Rheumatoid arthritis
When joints ache and swell, the first thought is usually the same one: age, wear and tear, time to take it easy.
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Medicines commonly prescribed for Rheumatoid arthritis
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: TABLET, 600 mgActive substance: ibuprofenManufacturer: Kern Pharma S.L.Prescription requiredDosage form: ORAL SOLUTION/SUSPENSION, 100 mg / 5 mlActive substance: ibuprofenManufacturer: Laboratorio Aldo Union S.L.Prescription requiredDosage form: INJECTABLE, 50 mg/mLActive substance: methotrexateManufacturer: Medac Gesellschaft Für Klinische Spezialpräparate GmbhPrescription required
When joints ache and swell, the first thought is usually the same one: age, wear and tear, time to take it easy. With rheumatoid arthritis that thought is the most expensive one you can have. Nothing is wearing out here — the immune system is attacking the lining of the joint, and for as long as the inflammation runs it eats into cartilage and bone. What is destroyed does not grow back. Hence an uncomfortable feature of this illness: time works against you, and the window in which treatment gives its best result is measured in months from the first symptoms, not in years.
Not wear and tear, but inflammation
Inside a joint there is a thin lining called the synovium, which makes the fluid that lubricates the cartilage. In rheumatoid arthritis the immune system mistakes this lining for something foreign and attacks it. The lining thickens, swells and releases substances that dissolve cartilage, undercut the bone at the joint margin and weaken the tendons and ligaments that hold the joint in line.
That is where the difference from osteoarthritis comes from. Osteoarthritis is mechanical: cartilage wears thin where the load is greatest. Rheumatoid arthritis can pick any joint regardless of how much it has been used, and it also reaches organs well beyond the joints.
Why the immune system goes wrong is still not known. What is known is the predisposition: the illness is commoner in women, commoner where there is a family history, and distinctly commoner in people who smoke. Smoking stands apart because it is the one factor you can act on, and it affects not only the risk of developing the disease but how well treatment works afterwards.
How to tell it from osteoarthritis
The difference shows in several signs, and you can spot most of them yourself.
- Morning stiffness. In osteoarthritis joints loosen up within ten or twenty minutes. In rheumatoid arthritis the stiffness lasts an hour or more, sometimes half the morning.
- What makes it better. Osteoarthritis hurts more after walking or working and eases with rest. Here it is the other way round: the worst time is on waking or after sitting still, and moving helps.
- Which joints. The small joints of the hands are usually first — the knuckles and the middle joints of the fingers — along with the equivalent joints at the base of the toes. The end joints next to the fingernail are largely spared in rheumatoid arthritis, whereas osteoarthritis often affects them.
- Symmetry. Both sides are affected to a similar degree: not one knee, but both hands.
- What the swelling is like. The joint does not simply ache — it swells softly, the skin over it feels warm and touch is uncomfortable. An early sign doctors check is pain when the hand or foot is squeezed across the knuckles.
- How you feel overall. Tiredness out of proportion to what you have done, a slight temperature, sweating, poor appetite, weight loss. Osteoarthritis produces none of this.
It usually builds up over several weeks, though in some people it arrives within days. Either way it is a reason to be seen, not to wait for things to settle by themselves.
Why this is counted in weeks
The argument against waiting is simple: the inflamed lining hollows out small pits in the bone at the edge of the joint, called erosions. An erosion does not fill back in. Treatment can halt the process and stop new ones forming, but what has already gone is gone, and the finger deformity that later makes a button hard to fasten is built out of exactly those losses.
This is why rheumatologists talk about a window — the first months of the illness, when treatment gives the best long-term result. Started within it, treatment brings many people to a state where the joints neither hurt nor deteriorate for years. The same treatment started two years later works less well, because by then some joints have already changed irreversibly.
The practical conclusion is a single one. With persistent swelling of the small joints and morning stiffness lasting over an hour, see a doctor within the next few weeks rather than when it becomes unbearable. A primary care doctor will examine the joints, arrange blood tests and refer you to a rheumatologist, who is the one who makes the diagnosis and chooses the treatment.
An illness that is not only about joints
The inflammation of rheumatoid arthritis is not confined to the joints. It can show up:
- in the lungs, as inflammation of the pleura with pain on breathing in, or as stiffening of lung tissue; increasing breathlessness and a persistent dry cough are the warning signs;
- in the eyes, as dryness that makes reading hard and, less often, as inflammation of the white of the eye: a red, painful eye with failing vision;
- in the blood vessels, as vasculitis: a rash, ulcers on the lower legs that will not close, darkening of the fingertips;
- under the skin, as firm painless nodules near the elbows and on the hands;
- in the blood, as anaemia, which on its own adds to the tiredness;
- in the upper neck, as loosening of the joints between the vertebrae. This is uncommon but serious, so tell the team before any operation under general anaesthetic: the position of the head during intubation is handled differently.
Cardiovascular risk deserves a separate mention. Years of inflammation damage the artery wall, and heart attack and stroke are commoner in people with rheumatoid arthritis than in others of the same age. This is not a reason to worry but a reason to take blood pressure, cholesterol and smoking seriously — and above all to keep the disease itself under control, because the quieter the inflammation, the lower that risk.
What the tests and scans show
There is no single test that confirms or rules out the diagnosis. It is the whole picture that counts: which joints are involved, for how long, what the blood shows and what the scans show.
Rheumatoid factor is found in roughly half of patients at the outset — and also in a proportion of healthy people, so on its own it settles little. Antibodies to cyclic citrullinated peptide (anti-CCP) are more specific: a high level points both to the diagnosis and to a course that is likely to be more active. The erythrocyte sedimentation rate and C-reactive protein measure how much inflammation is present now, and are used afterwards to follow the treatment. A full blood count picks up anaemia and helps exclude other causes.
One thing is worth knowing in advance: a normal sedimentation rate, a normal C-reactive protein and negative antibodies do not rule the diagnosis out. There is a form in which all of these are normal and the joints are damaged just the same. If the results come back clean but the joints have been swollen and stiff for months, that is a reason to look further, not a reason to relax.
Scans behave similarly. An X-ray in the first months is often normal: it shows erosions once they exist. They are picked up earlier by joint ultrasound and MRI, which see the inflamed lining and the fluid inside before the bone has suffered.
What the treatment involves
There is still no cure, but the disease can be stopped, and that is the point of modern treatment. The goal is stated plainly: switch the inflammation off completely or nearly so, and keep it that way.
- Disease-modifying drugs are the foundation. They are not painkillers: they damp down the immune process itself, so the effect appears after weeks or months. Giving up because "it has done nothing in a fortnight" is the commonest mistake. Methotrexate is usually the starting point.
- Biological medicines block particular steps of the inflammation selectively. They are used when the drugs above have not been enough; they are given by injection or drip, usually alongside a disease-modifying drug.
- Janus kinase inhibitors are tablets acting on the same process from inside the cell. They are an option when the earlier groups have not suited.
- Steroids settle inflammation quickly and are therefore used at the start and during flares, while the underlying drug has yet to take effect. They are prescribed in short courses: long-term use accumulates costs such as thinning bone, weight gain and rising blood sugar.
- Anti-inflammatories and painkillers make you feel better but do not affect the damage to the joint. Non-steroidal anti-inflammatory drugs irritate the stomach when taken for long periods, so a medicine that reduces acid is usually added.
Alongside medicines, exercise therapy and work with a physiotherapist help: movement preserves the range in a joint and the strength of the muscles around it, while rest turns into stiffness fast. Surgery is now needed by few people — those whose joint is already destroyed or whose tendon has ruptured.
Living on long-term treatment
All of these drugs damp the immune system to some degree, and several practical points follow from that.
The most important one: on this treatment an infection can run silently. The high temperature and the obvious picture you are used to may not appear, while the infection carries on. So the rule is simple: any fever, shivering, cough, sore throat, a wound that turns septic, stinging when passing urine — all of these are a reason to contact a doctor the same day, not to lie down and see how it goes. The same applies to contact with chickenpox or measles if you have not had them.
Beyond that:
- before a biological medicine is started, you are checked for past tuberculosis and viral hepatitis, since a damped immune system can wake them up;
- blood is taken regularly during treatment to watch the blood cells and the liver; this is not a formality but the way a problem is caught before it causes symptoms;
- flu and pneumococcal vaccines are usually recommended, while live vaccines are not given on these drugs — timing and choice are agreed with the rheumatologist in advance;
- alcohol sits badly with methotrexate, because both load the liver;
- check any over-the-counter remedy or supplement first: some interact with the treatment.
Family planning is discussed before conception, not after. Some drugs, methotrexate among them, are incompatible with pregnancy and have to be stopped in good time — and that applies to men as well. Pregnancy with rheumatoid arthritis is perfectly possible: there are medicines that are allowed during it, and the rheumatologist switches the treatment over well beforehand.
When waiting is not an option
Contact a doctor the same day, or call an ambulance (in Europe, the single number 112), if you develop:
- a single joint that has suddenly become hot, markedly swollen and very painful, with a temperature — this is how infection inside a joint presents, and it is more likely on a damped immune system; waiting here costs the joint days;
- fever, shivering or an obvious infection while on disease-modifying or biological treatment;
- breathlessness that keeps increasing, chest pain on breathing, coughing up blood;
- a red painful eye, discomfort in bright light, sudden loss of vision;
- weakness or numbness in the arms and legs, unsteady walking, an electric-shock sensation in the neck when the head is bent forward;
- a rash with ulcers, or fingertips turning black;
- sudden inability to bend or straighten a finger — this is how a ruptured tendon shows itself, and repair has a time limit.
Online consultation
Three things are handled well remotely. The first is working out whether your joint complaints look inflammatory and, if they do, which tests to arrange and whom to see so that you do not lose weeks going round in circles. The second is going through results you already have: what rheumatoid factor, anti-CCP and C-reactive protein mean in your case, and what to do if they are normal while the joints are still swollen. The third is the day-to-day questions of being on treatment: a side effect, a missed dose, a vaccination or an operation coming up, planning a pregnancy. The signs in the list above are not assessed online — with those, be seen in person straight away or call an ambulance.
This material is for information only and does not replace medical advice.
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