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Rheumatoid arthritis

The exact cause of rheumatoid arthritis is unknown. We know how the condition attacks the joints, but it is not yet known what triggers the initial attack.

The exact cause of rheumatoid arthritis is unknown. We know how the condition attacks the joints, but it is not yet known what triggers the initial attack.

Some theories suggest that an infection or virus may trigger rheumatoid arthritis, but none of these theories has been proven.

Autoimmune condition

Rheumatoid arthritis is an autoimmune condition. This type of condition causes the body’s immune system to attack itself. Normally, your immune system makes antibodies that attack bacteria and viruses, helping protect your body against infection. If you have rheumatoid arthritis, your immune system sends antibodies to the lining of your joints, where instead of attacking harmful bacteria, they attack the tissue surrounding the joint.

Synovium

The synovium is a membrane (thin layer of cells) that covers each of your joints. When antibodies attack the synovium, they leave it sore and inflamed. This inflammation causes chemicals to be released, causing the synovium to thicken. These chemicals can also damage bones, cartilage (the stretchy connective tissue between bones), tendons (tissue that connects bone to muscle) and ligaments (tissue that connects bone and cartilage). The chemicals gradually cause the joint to lose its shape and alignment and, eventually, can destroy the joint completely.

Genetic susceptibility

There is some evidence that rheumatoid arthritis can run in families. Your genes may be one factor in the cause of the condition. However, having a family member with rheumatoid arthritis does not necessarily mean you will inherit the condition. Even an identical twin of someone with rheumatoid arthritis only has a one in five chance of developing it, so genes do not explain much of the risk.

Hormones

Rheumatoid arthritis is three times more common in women than in men. This may be due to the effects of oestrogen (a female hormone). Research has suggested that oestrogen may be involved in the development and progression of the condition. However, this has not been conclusively proven.

Lifestyle factors

Although not a direct cause of rheumatoid arthritis, there is some evidence to show smokers are more likely to develop the condition. People who regularly drink more than the recommended maximum daily limit of alcohol are also at higher risk.

Read about quitting smoking and information on drinking and alcohol.

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National Rheumatoid Arthritis Society: Why me?

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Rheumatoid arthritis

The aim of rheumatoid arthritis treatment is to reduce inflammation in the joints, relieve pain, prevent or slow joint damage and reduce disability.

Medication

Many different medicines are used to treat rheumatoid arthritis. Some aim to relieve symptoms and others help slow the progression of the condition. Everyone with rheumatoid arthritis experiences it differently, so it may take time to find the best combination of medicines for your needs. Some of the different medicines that you may be prescribed are outlined below.

Painkillers

Painkillers reduce pain rather than inflammation and are used to control the symptoms of rheumatoid arthritis. The most commonly prescribed painkiller is paracetamol, Codeine is another painkiller that is sometimes prescribed as a combined medicine with paracetamol (known as co-codamol).

Non-steroidal anti-inflammatory drugs (NSAIDs)

Your GP may prescribe a non-steroidal anti-inflammatory drug (NSAID) to relieve pain and swelling in your joints. There are two types of NSAIDs and they work in slightly different ways. These are traditional NSAIDs – such as ibuprofennaproxen or diclofenac and COX-2 inhibitors (often called coxibs) – such as celecoxib or etoricoxib. NSAIDs help relieve pain and stiffness while also reducing inflammation. However, they will not slow down the progression of rheumatoid arthritis.

Your doctor will discuss with you what type of NSAID you should take and the benefits and risks associated with each of them. NSAID tablets may not be suitable if you have asthma, a peptic ulcerangina or if you have had a heart attack or stroke. If you are taking low-dose aspirin, discuss with your GP whether you should use an NSAID.

Taking an NSAID tablet can increase the risk of serious stomach problems, such as bleeding internally. Taking an NSAID can break down the lining that protects against damage from acids in the stomach. While the risk is serious, it is not common. According to research, if between 2,000 and 3,000 people take NSAIDs, one person is likely to have a stomach bleed. The COX-2 agents have a lower risk of serious stomach problems, but carry a risk of heart attacks and strokes.

If you are prescribed an NSAID tablet, you will almost certainly have to take another medicine, such as a proton pump inhibitor (PPI), as well. Taking a PPI reduces the amount of acid in your stomach, which greatly reduces the risk of damage to your stomach lining caused by the NSAID.

Corticosteroids

Corticosteroids help reduce pain, stiffness and swelling. They can be used as a tablet (for example, prednisolone) or an injection into the muscle (to help lots of joints). They are usually used when NSAIDs fail to provide relief. If you have a single inflamed or swollen joint, your doctor may inject the steroid into the joint. Relief is rapid and the effect can last from a few weeks to several months, depending on the severity of your condition.

Corticosteroids are usually only used on a short-term basis, as long-term use of corticosteroids can have serious side effects. These can include weight gain, osteoporosis (thinning of the bones), easy bruising, muscle weakness and thinning of the skin. They can also make diabetes and glaucoma (an eye disease) worse.

Disease-modifying anti-rheumatic drugs (DMARDs)

DMARDs help to ease symptoms and slow down the progression of rheumatoid arthritis. When antibodies attack the tissue in the joints, they produce chemicals that can cause further damage to the bones, tendons, ligaments and cartilage. DMARDs work by blocking the effects of these chemicals. The earlier you start taking a DMARD, the more effective it will be.

There are many different conventional DMARDs including methotrexate, leflunomidehydroxychloroquine and sulfasalazine.

Methotrexate is often the first drug given for rheumatoid arthritis. You may take it in combination with another DMARD. The most common side effects of methotrexate are sickness, diarrhoea, mouth ulcers, hair loss or hair thinning, and rashes on the skin. Sometimes, methotrexate can have an effect on your blood count and your liver, and you will have regular blood tests to monitor this. Less commonly, it can affect the lungs, so you will usually have a chest X-ray and possibly breathing tests when you start taking methotrexate, to provide a comparison if you develop shortness of breath or a persistent dry cough while taking it. However, most people tolerate methotrexate well and around half of those who start it will still be taking it five years later.

Methotrexate may also be combined with biological treatments (see below).

It can take four to six months to notice a DMARD working. Therefore, it is important to keep taking the medication, even if you do not notice it working at first. You may have to try two or three types of DMARD before you find the one that is most suitable for you. Once you and your doctor work out the most suitable DMARD, you will usually have to take the medicine in the long term.

Biological treatments 

Biological treatments are a newer form of treatment for rheumatoid arthritis. They include TNF-alpha inhibitors (etanercept, infliximabadalimumab and certolizumab), rituximab and tocilizumab.

They are usually taken in combination with methotrexate or sometimes with another DMARD. They work by stopping particular chemicals in the blood from activating your immune system to attack the lining of your joints.

Biological treatments are not suitable for use by everyone. 

TNF-alpha inhibitors are usually only available on the NHS if you have already tried methotrexate and another DMARD at standard doses and your rheumatoid arthritis is still quite active.

Rituximab and tocilizumab are recommended by NICE, in combination with methotrexate, for severe rheumatoid arthritis only if you've tried DMARDs and one of the TNF inhibitors and still have quite active rheumatoid arthritis.

Side effects from biological treatments are usually mild and include skin reactions at the site of injection, infections, nausea, fever and headaches. Some people may be at risk of getting more serious problems, including people who have had tuberculosis (TB)septicaemia or hepatitis B in the past. There is a slight risk that biological treatments can reactivate these conditions and, in rare cases, trigger new autoimmune problems.

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Surgery

Sometimes, despite medication, damage to your joints may occur. You may need surgery to help restore your ability to use your joint. Surgery may also reduce pain and correct deformities.

Finger and hand surgery to correct joint problems

There are different types of surgery to correct joint problems in the hand. Examples include: 

  • carpal tunnel release (cutting a ligament in the wrist to relieve pressure on a nerve)
  • release of tendons in the fingers to treat abnormal bending
  • removal of inflamed tissue that lines the finger joints

If surgery is needed on the wrist and fingers, the wrist is usually done first.

Arthroscopy

Arthroscopy removes inflamed joint tissue. A thin tube with a light source is inserted into the joint through a small cut in the skin so that the surgeon can see inside. Instruments are inserted through other small cuts in the skin to remove the damaged tissue. You usually do not have to stay overnight in hospital for this kind of surgery. The joint will need to be rested at home for several days.

Arthroplasty

Arthroplasty replaces part or all of a hip or knee joint, and may involve a long hospital stay. Depending on which joints are reshaped, it may take several weeks or months of rehabilitation to recover fully.

Joint replacement

Replacement of hip, knee or shoulder joints is a major operation that involves four to 10 days in hospital followed by months of rehabilitation. The new joints have a limited lifespan of 10-20 years. They are not perfect and some function may not be restored after the damaged joint is replaced by a new one.

Read more information about knee replacement and hip replacement.

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Supportive treatments

Your doctor may also refer you to other services that might be able to help you with your rheumatoid arthritis symptoms.

Physiotherapy

A physiotherapist may help you improve your fitness and muscle strength, and make your joints more flexible. They may also be able to help with pain relief using heat or ice packs, or trancutaneous electrical nerve stimulation (TENS). A TENS machine applies a small pulse of electricity to the affected joint, which numbs the nerve endings and can help ease the pain of rheumatoid arthritis.

Occupational therapy

If rheumatoid arthritis causes you problems with everyday tasks, or is making it difficult for you to move around, occupational therapy may help. An occupational therapist can provide training and advice that will help you to protect your joints, both while you are at home and at work. Some type of support for your joints, such as a splint, may also be recommended, or devices that can help open jars or turn on taps.

Read more information about occupational therapy.

Podiatry

If you have problems with your feet, a podiatrist may be able to help. You may also be offered some type of support for your joints or shoe insoles that can ease pain.

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Complementary and alternative therapies

Many people with rheumatoid arthritis try complementary therapies. In most cases, there is little or no evidence they are effective in the treatment of symptoms of rheumatoid arthritis. They include massage, acupuncture, osteopathy, chiropractic, hydrotherapy, electrotherapy and nutritional supplements including glucosamine sulphate, chondroitin and fish oil.

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Rheumatoid arthritis

Rheumatoid arthritis can be life-changing. You may need long-term treatment to control your symptoms and reduce joint damage.

Self management

Taking control of rheumatoid arthritis will help you cope with its impact on your lifestyle. Arthritis Care offers self management training courses to teach techniques for living positively with arthritis. Techniques include relaxation and breathing exercises to help pain control, goal-setting exercises and positive thinking to help give you some control over your condition.

A self management programme specifically for people with rheumatoid arthritis has been developed by the National Rheumatoid Arthritis Society (NRAS). The course helps people learn more about their condition and provides practical tips on how to manage everyday life.

    Talk to others in the same situation

    Many people find it helpful to talk to others in a similar position, and you may find support from an individual or group of people with rheumatoid arthritis. Patient organisations have local support groups where you can meet others diagnosed with the same condition.

    Call the National Rheumatoid Arthritis Society (NRAS) helpline free on 0800 298 7650 (Monday-Friday, 9.30am-4.30pm) to speak to a trained rheumatoid arthritis adviser. NRAS also has a team of medical advisers.

    You can also call Arthritis Care's free, confidential helpline on 0808 800 4050 (Monday-Friday, 10am-4pm). There is also a 24-hour helpline on 0845 600 6868 if you want to know more about Arthritis Care services and receive an information pack.

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    Tackling pain

    Pain is one of the most common symptoms of rheumatoid arthritis, but it can be managed in a number of ways, including:

    • drug treatment
    • heat treatment, such as warm baths or packs
    • cold treatment, such as cold packs or a TENS (transcutaneous electrical nerve stimulation) electrical device, which is thought to reduce pain by stimulating the nerves
    • relaxation techniques, for example simple methods of relaxation, massage or hypnosis

    To manage your symptoms, it is possible to use more than one of these approaches at the same time (for example, using a drug treatment, heat pack and relaxation techniques). The experience of pain is unique to everybody, so what works for you may differ from what works for someone else.

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    Understanding your feelings

    It can be hard to deal with the unpredictable nature of rheumatoid arthritis. Some days, the pain and stiffness will be much worse than others, and there is no way of knowing when a flare-up will occur.

    The difficult nature of rheumatoid arthritis can mean that some people develop depression or feelings of stress and anxiety. Sometimes, these feelings can be related to poorly controlled pain or fatigue. Living with any long-term condition makes you more likely to have a range of emotions such as frustration, fear, pain, anger and resentment.

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    Starting and raising a family

    If you are taking medicines for rheumatoid arthritis, let your healthcare team know if you want to start a family. Some drug treatments, such as methotrexate, leflunomide and biological treatments, should not be taken by men or women while they are trying for a baby. The doctors and nurses will work with you to ensure your rheumatoid arthritis is controlled while you are trying to get pregnant.

    Talk to your healthcare team if you want to get pregnant or are worried about becoming pregnant while on rheumatoid arthritis drugs.

    Babies and young children are physically and mentally demanding for any parent, but particularly if you have rheumatoid arthritis. If you are struggling to cope, talk to other people in the same situation as you. You may also be able to get additional support from your health visitor or occupational therapist to help you manage your young family.

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    Sex and relationships

    Pain, discomfort and changes in the way you look and feel can affect your sex life. Your self-esteem or thoughts about how you look may affect your confidence. Although many people find it difficult to talk about such private issues, there are resources that might help you. Talking to your partner or GP about the impact of rheumatoid arthritis on your sexuality and sexual relationships may help.

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    Money and benefits

    If you have to stop work or work part time because of your rheumatoid arthritis, you may find it hard to cope financially. You may be entitled to one or more of the following types of financial support:

    • If you have a job, but cannot work because of your illness, you are entitled to Statutory Sick Pay from your employer.  
    • If you do not have a job and cannot work because of your illness, you may be entitled to Employment and Support Allowance.  
    • If you are aged 64 or under and need help with personal care or have walking difficulties, you may be eligible for a Personal Independence Payment
    • If you are aged 65 or over, you may be able to get Attendance Allowance
    • If you are caring for someone with rheumatoid arthritis, you may be entitled to Carer’s Allowance.
    • You may be eligible for other benefits if you have children living at home or if you have a low household income.

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    Rheumatoid arthritis

    Having rheumatoid arthritis can put you at a higher risk of developing other conditions such as carpal tunnel syndrome and tendon inflammation.

    Having rheumatoid arthritis can put you at a higher risk of developing other conditions.

    These conditions are described below.

    Carpal tunnel syndrome

    Carpal tunnel syndrome is when there is too much pressure on the nerve in the wrist. It can cause aching, numbness and tingling in your thumb, fingers and part of the hand. This is a common condition in people with rheumatoid arthritis.

    Inflammation

    As rheumatoid arthritis is an inflammatory condition, it can sometimes cause inflammation to develop in other parts of your body. These areas are described below. 

    • Lungs – inflammation of the lung lining is known as pleurisy, which causes chest pain, particularly when you breathe deeply.
    • Heart – inflammation of the tissue around the heart is known as pericarditis, which causes mild to severe chest pain.
    • Eyes – inflammation of the eye glands is known as Sjogren's syndrome which can cause dry eyes and mouth. When the white part of the eye is affected (the sclerae), it is known as scleritis.
    • Blood vessels – inflammation of the blood vessels is known as vasculitis. Vasculitis is a rare condition that causes inflammation of the blood vessels. It can lead to the thickening, weakening, narrowing and scarring of blood vessel walls. In serious cases, it can affect blood flow to your body's organs and tissues.

    Tendon rupture

    Tendons are pieces of flexible tissue that attach muscle to bone. Rheumatoid arthritis can cause your tendons to become inflamed, which in severe cases can cause them to rupture. This most commonly affects the tendons on the backs of the fingers.

    Cervical myelopathy

    If you have had rheumatoid arthritis for some time, you are at increased risk of developing cervical myelopathy and you may need special assessment of your neck before any operation where you are put to sleep.

    This condition is caused by dislocation of joints at the top of the spine, which put pressure on the spinal cord. Although relatively uncommon, it is a serious condition that can greatly affect your mobility. 

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    Rheumatoid arthritis

    Read Jonathan Gledhill's account of living with rheumatoid arthritis.

    Jonathan Gledhill was diagnosed with rheumatoid arthritis in 2006, aged 27. He explains how arthritis affects his life.

    “I have sero-negative rheumatoid arthritis, which doesn’t show up in blood tests for arthritis. I have it in several joints but mainly in both knees, my right wrist, hands, feet, elbow and it may be affecting my spine a little now. I have pain and swelling in the joints, and muscle stiffness, especially in the morning.

    “It started in my right knee when I damaged the cartilage in a car accident in 2001. The knee was sore, swollen and stiff, and never recovered. During the next four years I developed pain in my wrists, thumb, feet and ankles, but blood tests for arthritis were negative. My GP prescribed anti-inflammatory painkillers for me.

    “I was eventually diagnosed via X-rays in 2006. There's a theory that a traumatic accident can start arthritis in the damaged area of the body, but the doctors couldn’t say for sure whether the accident started the arthritis or whether it was a coincidence. My grandma has arthritis, so I might have inherited it from her.

    “I started taking an anti-rheumatic drug to slow the progression of the arthritis. For about 18 months I didn’t have to take so many painkillers, but now the drug has become less effective. I go to the rheumatology clinic every six months to check my progress, and I have monthly blood tests to make sure the drug isn’t affecting my liver.

    “I’m lucky that I’m still quite mobile. I live with my girlfriend but can do everything for myself. I can walk unaided, though I’ve developed a limp. After 15 or 20 minutes of walking I get quite sore. I had an embarrassing incident in the cinema recently. I nearly fell over when I tried to stand up. My knee had locked and I couldn’t straighten it. My friends had to help me out and take me to A&E, but as soon as we arrived my knee relaxed and I could use it again.

    “I can still work in my job in IT, and my boss is understanding. He lets me work later hours so that I don’t have to rush in the morning when my pain and stiffness is at its worst. After a little while it starts to loosen up a bit.

    "Something I find frustrating is that people can look at you and not realise there's anything wrong. I'm not unwell enough to need a disabled badge, but the walk up the hill from the car park can make me sore. People often assume arthritis happens only to older people.

    “The pain in my feet feels as if I'm wearing shoes that are too tight and won't let me bend my toes. And because my hands are affected I sometimes have trouble opening cans and turning taps, but I’ve bought a tin opener with a ratchet handle instead of a twisting one, and that’s a lot easier to use. I’ve had to give up rugby and hillwalking but I can still drive and cycle. I took up exercise biking, which helps, and I lift light weights to strengthen my muscles. 

    “The main thing is to get plenty of rest. If I get enough sleep and don’t overdo things, it’s reasonably manageable.

    "Sometimes pain in my elbow wakes me up in the night, but generally I sleep well. Overdoing an activity, even DIY, can make me suffer the next day, so I make sure I have lots of breaks. Warm water helps too, having a nice hot bath or going swimming. I went on holiday to Florida and the warm weather there made me feel a lot better.

    "My condition will probably progress slowly to the stage where I'll need surgery, but hopefully that won't be for a long time.

    “When I was diagnosed, I felt relieved to be able to identify my symptoms, but also quite angry. There were things I still wanted to do, such as taking up running. I had to accept I wouldn’t be able to do them. It took me about a year to come to terms with my diagnosis and be more positive.

    "My family, friends and people with arthritis on the Arthritis Care forum helped me realise it’s not the worst thing you can have. Although arthritis has an impact on your life it won’t stop you doing a lot of the things you like to do.”

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