Rheumatoid Arthritis

Rheumatoid arthritis, often called RA, is a long-term condition in which the immune system causes inflammation in the joints. It commonly affects the hands, wrists and feet, although other joints can be involved. RA can cause pain, swelling, stiffness and tiredness. Without effective treatment, ongoing inflammation may damage joints.

RA affects each person differently. Your symptoms and treatment plan may therefore differ from someone else’s.

What happens in rheumatoid arthritis?

A joint is the place where two bones meet. Many joints have a thin lining called the synovium. In RA, the immune system mistakenly drives inflammation in this lining. The joint may become swollen, tender, warm and difficult to move.

If inflammation continues over time, it can affect cartilage, bone and nearby tendons. Treatment aims to settle the inflammation before lasting damage develops.

RA is an autoimmune condition. It is not an infection, and you cannot pass it to another person. Its exact cause is unknown. Genes and environmental factors both play a part; smoking is one recognised risk factor. Having RA is not your fault.

RA differs from osteoarthritis, although a person can have both. Osteoarthritis and RA can cause joint pain, but they develop through different processes and may need different treatment.

What symptoms can RA cause?

The most common symptoms are:

• Pain, tenderness or swelling in one or more joints
• Stiffness after waking or after sitting still, often improving as you begin to move
• Difficulty making a fist, gripping objects, walking or doing everyday tasks
• Tiredness that is out of proportion to your activity

RA often affects the small joints of the fingers, wrists and feet. Similar joints on both sides of the body may be affected, but the pattern is not identical in everyone. Symptoms may develop gradually, and some people have periods when they are better or worse.

You may also notice poor sleep, reduced appetite, low mood or a general feeling of being unwell. These symptoms deserve attention, but they can have causes other than RA.

Persistent joint swelling should be assessed. Do not wait for severe pain or visible joint changes before seeking advice.

Can RA affect more than the joints?

Yes. RA is a condition involving the immune system throughout the body. Some people develop inflammation or other problems involving the eyes, lungs, skin or other tissues. People with RA also need attention to their heart health. These problems do not happen to everyone, and many can be managed when recognised promptly.

Tell your clinician about symptoms such as a persistent cough, new breathlessness, a painful red eye or an unexplained change in your health. Do not assume every new symptom is due to RA; infections and other conditions can cause similar problems.

How is RA diagnosed?

There is no single test that can diagnose or rule out RA on its own. Your clinician puts together several pieces of information:

• Your symptoms: Which joints hurt or swell, how long symptoms have lasted, and how they change during the day.
• A joint examination: Looking for swelling, tenderness and changes in movement.
• Blood tests: These may include rheumatoid factor (RF), anti-CCP antibodies, and tests for inflammation such as ESR or CRP.
• Imaging: X-rays, ultrasound or occasionally MRI may help assess inflammation or joint damage.

A positive RF or anti-CCP result does not, by itself, mean you have RA. Equally, some people with RA have negative antibody tests. Inflammatory markers can also be normal. Your clinician will consider other possible causes of joint symptoms before making a diagnosis.

If RA is suspected, early assessment by a rheumatologist is valuable, particularly when joints are persistently swollen.

Why is early treatment important?

RA inflammation can damage joints even when symptoms seem manageable. Effective treatment can relieve pain and swelling, preserve movement and reduce the chance of future damage. The goal is usually remission, meaning little or no active inflammation. When remission is not possible, the aim is to keep disease activity as low as possible.

Your rheumatologist will assess your joints and symptoms over time and adjust treatment if inflammation remains active. This approach is sometimes called treat to target. Feeling better is important, but follow-up also helps check whether inflammation is adequately controlled.

There is currently no guaranteed cure for RA. Many people, however, achieve good control and continue to work, exercise and enjoy their usual lives.

What medicines treat RA?

Disease-modifying antirheumatic drugs

Disease-modifying antirheumatic drugs, or DMARDs, are the main treatment for RA. They reduce the inflammatory process and help protect joints. They usually take several weeks to work, so an immediate lack of improvement does not necessarily mean a medicine has failed.

Commonly used conventional DMARDs include methotrexate, hydroxychloroquine, sulfasalazine and leflunomide. Your rheumatologist may prescribe one medicine or a combination, depending on your disease and other health considerations.

Many DMARDs require blood tests or other checks. These appointments are part of safe treatment, even when you feel well. Tell your clinician about all medicines and supplements you take, including those bought without a prescription.

Methotrexate

Methotrexate is a commonly used RA medicine. For RA, it is taken once a week, not every day. It may be given as tablets or an injection. Your clinician will usually prescribe folic acid to reduce certain side effects and will arrange regular blood tests.

Check your prescribed methotrexate day and folic acid schedule carefully. If you are unsure whether you have taken a dose, contact your healthcare team before taking another. Tell your team promptly about troublesome mouth ulcers, unusual bruising, significant nausea, a persistent cough, fever or other concerning symptoms.

Methotrexate is unsafe in pregnancy. Discuss pregnancy plans and contraception with your rheumatologist well before trying to conceive. Do not stop or change your RA treatment without arranging an alternative plan.

Biologic and targeted medicines

If conventional DMARDs do not control RA sufficiently, your rheumatologist may discuss a biologic DMARD or a targeted synthetic DMARD. Biologic medicines are commonly given by injection or infusion. Targeted medicines such as JAK inhibitors are tablets.

These treatments act on specific parts of the inflammatory process. The choice depends on your RA, other medical conditions, infection history and personal circumstances. Before certain treatments, you may need checks for infections such as tuberculosis and hepatitis. Your team will also explain the benefits, possible risks and monitoring required for the medicine chosen.

Medicines for short-term symptom relief

Pain-relieving medicines and non-steroidal anti-inflammatory drugs (NSAIDs) may ease symptoms, but they do not replace a DMARD. NSAIDs are unsuitable for some people, including those with certain kidney, stomach or heart problems. Ask your clinician before using them regularly, even if they are available over the counter.

Steroids can reduce inflammation quickly. They may sometimes be used for a short period or injected into a particularly troublesome joint. Repeated or prolonged steroid use can cause important side effects, so your rheumatologist will consider how to minimise it. Do not change a prescribed steroid dose abruptly without medical advice.

Stronger pain medicines such as opioids do not treat RA inflammation or prevent joint damage.

What if the first treatment does not work?

Finding the right treatment can take time. A medicine may need several weeks to show its effect, and your clinician may adjust its dose, add another medicine or switch treatments. Side effects, pregnancy plans and other health conditions can also affect the choice.

Tell your rheumatology team if swelling and stiffness persist, your daily activities remain difficult, or a medicine causes problems. Do not stop a DMARD simply because you feel well: your good control may be the result of the treatment. Any change should be planned with your clinician.

What can I do day to day?

Keep moving

Regular movement helps maintain joint mobility, muscle strength and general fitness. Walking, cycling, swimming and suitable strength exercises are options. Start at a level you can manage and build up gradually. On difficult days, you may need to reduce the intensity while continuing gentle movement.

A physiotherapist can help you adapt exercise when pain, weakness or a particular joint makes activity difficult. An occupational therapist can suggest ways to make work and daily tasks easier, and may recommend a splint or assistive device when appropriate.

Protect your general health

RA care includes more than joint care. Avoid smoking, eat a varied and nutritious diet, maintain a weight that supports your health, and discuss blood pressure, cholesterol and other cardiovascular risks with your clinician.

There is no single diet that cures RA. Food choices can support overall health, but they do not replace medicines that control inflammation. Check before taking supplements or herbal products; “natural” products can still have side effects or interact with medicines.

Plan rest without giving up activity

Fatigue is a real part of RA for many people. It can help to spread demanding tasks across the day, take planned breaks and protect your sleep. If tiredness remains severe despite good RA control, tell your clinician. Poor sleep, anaemia, mood difficulties and other health problems may also contribute.

Look after your emotional health

Living with a long-term condition can be frustrating or worrying. Support from family, friends, a patient group or a mental health professional can help. If low mood or anxiety is affecting most days, bring it up at an appointment. It is part of your health and deserves care.

Use heat or cold for comfort

A warm pack may ease stiffness; a cold pack may feel better on a swollen or painful joint. Wrap either pack in a cloth to protect your skin. Avoid excessive heat or cold, and never sleep with a heating pad on.

Why are follow-up visits and vaccines important?

At follow-up visits, your team can assess joint swelling, review symptoms, check for medicine side effects and decide whether treatment needs to change. Keep your scheduled blood tests and bring an up-to-date medicine list to appointments.

Ask which vaccinations are appropriate for you. Some RA medicines affect how your body responds to infection or vaccines, and the timing of a vaccine may matter. Do not pause an RA medicine around a vaccine unless your rheumatology team tells you to.

What if I want to have a baby?

Many people with RA have healthy pregnancies. The safest approach is to plan ahead with your rheumatologist and obstetric team. Good RA control before pregnancy matters, and some medicines need to be changed before conception. Other treatments may be suitable during pregnancy or breastfeeding.

Do not assume RA will improve during pregnancy: its course varies. Symptoms can also flare after delivery. Ask for a plan that covers pregnancy, the period after birth and breastfeeding. If you think you may be pregnant while taking a medicine that could be harmful in pregnancy, contact your prescribing team promptly.

How do I recognise a flare?

A flare is a period when RA becomes more active. You may notice new or increased joint swelling, pain, morning stiffness or fatigue. Keep taking your prescribed treatment unless your clinician advises otherwise. Contact your rheumatology team if symptoms persist, repeatedly return or interfere with normal activities.

A suddenly very painful, hot, swollen joint—especially with fever—needs urgent medical assessment. It may be caused by an infection rather than an RA flare.

When should I seek medical help?

Contact your rheumatology team promptly if:

• Joint swelling or stiffness is increasing or your treatment is not helping as expected.
• You develop a fever or symptoms of infection while taking an immune-modifying medicine.
• You have troublesome medicine side effects, mouth ulcers, unusual bruising or bleeding.
• You develop a persistent cough, new breathlessness or a painful red eye.
• You are pregnant, may be pregnant, or want to plan a pregnancy.

Seek urgent medical assessment for severe breathlessness, chest pain, a suddenly hot and very painful joint, marked weakness, or a serious infection. Tell the treating team which RA medicines you take.

Questions worth asking at your next appointment

• How active is my RA at present?
• What is the goal of my treatment, and how will we know whether I am reaching it?
• When should I expect my medicine to help?
• What tests do I need, and when?
• Which side effects or infection symptoms should prompt me to call?
• What should I do if I miss a dose?
• Are my vaccinations up to date?
• Do I need to change my treatment before pregnancy?
• What exercise or rehabilitation would help me most?

This information is general. Discuss your diagnosis, medicines and monitoring schedule with your own healthcare team.