Tracking your RA pain can help you better understand your condition and talk about it with your doctor. Join ArthritisPower, a patient-centered research registry, to learn more about your RA. Sign up here.
If you live with rheumatoid arthritis (RA), there’s a good chance you’ll need a change in your treatment plan at one point or another. Only about one-third of patients will achieve disease control after taking methotrexate (the most common first-line treatment for RA), while the remaining two-thirds of people will need additional or other types of medication, says Elizabeth Schulman, MD, a rheumatologist at Hospital for Special Surgery (HSS) in New York City.
And even if you find an effective RA therapy to control your joint pain and inflammation, it may not continue to work forever. Just ask CreakyJoints and Global Healthy Living Foundation member Karen N., who says she’s been through three biologics and is “still searching.”
“Fortunately, we have many treatment options for rheumatoid arthritis,” says Dr. Schulman. “Unfortunately, we do not know which patient will respond to which medication, so it is often a thoughtful but ‘trial-and-error’ approach.”
Picking the right medication needs to account for a patient’s symptoms, underlying health, comorbid conditions, and possible side effects.
Adds Susan M. Goodman, MD, also a rheumatologist at HSS, “patients can have RA throughout their lifetime, so over a 50-year span of illness, there can be many therapy changes.”
Understanding the Cause of Your Pain
If you have rheumatoid arthritis and you’re reporting an uptick in pain or other symptoms, your rheumatologist will first need to rule out possible co-occurring conditions. Health issues such as osteoarthritis, fibromyalgia, carpal tunnel syndrome, tendinitis, bursitis, or others can commonly occur in people with rheumatoid arthritis.
Knowing whether your pain is due to an increase in RA-related inflammation versus a separate health concern will affect whether a medication change should be considered.
Read more about causes of RA pain aside from inflammation.
Your rheumatologist will likely use one of the following RA disease activity measures to assess your symptoms, pain level, swollen/tender joint count, mental state, and ability performing daily tasks.
- Clinical Disease Activity Index (CDAI)
- Disease Activity Scale-28 (DAS28-ESR/CRP)
- Patient Activity Scale II (PAS-11)
- Routine Assessment of Patient Index Data 3 (RAPID3)
- Simple Disease Activity Index (SDAI)
Your doctor will likely also order blood tests to check for inflammation (such as C-reactive protein or sedimentation rate) or an increase in disease activity (Vectra). They may also recommend imaging tests to check for joint damage.
If it has been determined that you have moderate to high disease activity — and that inflammation is the root cause of your RA pain — your rheumatologist will then have to dig a little deeper:
- Are you having a flare — a period in which your RA symptoms temporarily worsen — due to stress, another illness, or for no reason at all?
- Did your medication stop working? If after several months on a medication, you are still experiencing pain, inefficacy may be the reason. Sometimes you can start a medicine and never respond to it (known as primary non-response), and other times your medication can become less effective after it had been working well for years (known as secondary non-response).
- Is your disease progressing? Are you having more frequent, longer periods of pain and swelling, or new pain in different joints?
Understanding Your Treatment Options
If patients have a flare-up of RA that was previously controlled, it’s important to promptly seek the advice of your rheumatologist to decide which treatment plan is right for you, says Dr. Schulman.
“When a patient has had sustained disease activity over weeks or more, that indicates that the current regimen is failing and a different medication should be considered,” says Dr. Goodman.”
The medication your doctor recommends — whether it’s a new therapy or a higher dose or in addition to something you’re already taking — is very individualized. “Every single patient is different,” says Dr. Schulman.
The treatment options to consider will depend on the progression of the disease, severity of flare, comorbidities, and a patient’s personal preferences.
However, there is one common factor: “Treatment choices are always a balance between risks and benefits,” notes Dr. Goodman.
Here’s a closer look at some treatment change options that you and your rheumatologist may discuss:
A short course of anti-inflammatories (prednisone or NSAIDs like ibuprofen or naproxen) to treat the inflammatory response.
An increase in dosage of your current medication. “Sometimes adjusting doses and optimizing the ongoing therapy can be sufficient,” says Dr. Goodman.
A change in the route of administration — for example, changing from pills to injections for better absorption, says Dr. Schulman.
Adding a medication to your current medication — for example, if you’re taking a conventional disease-modifying anti-rheumatic drug (DMARD) such as methotrexate, you may add an additional DMARD like sulfasalazine or hydroxychloroquine.
Stopping your current medication and switching to an alternative treatment, including:
- If you’re on a DMARD, your doctor might add a biologic drug like a TNF inhibitor that is used in people with more severe RA symptoms.
- If you’re already taking a biologic, you might be switched to another type of biologic that targets a different part of the inflammation process.
- If you’re already taking a biologic, you may be switched to a new class of drugs like Janus kinase (JAK) inhibitors, which are oral pills that act on the immune system in a different way.
How Medications Work to RA Treat Pain
Here’s a look at how different kinds of RA medications work to help manage your disease and minimize pain:
Nonsteroidal anti-inflammatory (NSAIDs) like ibuprofen (Motrin, Advil) and naproxen sodium (Aleve) can be used for breakthrough pain symptoms.
Glucocorticoids (steroids), also called corticosteroids or “steroids,” can be used short-term for quick pain relief from a flare. “However, if the flare is sustained over time, they are less likely to be effective and the patient becomes at risk for the many side effects of steroids,” says Dr. Goodman.
DMARDs, or disease-modifying antirheumatic drugs, can both block RA inflammation and help prevent the production of anti-drug antibodies. “They may take several months to build up in a patient’s system and take effect,” says Dr. Schulman. The most commonly used DMARD for RA is methotrexate, along with hydroxychloroquine (Plaquenil), leflunomide (Arava), and leflunomide (Arava).
TNFi biologics can reduce inflammation and pain by targeting tumor necrosis factor proteins (TNF) that sends signals to your body, leading to inflammation. TNFi biologics include adalimumab (Humira), certolizumab pegol (Cimzia), etanercept (Enbrel), golimumab (Simponi, Simponi Aria), and infliximab (Remicade).
Non-TNFi biologics, block different kinds of chemicals that cause inflammation and pain. For rheumatoid arthritis, these medications include abatacept (Orencia), anakinra (Kineret), rituximab (Rituxan), sarilumab (Kevzara),and tocilizumab (Actemra).
Janus kinase (JAK) inhibitors, which can be used with or without methotrexate, are known as small molecule medications (oral pills) that work by decreasing the immune system’s ability to make certain enzymes that can lead to RA pain. They can take up to three to six months to reach full effectiveness. Common JAK inhibitors include baricitinib (Olumiant), tofacitinib (Xeljanz), and upadacitinib (Rinvoq).
Talking to Your Doctor About a Medication Switch
If you’re in chronic pain, your rheumatologist wants to know. It’s not okay to just “feel fine” or “live with it” — for several good reasons.
“I don’t want my patients to be living in pain,” says Leah Alon (Nichols), MD, a rheumatologist in New York City. “Chronic pain is related to depression and acute pain is related to anxiety. Pain also impacts your relationships, your ability to care for your family, and your ability to find and maintain a job.”
If your medication isn’t working well enough and RA inflammation persists, it can cause permanent damage to the joints. “Once you get damage to the joint, there is no way back,” says Dr. Alon. “You can prevent further damage, but you can’t correct the damage that was already done.”
What’s more, since untreated RA can cause systemic — or all-over — inflammation, it can have a negative impact on many parts of your body, including skin, lungs, heart, nerves, and kidneys.
If you’re anxious about trying a new medication or are afraid you can’t afford it, don’t hesitate to let your rheumatologist know. “We want to understand all of your concerns surrounding your medication so we can help guide you and make recommendations,” says Dr. Schulman.
When it comes to considering a treatment change, “it’s always a shared decision we make together.”
Here are a few questions you can ask your rheumatologist if you’re considering a treatment change:
- Have we discussed all of my pain treatment options?
- How will this medication work to relieve my pain?
- Why do the benefits of taking this medication outweigh the risks for me?
- How soon should I expect the medication to start working?
- How should we monitor whether or not the medication is working?
- What short and long-term side effects might I expect?
- Is there anything I can do to help manage potential side effects?
- Are there any medication interactions (with any other drugs or supplements)?
- Is there a best time of the day or week to take the medication?
- Is there anything I need to avoid — eating, drinking, or doing — while on this medication?
- Are there any other tips to ensure I’m taking the medication safely?
- If I have a concern or question about this medication, who should I call?
The good news is that there are more medications than ever to treat RA and manage pain.
“The goal is to get patients back to doing what they love to do and to restore their quality of life and function,” says Dr. Schulman. This goal wasn’t always possible 10 to 20 years ago when there were limited treatment options.
- Rheumatoid Arthritis Pain and Flare-Ups: What to Know and Do
- 6 Causes of Rheumatoid Arthritis Pain Aside from Inflammation
- How to Discuss Your Rheumatoid Arthritis Pain During a Telehealth Visit
- Rheumatoid Arthritis Pain: 7 Things You Should Tell Your Rheumatologist
Track Your RA Pain with ArthritisPower
ArthritisPower is a patient-centered research registry for joint, bone, and inflammatory skin conditions like rheumatoid arthritis. You can select different health assessments that matter to you, and choose how often you want to take them. When you have an upcoming doctor appointment, you can discuss your latest assessments and feel more informed. Learn more and sign up here.
This article is part of A Patient’s Guide to Understanding Rheumatoid Arthritis Pain and was made possible by a grant from Sanofi Genzyme.
Emery P, et al. Efficacy of Monotherapy with Biologics and JAK Inhibitors for the Treatment of Rheumatoid Arthritis: A Systematic Review. Advances in Therapy. October 2018. doi: https://doi.org/10.1007/s12325-018-0757-2.
Interview with Elizabeth Schulman, MD, a rheumatologist at Hospital for Special Surgery (HSS) in New York City
Interview with Leah Alon (Nichols), MD, a rheumatologist in New York City
Interview with Susan M. Goodman, MD, a rheumatologist at Hospital for Special Surgery (HSS) in New York City
Seargant JC, et al. Prediction of primary non-response to methotrexate therapy using demographic, clinical and psychosocial variables: results from the UK Rheumatoid Arthritis Medication Study (RAMS). Arthritis Research & Therapy. July 2018. doi: https://doi.org/10.1186/s13075-018-1645-5.