Rheumatoid arthritis

Rheumatoid arthritis is a long-term condition that causes pain, swelling and stiffness in the joints.

The hands, feet and wrists are commonly affected, but it can also cause problems in other parts of the body.

There may be periods where your symptoms become worse, known as a flare-up or flare. A flare can be difficult to predict, but with treatment it is possible to decrease the number of flares and minimise or prevent long-term damage to the joints.

Read more about the symptoms of rheumatoid arthritis and living with rheumatoid arthritis.

When to seek medical advice

You should see your GP if you think you have symptoms of rheumatoid arthritis, so your GP can try to identify the underlying cause.

Diagnosing rheumatoid arthritis quickly is important because early treatment can help stop the condition getting worse and reduce the risk of further problems such as joint damage.

Read more about diagnosing rheumatoid arthritis.

What causes rheumatoid arthritis?

Rheumatoid arthritis is an autoimmune disease. This means that your immune system – which usually fights infection – attacks the cells that line your joints by mistake, making them swollen, stiff and painful.

Over time, this can damage the joint itself, the cartilage and nearby bone.

It's not clear what triggers this problem with the immune system, although you are at an increased risk if you are a woman, you have a family history of rheumatoid arthritis, or you smoke.

Read more about the causes of rheumatoid arthritis.

Who is affected

Rheumatoid arthritis affects around 400,000 people in the UK.

It can affect adults at any age, but most commonly starts between the ages of 40 and 50. About three times as many women as men are affected.

How rheumatoid arthritis is treated

There is no cure for rheumatoid arthritis, but early diagnosis and appropriate treatment enables many people with rheumatoid arthritis to have periods of months or even years between flares and to be able to lead full lives and continue regular employment.

The main treatment options include:

• medication that is taken in the long-term to relieve symptoms and slow the progress of the condition
• supportive treatments, such as physiotherapy and occupational therapy, to help keep you mobile and find ways around any problems you have with daily activities
• surgery to correct any joint problems that develop 

Read more about treating rheumatoid arthritis.

Possible complications

Having rheumatoid arthritis can lead to several other conditions that may cause additional symptoms and can sometimes be life-threatening.

Possible complications include carpal tunnel syndrome, inflammation of other areas of the body (such as the lungs, heart and eyes), and an increased risk of heart attacks and strokes.

Ensuring that rheumatoid arthritis is well controlled helps reduce your risk of complications such as these.

Read more about the complications of rheumatoid arthritis.

Rheumatoid arthritis mainly affects the joints, although it can cause problems in other parts of the body too.

The symptoms of rheumatoid arthritis often develop gradually over several weeks, but some cases can progress quickly over a number of days.

The symptoms vary from person to person. They can come and go, and may change over time. You may occasionally experience flares when your condition deteriorates and your symptoms become more severe.

Symptoms affecting the joints

Rheumatoid arthritis is primarily a condition that affects the joints. It can cause problems in any joint in the body, although the small joints in the hands and feet are often the first to be affected.

Rheumatoid arthritis typically affects the joints symmetrically (both sides of the body at the same time and to the same extent), but this is not always the case.

The main symptoms of rheumatoid arthritis affecting the joints are outlined below.

Pain

The joint pain associated with rheumatoid arthritis is usually a throbbing and aching pain. It is often worse in the mornings and after a period of inactivity.

Stiffness

Joints affected by rheumatoid arthritis can feel stiff. For example, if your hands are affected, you may not be able to fully bend your fingers or form a fist.

Like joint pain, the stiffness is often more severe in the morning or after a period of inactivity. Morning stiffness associated with another type of arthritis called osteoarthritis usually wears off within 30 minutes of getting up, but rheumatoid arthritis morning stiffness often lasts longer than this.

Swelling, warmth and redness

The lining of joints affected by rheumatoid arthritis become inflamed, which can cause the joints to swell, and become hot and tender to touch.

In some people, firm swellings called rheumatoid nodules can also develop under the skin around affected joints.

Additional symptoms

As well as problems affecting the joints, some people with rheumatoid arthritis experience a range of more general symptoms, such as:

• tiredness and a lack of energy
• a high temperature (fever)
• sweating
• a poor appetite
• weight loss

The inflammation associated with rheumatoid arthritis can also sometimes cause problems affecting other areas of the body, including dry eyes if the eyes are affected and chest pain if the heart or lungs are affected. Read more about the complications of rheumatoid arthritis.

When to seek medical advice

You should see your GP if you think you have symptoms of rheumatoid arthritis.

There are a number of conditions that can cause problems such as joint pain and stiffness, so it's important to get a proper diagnosis.

Diagnosing rheumatoid arthritis as soon as possible is particularly important because early treatment can help stop the condition getting worse and reduce the risk of further problems such as joint damage.

Read more about diagnosing rheumatoid arthritis.

Rheumatoid arthritis is an autoimmune condition, which means it is caused by the body’s immune system attacking itself. However, it is not yet known what triggers this.

Normally, your immune system makes antibodies that attack bacteria and viruses, helping fight infection. But if you have rheumatoid arthritis, your immune system mistakenly sends antibodies to the lining of your joints, where they attack the tissue surrounding the joint.

This causes the thin layer of cells (synovium) covering your joints to become sore and inflamed.

This inflammation in turn causes chemicals to be released that thicken the synovium and damage nearby:

• bones
• cartilage – the stretchy connective tissue between bones
• tendons – the tissue that connects bone to muscle
• ligaments – the tissue that connects bone and cartilage

If the condition is not treated, these chemicals gradually cause the joint to lose its shape and alignment and, eventually, can destroy the joint completely.

Various theories of why the immune system starts to attack the joints have been suggested, including that an infection or virus may trigger this, but none of these theories has been proven.

Possible risk factors

There are a number of things that may increase your risk of developing rheumatoid arthritis, including:

• your genes – there is some evidence that rheumatoid arthritis can run in families, although the risk of inheriting the condition is thought to be low as genes are only thought to play a small role in the condition
• hormones – rheumatoid arthritis is more common in women than men, which may be due to the effects of a hormone called oestrogen that is found at higher levels in women, although this has not been conclusively proven
• smoking – some evidence suggests that people who smoke are at an increased risk of developing rheumatoid arthritis

Want to know more?

• National Rheumatoid Arthritis Society (NRAS): Possible causes and risk factors

Rheumatoid arthritis can be difficult to diagnose because many conditions cause joint stiffness and inflammation and there is no definitive test for the condition.

You should see your GP if you have these symptoms so they can try to determine the cause.

Seeing your GP

Your GP will carry out a physical examination, checking your joints for any swelling and to assess how easily they move. Your GP will also ask you about your symptoms.

It is important to tell your GP about all your symptoms, not just ones you think are important, as this will help the doctor make the correct diagnosis.

If your GP thinks you have rheumatoid arthritis, they will refer you to a specialist (rheumatologist).

Your GP may arrange blood tests to help confirm the diagnosis after conducting a physical examination and consulting your medical history, or they may refer you at the same time as requesting tests.

Blood tests

No blood test can definitively prove or rule out a diagnosis of rheumatoid arthritis, but a number of tests can show possible indications of the condition. Some of the main tests used are outlined below.

Erythrocyte sedimentation rate (ESR)

In an ESR test, a sample of your red blood cells is placed into a test tube of liquid. The cells are then timed to see how fast they fall to the bottom of the tube (measured in millimetres per hour). If they are sinking faster than usual, you may have an inflammatory condition, such as rheumatoid arthritis.

C-reactive protein (CRP)

A CRP test can indicate if there is inflammation anywhere in the body by checking how much CRP is present in your blood. CRP is produced by the liver. If there is more CRP than usual, there is inflammation in your body.

Full blood count

The full blood count will measure your red cells to rule out anaemia. Anaemia is a condition where the blood is unable to carry enough oxygen, due to a lack of blood cells.

Anaemia is common in people with rheumatoid arthritis, although the problem can have many causes, so having anaemia does not prove that you have rheumatoid arthritis.

Rheumatoid factor and anti-CCP antibodies

Specific blood tests can help to diagnosis rheumatoid arthritis, but are not accurate in every person. About half of all people with rheumatoid arthritis have a positive rheumatoid factor present in their blood when the disease starts, but about one in every 20 people without rheumatoid arthritis also tests positive for this.

Another antibody test known as anti-CCP (anti-cyclic citrullinated peptide) is also available. People who test positive for anti-CCP are very likely to develop rheumatoid arthritis, but not everybody found to have rheumatoid arthritis has this antibody.

Those who test positive for both rheumatoid factor and anti-CCP may be more likely to have severe rheumatoid arthritis requiring higher levels of treatment.

Joint imaging

A number of different scans may also be carried out to check for joint inflammation and damage. These can help differentiate between different types of arthritis and can be used to monitor how your condition is progressing over time.

Scans that may be carried out to diagnose and monitor rheumatoid arthritis include:

• X-rays – where radiation is passed through your body to examine your bones and joints
• ultrasound scans – where high frequency sound waves are used to create an image of joints
• magnetic resonance imaging (MRI) scans – where strong magnetic fields and radio waves are used to produce detailed images of your joints

Stopping the condition progressing

There are a number of medications available that can be used to help stop rheumatoid arthritis getting worse and reduce your risk of further problems.

These are often divided into two types of medication: 'disease-modifying anti-rheumatic drugs (DMARDs)' and 'biological treatments'.

Disease-modifying anti-rheumatic drugs (DMARDs)

If you have been diagnosed with rheumatoid arthritis, you will normally be offered a combination of DMARD tablets as part of your initial treatment, as these medications are particularly effective in easing symptoms of the condition and slowing down its progression.

DMARDs work by blocking the effects of the chemicals released when the immune system attacks the joints, which could otherwise cause further damage to nearby bones, tendons, ligaments and cartilage.

There are many different DMARDs that can be used, including methotrexate, leflunomide, hydroxychloroquine and sulfasalazine.

Methotrexate is normally the first medicine given for rheumatoid arthritis, often alongside another DMARD and a short-course of corticosteroids to relieve any pain (see below). It may also be combined with the biological treatments mentioned below.

Common side effects of methotrexate include feeling sick, loss of appetite, a sore mouth, diarrhoea, headaches and hair loss. The medication can also sometimes have an effect on your blood count and your liver, so you will have regular blood tests to monitor this.

Less commonly, methotrexate 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.

It can take a few months to notice a DMARD working. 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 etanercept, infliximab, adalimumab, certolizumab, golimumab, rituximab, abatacept and tocilizumab.

They are usually taken in combination with methotrexate or another DMARD and are normally only used if these medications alone have not been effective.

Biological medications are given by injection and they work by stopping particular chemicals in the blood from activating your immune system to attack your joints.

Side effects from biological treatments are usually mild and include skin reactions at the site of the injections, infections, feeling sick, a high temperature (fever) and headaches.

Some people may also be at risk of getting more serious problems, including the reactivation of infections such as tuberculosis (TB) in people who have had them in the past.

Relieving pain

In addition to the medications used to control the progression of rheumatoid arthritis, you may also need to take medication specifically to relieve pain.

Some of the different medicines that may be used to relieve pain are outlined below.

Painkillers

In some cases, you may be advised to use painkillers such as paracetamol, or a combination of paracetamol and codeine (co-codamol) to relieve the pain associated with rheumatoid arthritis.

These medications don't help treat the underlying inflammation of your joints, but they can sometimes be helpful in relieving pain. For example, they may be recommended while you are waiting to see a specialist or during periods where your symptoms are particularly bad (flare-ups).

Non-steroidal anti-inflammatory drugs (NSAIDs)

In addition to – or instead of – the painkillers mentioned above, your doctor may prescribe a non-steroidal anti-inflammatory drug (NSAID).

This may be a traditional NSAID (such as ibuprofen, naproxen or diclofenac) or an alternative type called a COX-2 inhibitor (such as celecoxib or etoricoxib).

These medications can help relieve pain while also reducing inflammation in the joints, although they will not stop rheumatoid arthritis getting worse over time.

Your doctor will discuss with you what type of NSAID you should take and the benefits and risks associated with each of them.

Although uncommon, taking an NSAID tablet can increase the risk of serious stomach problems – such as internal bleeding – because the medications can break down the lining that protects the stomach against damage from stomach acids.

If you are prescribed an NSAID tablet, you will often 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.

Corticosteroids

Corticosteroids are powerful medications that can help reduce pain, stiffness and inflammation.

They can be used as a tablet (for example, prednisolone), as an injection directly into a painful joint, or as an injection into the muscle (to help lots of joints).

They are usually used to provide short-term pain relief – for example, while you are waiting for DMARD medication to take effect or during a flare-up.

Corticosteroids are normally only used in this way because long-term use of corticosteroids can have serious side effects, such as weight gain, osteoporosis (thinning of the bones), easy bruising, muscle weakness and thinning of the skin.

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 transcutaneous 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, 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.

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.

Surgery

Sometimes, despite medication, damage to your joints may occur. In such cases, you may need surgery to help restore your ability to use your joint.

Surgery may also be recommended to reduce pain or correct deformities.

Finger, hand and wrist surgery

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

Arthroscopy

Arthroscopy is a procedure to remove inflamed joint tissue.

During the operation, a thin tube with a light source and camera (arthroscope) is inserted into the joint through a small cut in the skin so that the surgeon can see the affected joint.

Special surgical 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, but the joint will need to be rested at home for several days.

Joint replacement

Some people with rheumatoid arthritis will need surgery to replace part or all of a joint, such as the hip, knee or shoulder joint. This is known as a joint replacement or arthroplasty.

Replacement of these joints is a major operation that involves several days in hospital followed by months of rehabilitation.

The latest 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 about knee replacement and hip replacement.

Complementary and alternative therapies

Many people with rheumatoid arthritis try complementary therapies, such as:

• massage
• acupuncture
• osteopathy
• chiropractic

In most cases, there is little or no evidence these are effective in the long-term, although some people may experience a short-term benefit from them.

Nutritional supplements and dietary changes

There is no strong evidence to suggest that specific dietary changes can help improve rheumatoid arthritis, although some people with rheumatoid arthritis feel that their symptoms get worse after they have eaten certain foods.

If you think this may be the case for you, it may be useful to try avoiding problematic foods for a few weeks to see if your symptoms improve. However, it is important to ensure your overall diet is still healthy and balanced.

There is also little evidence supporting the use of supplements in rheumatoid arthritis, although some can be useful in preventing side effects of medications you may be taking. For example, calcium and vitamin D supplements may help prevent osteoporosis if you are taking steroids and folic acid supplements may help prevent some of the side effects of methotrexate.

However, there is some evidence to suggest that taking fish oil supplements may help reduce joint pain and stiffness caused by rheumatoid arthritis.

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

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 NRAS helpline free on 0800 298 7650 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).

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.

Speak to your healthcare team if you are struggling to deal with your condition emotionally. They may be able to offer medication or psychological interventions to help.

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 or if you are worried about becoming pregnant while on medication.

Some medications, 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.

Babies and young children are physically and mentally demanding for any parent, but particularly so if you have rheumatoid arthritis. If you are struggling to cope, it may help to 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.

Sex and relationships

Pain, discomfort and changes in the way you 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.

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 also be eligible for other benefits if you have children living at home or if you have a low household income.

Telecare Self-Check online tool

Visit the Telecare Self-Check online tool to find the right support for you in your area. This easy to use online tool allows you to find helpful information on telecare services that could help you live independently at home for longer.

Having rheumatoid arthritis can put you at a higher risk of developing other conditions, particularly if it isn't well controlled.

Carpal tunnel syndrome

Carpal tunnel syndrome is a common condition in people with rheumatoid arthritis.

It is the result of compression of the nerve that controls sensation and movement in the hands (median nerve) and can cause symptoms such as aching, numbness and tingling in your thumb, fingers and part of the hand.

Symptoms of carpal tunnel syndrome can sometimes be controlled with wrist splints or corticosteroid injections, although surgery to release the pressure on the median nerve may be needed in severe cases.

Widespread inflammation

As rheumatoid arthritis is an inflammatory condition, it can cause inflammation to develop in other parts of your body, such as the:

• Lungs – inflammation of the lungs or lung lining can lead to pleurisy or pulmonary fibrosis, which can cause chest pain, a persistent cough and shortness of breath.
• Heart – inflammation of the tissue around the heart can lead to pericarditis, which causes chest pain.
• Eyes – inflammation of the eyes can lead to scleritis or Sjogren's syndrome. Scleritis can cause eye redness and pain, whereas Sjogren's syndrome can cause dry eyes.
• Blood vessels – inflammation of the blood vessels is known as vasculitis. This 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 and can be life-threatening.

However, thanks to early treatment, inflammation due to rheumatoid arthritis affecting other parts of the body is becoming less common. 

Joint damage

If rheumatoid arthritis is not treated early or is not well controlled, the inflammation in your joints could lead to significant and permanent damage.

Problems that can affect the joints include:

• damage to nearby bone and cartilage (a tough, flexible tissue that covers the surface of joints)
• damage to nearby tendons (flexible tissue that attach muscle to bone), which could cause them to break (rupture)
• joint deformities

These problems will sometimes need to be treated with surgery to prevent loss of function in the affected joints. 

Cardiovascular disease

If you have rheumatoid arthritis, you are at a higher risk of developing cardiovascular disease (CVD) than the population at large.

CVD is a general term that describes conditions affecting the heart or blood vessels, and it includes life-threatening problems such as heart attacks and strokes.

It's not clear exactly why people with rheumatoid arthritis are at an increased risk of these problems, but you can reduce your risk by ensuring your arthritis is well controlled and by reducing the impact of other factors that contribute to CVD, such as by stopping smoking, eating healthily and exercising regularly.

Read more about preventing CVD.

Cervical myelopathy

If you have had rheumatoid arthritis for some time, you are at increased risk of developing cervical myelopathy and you may need a 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 and can lead to permanent spinal cord damage if not treated promptly with surgery.