The immune system Overview of the Immune System The immune system is designed to defend the body against foreign or dangerous invaders. Such invaders include Microorganisms (commonly called germs, such as bacteria, viruses, and fungi) Parasites... read more damages the joints and connective tissues.
Joints (typically the small joints of the limbs) become painful and have stiffness that persists for more than 60 minutes on awakening and after inactivity.
Fever, weakness, and damage to other organs may occur.
Diagnosis is based mainly on symptoms but also on blood tests for rheumatoid factor and anti-cyclic citrullinated peptide (anti-CCP) and on x-rays.
Treatment can include exercises and splinting, medications (nonsteroidal anti-inflammatory drugs, disease-modifying antirheumatic drugs, and immunosuppressive drugs), and sometimes surgery.
Worldwide, rheumatoid arthritis develops in about 1% of the population, regardless of race or country of origin, affecting women 2 to 3 times more often than men. Usually, rheumatoid arthritis first appears between 35 years and 50 years of age, but it may occur at any age. A disorder similar to rheumatoid arthritis can occur in children. The disease is then called juvenile idiopathic arthritis Juvenile Idiopathic Arthritis (JIA) Juvenile idiopathic arthritis is a group of related childhood diseases that begin by age 16 and involve persistent or recurring inflammation of the joints. Certain forms of juvenile idiopathic... read more . However, the prognosis for juvenile idiopathic arthritis is often somewhat different.
The exact cause of rheumatoid arthritis is not known. It is considered an autoimmune disease Autoimmune Disorders An autoimmune disorder is a malfunction of the body's immune system that causes the body to attack its own tissues. What triggers an autoimmune disorder is not known. Symptoms vary depending... read more . Components of the immune system attack the soft tissue that lines the joints (synovial tissue) and can also attack connective tissue in many other parts of the body, such as the blood vessels and lungs. Eventually, the cartilage, bone, and ligaments of the joint erode (wear away), causing deformity, instability, and scarring within the joint. The joints deteriorate at a variable rate. Many factors, including genetic predisposition, may influence the pattern of the disease. Unknown environmental factors (such as viral infections and cigarette smoking) are thought to play a role.
Risk factors for rheumatoid arthritis include the following:
Changes in the microbiome (the group of microorganisms that normally live in a particular part of the body, such as the digestive tract, mouth, and lungs)
Did You Know...
Symptoms of Rheumatoid Arthritis
People with rheumatoid arthritis may have
Relatively mild symptoms
Occasional flare-ups with long periods of remission (in which the disease is inactive)
A severe, steadily progressive disease, which may be slow or rapid
Rheumatoid arthritis may start suddenly, with many joints becoming inflamed at the same time. More often, it starts subtly, gradually affecting different joints. Usually, the inflammation is symmetric, with joints on both sides of the body affected about equally. Rheumatoid arthritis can affect any joint, but most often the first inflamed are the small joints in the
Other commonly affected joints include the
Rheumatoid arthritis can also affect the neck. The lower spine and the joints at the tips of the fingers are not affected.
The inflamed joints are usually painful and often stiff, especially just after awakening (such stiffness generally lasts for more than 60 minutes) or after prolonged inactivity. Some people feel tired and weak, especially in the early afternoon. Rheumatoid arthritis may cause a loss of appetite with weight loss and a low-grade fever.
Affected joints are often tender, warm, and enlarged because of swelling of the soft tissue lining the joint (synovitis) and sometimes fluid within the joint (synovial fluid). Joints can quickly become deformed. Joints may freeze in one position so that they cannot bend or open fully, which leads to a limited range of motion. The fingers may tend to dislocate slightly from their normal position toward the little finger on each hand, causing tendons in the fingers to slip out of place, or may develop other deformities (see swan-neck deformity Swan-Neck Deformity Swan-neck deformity is a bending in (flexion) of the base of the finger, a straightening out (extension) of the middle joint, and a bending in (flexion) of the outermost joint. (See also Overview... read more and boutonnière deformity Boutonnière Deformity Boutonnière deformity is a deformity in which the middle finger joint is bent in a fixed position inward (toward the palm) and the outermost finger joint is bent excessively outward (away from... read more ).
When the Fingers Are Abnormally Bent
Some disorders, such as rheumatoid arthritis, and injuries can cause the fingers to bend abnormally. In swan-neck deformity, the joint at the base of the finger bends in (flexes), the middle joint straightens out (extends), and the outermost joint bends in (flexes). In boutonnière deformity, the middle finger joint is bent inward (toward the palm), and the outermost finger joint is bent outward (away from the palm).
Swollen wrists can pinch a nerve and result in numbness or tingling due to carpal tunnel syndrome Carpal Tunnel Syndrome Carpal tunnel syndrome is a painful compression (pinching) of the median nerve as it passes through the carpal tunnel in the wrist. The cause of most cases of carpal tunnel syndrome is unknown... read more .
Cysts, which may develop behind affected knees, can rupture, causing pain and swelling in the lower legs. Up to 30% of people with rheumatoid arthritis have hard bumps just under the skin (called rheumatoid nodules), usually near sites of pressure (such as the back of the forearm near the elbow).
Rarely, rheumatoid arthritis causes an inflammation of blood vessels (vasculitis Overview of Vasculitis Vasculitic disorders are caused by inflammation of the blood vessels (vasculitis). Vasculitis can be triggered by certain infections or drugs or can occur for unknown reasons. People may have... read more ). Vasculitis reduces the blood supply to tissues and may cause nerve damage or leg sores (ulcers). Inflammation of the membranes that cover the lungs (pleura) or of the sac surrounding the heart (pericardium) or inflammation and scarring of the lungs or heart can lead to chest pain or shortness of breath. Some people develop swollen lymph nodes (lymphadenopathy), Felty syndrome (a low white blood cell count and an enlarged spleen), Sjögren syndrome Sjögren Syndrome Sjögren syndrome is a common autoimmune connective tissue disorder and is characterized by excessive dryness of the eyes, mouth, and other mucous membranes. White blood cells can infiltrate... read more (dry mouth and eyes), thinning of the white of the eye (sclera), or red, irritated eyes caused by inflammation (episcleritis Episcleritis Episcleritis is inflammation of the tissue lying between the sclera (the tough, white, fiber layer covering the eye) and the conjunctiva (the membrane that lines the eyelid and covers the white... read more ).
Rheumatoid arthritis can also affect the neck, making the bones unstable and increasing the risk of the bones putting pressure on (compressing) the spinal cord Compression of the Spinal Cord Injuries and disorders can put pressure on the spinal cord, causing back or neck pain, tingling, muscle weakness, and other symptoms. The spinal cord may be compressed by bone, blood (hematomas)... read more . Neck involvement is common in longstanding, active rheumatoid arthritis and usually causes headaches and pain and stiffness, sometimes with pain that radiates down the arms or legs.
People with rheumatoid arthritis are at increased risk for early coronary artery disease Coronary Artery Disease and bone disease, such as osteopenia Osteoporosis Osteoporosis is a condition in which a decrease in the density of bones weakens the bones, making breaks (fractures) likely. Aging, estrogen deficiency, low vitamin D or calcium intake, and... read more and osteoporosis Osteoporosis Osteoporosis is a condition in which a decrease in the density of bones weakens the bones, making breaks (fractures) likely. Aging, estrogen deficiency, low vitamin D or calcium intake, and... read more .
Diagnosis of Rheumatoid Arthritis
Examination of joint fluid
In addition to the important characteristic pattern of symptoms, doctors follow established criteria when evaluating a person for rheumatoid arthritis. Doctors suspect people have rheumatoid arthritis if they have more than one joint with definite swelling of the joint's lining that is not caused by another disorder. Doctors diagnose people with rheumatoid arthritis if they have certain combinations of the following criteria:
Involvement of the joints that are most typical of rheumatoid arthritis
High blood levels of rheumatoid factor, anti-cyclic citrullinated peptide (anti-CCP) antibodies, or both
High blood levels of C-reactive protein, a high erythrocyte sedimentation rate (ESR), or both
Symptoms that have lasted at least 6 weeks
Doctors check blood tests to determine a person's levels of rheumatoid factor and anti-CCP antibodies and usually C-reactive protein, ESR, or both. They also frequently do x-rays of the hands, wrists, and affected joints. X-rays X-Rays X-rays are a type of medical imaging that use very low-dose radiation waves to take pictures of bones and soft tissues. X-rays may be used alone (conventional x-ray imaging) or combined with... read more show characteristic changes in the joints caused by rheumatoid arthritis. Magnetic resonance imaging Magnetic Resonance Imaging (MRI) Magnetic resonance imaging (MRI) is a type of medical imaging that uses a strong magnetic field and very high frequency radio waves to produce highly detailed images. During an MRI, a computer... read more (MRI), another imaging test, detects joint abnormalities at an earlier stage but is not always needed.
Doctors may also insert a needle into a joint to draw a sample of synovial fluid. The fluid is examined to determine whether it is consistent with features of rheumatoid arthritis and to rule out other disorders that cause symptoms similar to rheumatoid arthritis. Synovial fluid needs to be analyzed to establish that a person has rheumatoid arthritis but does not always need to be analyzed whenever a flare-up causes joints to become swollen.
Many people with rheumatoid arthritis have distinctive antibodies in their blood, such as rheumatoid factor and anti-CCP antibodies. However, doctors do not rely only on blood tests to diagnose rheumatoid arthritis.
Rheumatoid factor is present in 70% of people with rheumatoid arthritis. (Rheumatoid factor also occurs in several other diseases, such as cancers, systemic lupus erythematosus, hepatitis, and some other infections. Some people without any disorder, particularly older adults, have rheumatoid factor in their blood.)
Anti-CCP antibodies are present in over 75% of people who have rheumatoid arthritis and are almost always absent in people who do not have rheumatoid arthritis. The presence of anti-CCP and rheumatoid factor, especially in people who smoke cigarettes, predicts that their arthritis will be more severe.
C-reactive protein levels are often high in people with rheumatoid arthritis. Levels of C-reactive protein (a protein that circulates in the blood) dramatically increase when there is inflammation. High C-reactive protein levels can mean the disease is active.
The ESR is increased in 90% of people who have active rheumatoid arthritis. The ESR is another test for inflammation and measures the rate at which red blood cells settle to the bottom of a test tube containing blood. However, similar increases in the ESR, C-reactive protein level, or both occur in many other disorders. Doctors may monitor the ESR or C-reactive protein to help determine whether the disease is active.
Most people with rheumatoid arthritis have mild anemia Overview of Anemia Anemia is a condition in which the number of red blood cells is low. Red blood cells contain hemoglobin, a protein that enables them to carry oxygen from the lungs and deliver it to all parts... read more (an insufficient number of red blood cells). Rarely, the white blood cell count becomes abnormally low. When a person with rheumatoid arthritis has a low white blood cell count and an enlarged spleen, the disorder is called Felty syndrome.
Prognosis for Rheumatoid Arthritis
The course of rheumatoid arthritis is unpredictable. The disorder progresses most rapidly during the first 6 years, particularly the first year, and 80% of untreated people develop permanent joint abnormalities within 10 years. Rheumatoid arthritis decreases life expectancy by 3 to 7 years. Heart disease (a risk with rheumatoid arthritis), infection, and gastrointestinal bleeding are the most common complications that cause death. Side effects of drug treatment, cancer, and the underlying disease also may be responsible. Rarely, rheumatoid arthritis resolves spontaneously.
Treatment relieves symptoms in 3 of 4 people. However, at least 10% of people with rheumatoid arthritis are eventually severely disabled despite full treatment. Factors that tend to predict a poorer prognosis include the following:
Being White, a woman, or both
Having rheumatoid nodules
Being older when the disorder begins
Having inflammation in 20 or more joints
Being a cigarette smoker
Having a high erythrocyte sedimentation rate (ESR)
Having high levels of rheumatoid factor or anti-cyclic citrullinated peptide (anti-CCP) antibodies
Treatment of Rheumatoid Arthritis
Lifestyle measures, such as rest, diet, exercise, and stopping smoking
Physical therapy and occupational therapy
Treatments include simple, conservative measures in addition to medications and surgical treatments. Simple measures are meant to help the person’s symptoms and include rest, adequate nutrition, and physical treatments. People should take measures that decrease their risk of heart disease, such as stopping smoking and getting treated, if necessary, for high blood pressure and high blood lipids or cholesterol.
Because disease-modifying antirheumatic drugs Disease-modifying antirheumatic drugs (DMARDs) Rheumatoid arthritis is an inflammatory arthritis in which joints, usually including those of the hands and feet, are inflamed, resulting in swelling, pain, and often destruction of joints.... read more (DMARDs) may actually slow progression of the disease as well as relieve symptoms, they are often started soon after the diagnosis of rheumatoid arthritis is made. For other medications used to treat rheumatoid arthritis, see Medications for Rheumatoid Arthritis Medications for Rheumatoid Arthritis Rheumatoid arthritis is an inflammatory arthritis in which joints, usually including those of the hands and feet, are inflamed, resulting in swelling, pain, and often destruction of joints.... read more .
Rest and nutrition
Complete bed rest is rarely necessary, even for a short time. However, quality sleep is important, because poor sleep increases pain.
Severely inflamed joints should be rested because using them can aggravate the inflammation. Regular rest periods often help relieve pain, and sometimes a short period of bed rest helps relieve a severe flare-up in its most active, painful stage.
Splints can be used to immobilize and rest one or several joints, but some systematic movement of the joints is needed to prevent nearby muscles from weakening and joints from freezing in place.
A regular, healthy diet is generally appropriate. A diet rich in fish (omega-3 fatty acids) and plant oils but low in red meat can partially relieve symptoms in some people. Some people may have flare-ups after eating certain foods, and if so, these foods should be avoided, but such flare-ups occur rarely. No specific foods have been proved to cause flare-ups. Many diets have been proposed but have not proved helpful. Fad diets should be avoided.
Along with medications to reduce joint inflammation, a treatment plan for rheumatoid arthritis should include nondrug therapies, such as exercise, physical therapy Physical Therapy (PT) Physical therapy, a component of rehabilitation, involves exercising and manipulating the body with an emphasis on the back, upper arms, and legs. It can improve joint and muscle function, helping... read more (which includes massage Massage Professional rehabilitation therapists treat pain and inflammation. Such treatment makes movement easier and enables people to participate more fully in rehabilitation. Techniques used include... read more , traction, and deep heat treatments Heat therapy Professional rehabilitation therapists treat pain and inflammation. Such treatment makes movement easier and enables people to participate more fully in rehabilitation. Techniques used include... read more ), and occupational therapy Occupational Therapy (OT) Occupational therapy, a component of rehabilitation, is intended to enhance a person's ability to do basic self-care activities, useful work, and leisure activities. These activities include... read more (which includes self-help devices).
Inflamed joints should be gently stretched so they do not freeze in one position. Heat therapy can be helpful because heat improves muscle function by reducing stiffness and muscle spasm. As the inflammation subsides, regular, active exercises can help, although a person should not exercise to the point of excessive fatigue. For many people, exercise in warm water may be easier.
Treatment of tight joints consists of intensive exercises and occasionally the use of splints to gradually extend the joint. Cold Cold therapy (cryotherapy) Professional rehabilitation therapists treat pain and inflammation. Such treatment makes movement easier and enables people to participate more fully in rehabilitation. Techniques used include... read more may be applied to reduce pain caused by temporary worsening in one joint.
People who are disabled by rheumatoid arthritis can use several aids to accomplish daily tasks. For example, specially modified orthopedic or athletic shoes can make walking less painful, and self-help devices such as grippers reduce the need to squeeze the hand forcefully.
If medications have not helped, surgical treatment may be needed. Surgical repair must always be considered in terms of the total disease. For example, deformed hands and arms limit a person’s ability to use crutches during rehabilitation, and seriously affected knees and feet limit the benefits of hip surgery. Reasonable objectives for each person must be determined, and ability to function must be considered. Surgical repair may be performed while the disease is active.
Surgically replacing knee or hip joints is the most effective way to restore mobility and function when the joint disease is advanced. Joints can also be removed or fused together, especially in the foot, to make walking less painful. The thumb can be fused to enable a person to pinch, and unstable vertebrae at the top of the neck can be fused to prevent them from compressing the spinal cord.
Joint repair with prosthetic joint replacement is indicated if damage severely limits function. Total hip replacements and knee replacements are most consistently successful.
Replacing All of a Hip (Total Hip Replacement)
Sometimes the whole hip joint must be replaced. The whole hip joint is the top (head) of the thighbone (femur) and the surface of the socket into which the head of the thighbone fits. This procedure is called total hip replacement or total hip arthroplasty. The head of the thighbone is replaced with a ball-shaped part (prosthesis), made of metal. The prosthesis has a strong stem that fits within the center of the thighbone. The socket is replaced with a metal shell lined with durable plastic.
Replacing a Knee
A knee joint damaged by osteoarthritis may be replaced with an artificial joint. After a general anesthetic is given, the surgeon makes an incision over the damaged knee. The knee cap (patella) may be removed, and the ends of the thigh bone (femur) and shinbone (tibia) are smoothed so that the parts of the artificial joint (prosthesis) can be attached more easily. One part of the artificial joint is inserted into the thigh bone, the other part is inserted into the shinbone, and then the parts are cemented in place.
Medications for Rheumatoid Arthritis
The main goal of drug treatment is to reduce inflammation and thereby prevent erosions, progression of the disease, and loss of joint function.
The main categories of medications used to treat rheumatoid arthritis are
Many of these medications are used in combination. For example, doctors may prescribe two DMARDs together or a corticosteroid plus a DMARD. However, the best combinations of medications are not yet clear. Typically, biologic agents are not used in combination with other biologic agents because these combinations increase the frequency of infections.
All the categories of drugs have potentially serious side effects that must be looked for during treatment.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
NSAIDs Nonsteroidal Anti-Inflammatory Drugs Pain relievers (analgesics) are the main drugs used to treat pain. Doctors choose a pain reliever based on the type and duration of pain and on the drug's likely benefits and risks. Most pain... read more can be used to treat the symptoms of rheumatoid arthritis. They do not prevent the damage caused by rheumatoid arthritis from progressing and thus should not be considered the primary treatment. (See also table .)
NSAIDs can reduce the swelling in affected joints and relieve pain and stiffness. They can be taken by mouth or applied directly to the skin over painful joints. Rheumatoid arthritis, unlike osteoarthritis, causes considerable inflammation. Thus, medications that decrease inflammation, including NSAIDs, have an important advantage over medications such as acetaminophen that reduce pain but not inflammation. However, NSAIDs should generally not be taken by people who have a history of digestive tract (peptic) ulcers Peptic Ulcer Disease A peptic ulcer is a round or oval sore where the lining of the stomach or duodenum has been eaten away by stomach acid and digestive juices. Peptic ulcers can result from infection with Helicobacter... read more —including stomach ulcers or duodenal ulcers—because NSAIDs can upset the stomach and cause ulcers to bleed. Medications called proton pump inhibitors (such as esomeprazole, lansoprazole, omeprazole, pantoprazole, and rabeprazole) can reduce the risk of stomach or duodenal ulcers (see table ).
Other possible side effects of NSAIDs may include headache, confusion, elevation of blood pressure, worsening of kidney function, swelling, and decreased platelet function, causing bruising or bleeding. People who get hives, inflammation and swelling in the nose, or asthma after they take aspirin may have the same symptoms after taking other NSAIDs. NSAIDs may increase the risk of heart attacks and strokes. The risk appears to be higher if the drug is used at higher doses and for longer periods of time.
Aspirin is no longer used to treat rheumatoid arthritis because effective doses are often toxic.
The cyclooxygenase (COX-2) inhibitors (coxibs, such as celecoxib) are NSAIDs that act similarly to the other NSAIDs but are slightly less likely to damage the stomach and do not affect platelet function and cause bruising or bleeding like the other NSAIDs. However, if a person also takes aspirin, stomach damage is almost as likely to occur as with other NSAIDs. Caution should be taken with use of coxibs and probably all NSAIDs for long periods or by people with risk factors for heart attack and stroke.
Disease-modifying antirheumatic drugs (DMARDs)
DMARDs, such as methotrexate, hydroxychloroquine, leflunomide, and sulfasalazine, slow the progression of rheumatoid arthritis and are given to nearly all people with rheumatoid arthritis. Doctors typically prescribe these drugs as soon as the diagnosis of rheumatoid arthritis is made. Many take weeks to have an effect. Even if pain is decreased with NSAIDs, a doctor will likely prescribe a DMARD because the disease may otherwise progress even if symptoms are lessened. (See also table .)
About two thirds of people improve overall, and complete remissions are becoming more common. The progression of arthritis usually slows, but pain may remain. People should be fully aware of the risks of DMARDs and monitored carefully for evidence of toxicity.
Combinations of DMARDs may be more effective than single drugs. For example, hydroxychloroquine, sulfasalazine, and methotrexate together are more effective than methotrexate alone or the other two together. Also, combining biologic agents with a DMARD is often more effective than using a single drug or certain combinations of DMARDs. For example, methotrexate can be combined with a TNF inhibitor.
Methotrexate is taken by mouth once weekly. It is anti-inflammatory at the low doses used to treat rheumatoid arthritis. It is very effective and begins to work within 3 to 4 weeks, which is relatively rapid for a DMARD. The liver can scar, but this scarring most often can be detected by monitoring with regular blood tests and reversed before major damage develops. People must refrain from drinking alcohol to minimize the risk of liver damage. Bone marrow suppression (suppression of the production of red blood cells, white blood cells, and platelets) may occur. Blood counts should be tested about every 2 to 3 months in all people taking the drug. Inflammation of the lung (pneumonitis) is rare. Inflammation in the mouth and nausea can also develop. Severe relapses of arthritis can occur after methotrexate is discontinued. Folate (folic acid) tablets may decrease some of the side effects, such as mouth ulcers. Rheumatoid nodules may enlarge with methotrexate therapy.
Hydroxychloroquine is given daily by mouth. Side effects, which are usually mild, include rashes, muscle aches, and eye problems. However, some eye problems can be permanent, so people taking hydroxychloroquine must have their eyes checked by an ophthalmologist before treatment begins and every 12 months during treatment. If the medication has not helped after 9 months, it is discontinued. Otherwise, hydroxychloroquine can be continued as long as necessary.
Leflunomide is taken daily by mouth and has benefits that are similar to those of methotrexate but it is less likely to cause suppression of blood cell production in the bone marrow, abnormal liver tests, or inflammation of the lungs (pneumonitis). It can be given at the same time as methotrexate. The major side effects are rashes, liver dysfunction, hair loss, diarrhea, and rarely nerve damage (neuropathy).
Sulfasalazine is initially given by mouth and can relieve symptoms and slow the development of joint damage. Sulfasalazine can also be used in people who have less severe rheumatoid arthritis or added to other medications to boost their effectiveness. The dose is increased gradually, and improvement usually is seen within 3 months. Because sulfasalazine may quickly cause a person's white blood cell count to become very low (neutropenia), blood tests are done after the first 2 weeks and then about every 12 weeks while the person is taking the drug. Like the other DMARDs, it can cause stomach upset, diarrhea, liver problems, blood cell disorders, and rashes. In males, sulfasalazine may cause a low sperm count, which is reversible.
Corticosteroids are potent anti-inflammatory drugs that suppress the immune system. Corticosteroids, such as prednisone, are the most dramatically effective drugs for reducing inflammation and symptoms of rheumatoid arthritis anywhere in the body. (See also table .)
There is some controversy as to whether corticosteroids can slow the progression of rheumatoid arthritis. Furthermore, the long-term use of corticosteroids almost invariably leads to side effects, potentially involving almost every organ in the body (see Corticosteroids: Uses and Side Effects Corticosteroids: Uses and Side Effects ). Consequently, doctors usually reserve corticosteroids for short-term use in the following situations:
When beginning treatment for severe symptoms (until a DMARD has taken effect)
In severe flare-ups when many joints are affected
They are also useful in treating rheumatoid inflammation outside of joints, for example, in the membranes covering the lungs (pleura) or in the sac surrounding the heart (pericardium).
Because of the risk of side effects, the lowest effective dose is almost always used. When corticosteroids are injected into a joint, the person does not get the same side effects as when taking a corticosteroid by mouth (orally) or vein (intravenously). Corticosteroids can be injected directly into affected joints for fast, short-term relief of pain and swelling.
When used for a long time, corticosteroids may cause weight gain, high blood pressure, diabetes, thinning and bruising of the skin, glaucoma and other eye problems such as cataracts, and increase the risk of certain infections.
A biologic agent is something made from a living organism, often using cells in a laboratory. Many biologic agents used to treat rheumatoid arthritis are antibodies. Biologic agents used to treat rheumatoid arthritis include abatacept, rituximab, tumor necrosis factor (TNF)–inhibiting drugs (adalimumab, certolizumab pegol, etanercept, golimumab, and infliximab), an interleukin-1 receptor blocker (anakinra), and interleukin-6 receptor blockers (tocilizumab and sarilumab). (See also table .)
Biologic agents may suppress the inflammation so that corticosteroids can be avoided or given in lower doses. But by interfering with the immune system, biologic agents may increase the risks of infection and certain cancers. Because treatment with biologic agents increases the risk of infection, before starting treatment with a biologic agent people should be up to date on vaccinations (see table ).
Etanercept, infliximab, golimumab, certolizumab pegol, and adalimumab are TNF inhibitors and can be dramatically effective for people who do not respond sufficiently to methotrexate alone.
Etanercept is given once a week by injection under the skin.
Infliximab is given by vein. After the first dose of infliximab is given, the next two doses are given at 2 and at 6 weeks. Then infliximab is given every 8 weeks.
Golimumab is given by injection under the skin once every 4 weeks.
Certolizumab pegol is given by injection under the skin. After the first dose, the next two doses are given at 2 and at 4 weeks. Then the drug is given at 2-week or 4-week intervals, depending on the dose.
Adalimumab is injected under the skin once every 1 to 2 weeks.
TNF is an important part of the body’s immune system, so inhibition of TNF can impair the body’s ability to fight infections, particularly a reactivated tuberculosis infection. These drugs should be avoided in people who have active infections and should be discontinued before major surgery. Etanercept, infliximab, and adalimumab can be and are often used with methotrexate. People who have severe heart failure should not take high doses of infliximab.
Side effects of TNF inhibitors include the potential risk of reactivation of infection (particularly tuberculosis Tuberculosis (TB) Tuberculosis is a chronic contagious infection caused by the airborne bacteria Mycobacterium tuberculosis. It usually affects the lungs, but almost any organ can be involved. Tuberculosis... read more and fungal infections Overview of Fungal Infections Fungi are living organisms, but they are not plants or animals. All living things are divided into categories called kingdoms, and fungi have their own kingdom. Some fungi cause infections in... read more ), skin cancers other than melanoma, and reactivation of hepatitis B Hepatitis B, Chronic Chronic hepatitis B is inflammation of the liver that is caused by the hepatitis B virus and that has lasted more than 6 months. Most people with chronic hepatitis B have no symptoms, but some... read more .
Anakinra is an interleukin-1 (IL-1) receptor blocker, which means it interrupts one of the major chemical pathways involved in inflammation. Anakinra is given as a single daily injection under the skin. Pain and itching at the injection site are the most common side effects. IL-1 is part of the immune system, so inhibiting IL-1 can impair the ability to fight infections. Anakinra can also suppress production of white blood cells. It should not be used with TNF inhibitors. It is prescribed less often because it must be given every day.
Rituximab is a biologic agent that decreases the number of B-cell lymphocytes, one of the white blood cells responsible for causing inflammation and for fighting infection. Rituximab is usually reserved for people who do not improve enough after taking methotrexate and a TNF inhibitor. It is injected in a vein, usually as 2 doses given 2 weeks apart. Side effects, as with other immunosuppressive drugs, may include increased risk of infections. In addition, rituximab can cause effects while it is being given, such as rashes, nausea, back pain, itching, and high or low blood pressure. It can cause severe liver damage by reactivating hepatitis B Hepatitis B, Acute Acute hepatitis B is inflammation of the liver that is caused by the hepatitis B virus and that lasts from a few weeks up to 6 months. Hepatitis B is spread through contact with blood or other... read more in people who had previously been infected with this virus.
The COVID-19 vaccine COVID-19 Vaccine Coronavirus disease 2019 (COVID-19) vaccines provide protection against COVID-19. COVID-19 is the disease caused by infection with the SARS-CoV-2 virus. There are multiple COVID-19 vaccines... read more may be less effective in people taking rituximab, and people on rituximab may have poorer outcomes if infected with COVID-19. Therefore, doctors now try to reserve rituximab for people who did not respond to other biologic DMARDs and to those with certain lymphatic disorders and cancers.
Abatacept is another biologic agent that interferes with the communication between cells that coordinates inflammation. Side effects include lung problems, headache, increased susceptibility to infection, and upper respiratory infection. The first injection in the vein takes over 30 minutes to complete. After that, it is injected in a vein or under the skin at 2 weeks and at 4 weeks after the first dose and every 4 weeks thereafter.
Sarilumab is an IL-6 receptor blocker, which means it interrupts one of the major chemical pathways involved in inflammation. This drug is given to people who have not been helped by or who cannot tolerate DMARDs. Sarilumab causes suppression of blood cell production in the bone marrow (neutropenia), suppression of platelet production in the bone marrow (sometimes with increased susceptibility to bleeding), and increased liver enzymes. It is given by injection under the skin (subcutaneously) once every 2 weeks.
Tocilizumab also is an IL-6 receptor blocker. It is often used to treat people who are also taking methotrexate. Side effects include infection (such as tuberculosis Tuberculosis (TB) Tuberculosis is a chronic contagious infection caused by the airborne bacteria Mycobacterium tuberculosis. It usually affects the lungs, but almost any organ can be involved. Tuberculosis... read more ), suppression of blood cell production in the bone marrow (neutropenia), anaphylaxis Anaphylactic Reactions Anaphylactic reactions are sudden, widespread, potentially severe and life-threatening allergic reactions. Anaphylactic reactions often begin with a feeling of uneasiness, followed by tingling... read more (a life-threatening allergic reaction), and increased liver enzymes. It is given by vein every 4 weeks. There may be an increased risk when people who have had diverticulitis use tocilizumab.
Janus kinase (JAK) inhibitors
Janus kinase inhibitors are small molecule agents that interfere with the communication between cells that coordinate inflammation by inhibiting the enzyme JAK. JAK inhibitors include tofacitinib, baricitinib, and upadacitinib. (See also table .) Because treatment with JAK inhibitors increases the risk of infection, including herpes zoster infection, people should be vaccinated against zoster Shingles Vaccine The herpes zoster virus that causes shingles is the same virus that causes chickenpox. After chickenpox resolves, the virus remains in the body. It can be reactivated years later and cause shingles... read more before starting treatment with a JAK inhibitor.
Baricitinib is given to people who have not been helped by or who cannot tolerate TNF antagonists. Baricitinib increases the risk of nonmelanoma skin cancer, high cholesterol levels Dyslipidemia Dyslipidemia is a high level of cholesterol and/or triglycerides or a low level of high-density lipoprotein (HDL) cholesterol. Lifestyle, genetics, disorders (such as low thyroid hormone levels... read more (hypercholesterolemia), and deep vein thrombosis Deep Vein Thrombosis (DVT) Deep vein thrombosis is the formation of blood clots (thrombi) in the deep veins, usually in the legs. Blood clots may form in veins if the vein is injured, a disorder causes the blood to clot... read more (DVT). It is taken by mouth once a day.
Tofacitinib is used if a person has taken methotrexate and has not improved enough. Tofacitinib can be used at the same time as methotrexate. Side effects include nonmelanoma skin cancer and high cholesterol levels Dyslipidemia Dyslipidemia is a high level of cholesterol and/or triglycerides or a low level of high-density lipoprotein (HDL) cholesterol. Lifestyle, genetics, disorders (such as low thyroid hormone levels... read more . Tofacitinib is taken by mouth twice a day.
Upadacitinib is given to adults with moderately to severely active rheumatoid arthritis when methotrexate has not been effective enough.
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