthritis to perform activities of daily living. Exercise should proceed as tolerated. During acute inflammation, passive range-of-motion exercise helps prevent flexion contractures. Heat therapy can be applied to help alleviate stiffness. Range-of-motion exercises done in warm water are helpful because heat improves muscle function by reducing stiffness and muscle spasm. However, contractures can be prevented and muscle strength can be restored more successfully after inflammation begins to subside; active exercise (including walking and specific exercises for involved joints) to restore muscle mass and preserve range of joint motion are recommended. Flexion contractures may require intensive exercise, casting, or immobilization (eg, splinting) in progressively more stretched-open positions. Paraffin baths can warm digits and facilitate finger exercise. Massage by trained therapists, Surgery may be considered if drug therapy is unsuccessful. Surgery must always be considered in terms of the total disease and patient expectations. For example, deformed hands and arms limit crutch use during rehabilitation; seriously affected knees and feet limit benefit from hip surgery. Reasonable objectives for each patient must be determined, and function must be considered; straightening ulnar-deviated fingers may not improve hand function. Surgery may be done while the disease is active. Arthroplasty with prosthetic joint replacement is indicated if damage severely limits function; total hip and knee replacements are most consistently successful. Prosthetic hips and knees may limit vigorous activity (eg, competitive athletics). Excision of subluxed painful metatarsophalangeal joints may greatly aid walking. Thumb fusions may provide stability for pinch. Neck fusion may be needed for C1-2 subluxation with severe pain or potential for spinal cord compression. Arthroscopic or open synovectomy can relieve joint inflammation but only temporarily unless disease activity can be controlled. Withholding some immunosuppressive medications at the time of arthroplasty should be considered to limit the risk of infection. Even low-doseprednisone(< 7.5 mg a day) may increase infectious risk. 1.Fraenkel L, Bathon JM, England BR, et al: 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis.Arthritis Rheumatol73(7):1108-1123, 2021. doi:10.1002/art.41752 2.Smolen JS, Landewé RBM, Bijlsma JWJ, et al: EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update.Ann Rheum Dis79(6):685-699, 2020. doi:10.1136/annrheumdis-2019-216655 