Rheumatoid arthritis (RA)

Rheumatoid arthritis is an autoimmune disease that occurs when your immune system sends inflammatory substances, such as certain types of white blood cells (WBCs), to attack the lining of your joints, called the synovium. Your synovium lies beneath your cartilage, covering the ends of your bones and producing fluid to lubricate joints and to absorb the stress on them from everyday wear and tear.

Your immune system usually reserves this defensive response for foreign organisms (such as bacteria or viruses) that enter the body. In RA’s case, your immune system mistakes your body’s healthy cells and tissues for one of these disease-causing agents.

This autoimmune response leads to an overproduction of immune system proteins called cytokines. These substances, which include interleukin-1 (IL-1), IL-6, and tumor necrosis factor (TNF), usually help control the body’s response to disease and infection. But when your immune system secretes too much of them, cytokines promote inflammation and tissue damage instead.

The immune response also produces autoantibodies, including anticitrullinated protein antibodies (ACPA) and rheumatoid factor (RF). Autoantibodies ordinarily work against foreign substances, but in the case of RA, they mistakenly target, damage, and destroy your body’s healthy tissues and cells.

How does RA look and feel?

As WBCs converge on the synovium in your joints, it becomes inflamed, causing affected tissues to appear swollen and thicker. This visible swelling in your joints is accompanied by joint pain, tenderness, and warmth.

The pain can feel deeply achy or dull. Your joints might also stiffen, a feeling that can last for more than an hour after you wake up or when you haven’t been active for a while. Moving the affected joints can also cause a sharp or shooting pain.

Uncontrolled inflammation that builds up can damage cartilage. Without enough synovial fluid and cartilage to serve as a cushion in your joints, your bones rub together and may begin to erode.

Over time, to accommodate irritation, your joints may fuse together. Along with persistent inflammation and continued erosion of bone and synovium, this causes the joints in the fingers, hands, and other affected areas to shorten, bend, or curve.

What’s the difference between RA and osteoarthritis (OA)?

Osteoarthritis is the most common type of arthritis. It is not an autoimmune disease, but rather a degenerative disease. This means cartilage breaks down and bone erodes over time due to everyday use and stress placed on the affected joints.

Here are a few ways to understand the difference between rheumatoid arthritis and osteoarthritis:

Age: RA most often starts to develop between the ages of 30 and 60 years old, although children can also be affected. The risk of OA increases with age, typically starting after age 50.

Location: RA symptoms often affect the hands and feet first. Then, as the condition progresses, most patients experience inflammation of the joints in the arms or legs. In rarer instances, some may experience inflammation of the hips and the upper part of the spine. OA tends to affect the hips, knees, feet, and spine.

Heat: RA produces heat at the joint site due to inflammation. Although swelling occurs with OA, the affected joint doesn’t usually feel warm.

Pattern: Rheumatoid arthritis tends to affect joints symmetrically, meaning it usually affects the same joints on both sides of the body, such as both hands, wrists, or feet. Despite the symmetry of RA, symptoms may feel worse on one side or the other. Although OA can also affect joints on both sides of the body at once, it often follows an asymmetrical pattern, meaning it usually starts with one body part at a time. 

Growths: OA can result in round, bony growths at the finger joints called Bouchard’s or Heberden’s nodes. Abnormal lumps or growths called rheumatoid nodules may develop under the skin or in organs such as the heart and lungs in patients with RA.

Markers: Since RA is an autoimmune disease, blood tests may show markers or signs of the disease. This isn’t the case for OA.

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Rheumatoid arthritis symptoms tend to come on slowly and gradually, sometimes taking weeks or months to progress to the point where a person might seek medical care. The type and severity of symptoms you experience may differ from those experienced by others, and symptoms can increase or decrease in intensity over the course of your day or from one day to the next.

RA symptoms can also come and go, meaning you may go through periods when new symptoms develop or you experience RA flare-ups (worsening of symptoms). These flares may be followed by remission periods when you’re free of symptoms for days, months, or even longer.

Early and common rheumatoid arthritis symptoms

Systemic symptoms that affect your entire body are often among the first to appear. Examples include:

• Low-grade fever (around 99 to 100 degrees Fahrenheit or 37 to 38 degrees Celsius)
• Malaise (feeling unwell, uncomfortable, or weak in general)
• Weight or appetite loss

Nonspecific symptoms like these may be associated with other types of illnesses and diseases, so it may not be obvious early on that they indicate RA. But joint-related RA symptoms may soon develop, including:

• Redness or discoloration
• Swelling
• Stiffness, pain, or tenderness
• Warmth or heat to the touch

What joints does RA affect?

RA can affect most of the joints in the body, although the lower spine and the joints at the tips of the fingers aren’t usually involved.

More commonly, joint swelling, stiffness, and pain from RA may affect:

Hands and RA

The joints in your hands are usually the first to be affected. They may feel tender when squeezed and your grip strength may feel weaker. You may also notice redness, discoloration, and swelling over the affected joint.

Carpal tunnel syndrome (CTS) also develops in roughly 1 to 5 percent of people with RA. Swelling in your hands compresses the nerve that runs through your wrist and controls hand movement and sensation. CTS can cause your fingers and other areas of your hand to ache or feel weak, numb, or tingly or prickly.

Over time, persistent joint inflammation can lead to contractures, which occur when muscle fibers and joints permanently stiffen and shorten. These contractures can cause deformities in your hands such as:

• Boutonnière deformity: The middle joint becomes stuck in a bent position, while the joint closer to the fingertip flexes in the opposite direction.
• Bowstring sign: The tendons on the back of your hands may bulge or appear taut (like the string of a bow and arrow).
• Hitchhiker’s thumb (also called Z-shaped deformity or distal joint hyperextensibility): The joint at the base of the thumb bends in while the joint below the thumbnail bends backward.
• Swan-neck deformity: The middle joint bends down, the last joint of the finger bends upward, and the tip of the finger points downward.

Wrists and RA

You may find it hard to bend your wrists backwards because of rheumatoid arthritis symptoms.

Elbows and RA

Inflammation in your elbows can compress the nerves that travel through your arms, causing numbness and tingling in your fingers.

Shoulders and RA

As your RA becomes more advanced, your shoulders may feel inflamed. This can limit movement and cause pain.

Feet and RA

The joints in your feet, especially those at the base of your toes and less commonly your big toes, are usually affected early in the course of the disease. You may find yourself placing your weight on your heels and bending your toes backwards when standing or walking to offset the discomfort you feel in your feet. Your heels may also feel painful at times and the tops of your feet may appear red, discolored, and swollen.

Ankles and RA

Nerve damage may also occur in your ankle joints. This can cause numbness and tingling in your feet.

Knees and RA

A fluid-filled cyst, called a Baker’s cyst, can form in the hollow space at the back of the knee. Inflammation in knee joints can also:

• Make it hard for you to bend them
• Loosen the ligaments that surround and support them
• Erode the bones that meet at your knees

Hips and RA

Hip inflammation may occur in the later stages of RA, making it hard to walk.

Neck and RA

Your cervical spine (neck) may become inflamed, which can cause headaches and neck pain and stiffness. These symptoms can make it hard to turn your head and bend your neck.

Cricoarytenoid joint and RA

The cricoarytenoid joint near your trachea (windpipe) may also become inflamed, although this doesn’t occur often. The inflammation can cause:

• Dysphonia or hoarseness (strained, raspy, breathy, or husky voice)
• Feeling like you have something stuck in your throat
• Acute respiratory failure. (In these rare cases, you have difficulty breathing and your lungs can’t get enough oxygen from the blood.)

Does rheumatoid arthritis cause fatigue?

As many as 80 percent of people with rheumatoid arthritis report feelings of fatigue. It’s often the main issue cited by people with the disease, even more than pain.

Fatigue is described as feeling weak and exhausted. You may also feel weary, drowsy, irritable, and unable to think clearly. The mental stress that comes with living with a chronic condition contributes to or exacerbates fatigue, but prolonged inflammation can also cause or worsen this common RA symptom.

Ordinarily, people respond to fatigue by resting and allowing their bodies to recover from things like strenuous physical activity or a bout of cold or flu. But with RA, neither rest nor treatments are often enough to relieve exhaustion caused by the disease.

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Scientists continue to research why the immune system attacks the synovium. What’s known is that multiple factors can intermingle to raise the risk for rheumatoid arthritis.

These may be classified as:

• Susceptibility factors
• Initiating factors

Susceptibility factors that may raise the risk of RA

RA is more likely to occur if you’re more susceptible to the disease based on certain biological risk factors you inherit or can’t change. These may include your:

Age and RA risk

Anyone at any age can get rheumatoid arthritis, but the risk goes up with age. The disease is more prevalent among adults over the age of 40, but the onset of the disease is highest among adults in their 60s.

Sex and RA risk

People assigned female at birth (AFAB) have two to three times greater risk of developing rheumatoid arthritis compared to people assigned male at birth (AMAB), according to the Centers for Disease Control and Prevention (CDC). One 2019 study published in Clinical Rehabilitation noted the risk for people AFAB may be up to five times higher than those AMAB.

Findings such as these suggest that sex hormones contribute to disease risk. But despite numerous studies, the ways in which hormones affect the development and progression of the disease remain unclear.

Studies have most consistently found a higher risk of RA during early menopause and the period following childbirth and less disease activity during pregnancy, according to a 2022 review of studies published in Frontiers in Medicine. Waning levels of the hormones estrogen and progesterone during the post-pregnancy period and menopause may play a role in the development of RA.

These hormones tend to be higher in people AFAB during their natural childbearing years compared to those AMAB. The childbearing years usually start with the first menstrual cycle and end with menopause. Increases in the levels of these hormones during pregnancy may play a protective role against RA.

Genetics and RA risk

Although rheumatoid arthritis may occur more often among immediate biological relatives (such as parents, children, and siblings), family history alone doesn’t usually predict the onset of the disease. In fact, some people without a family history of RA develop it.

Genetic risk factors account for about 60 percent of the risk for developing RA, according to a 2020 review of studies published in the Journal of Autoimmunity. Numerous genes have been identified as possible contributors to the disease.

Chief among them are the human leukocyte antigen (HLA) genes, which account for 30 to 50 percent of total genetic risk for RA. These genes instruct your immune system to make a group of proteins referred to as the HLA complex. HLA proteins usually help the immune system distinguish between the body’s own proteins and those produced by disease-causing organisms and agents, called antigens.

In contrast, some mutations to HLA genes may increase susceptibility to autoimmune diseases like rheumatoid arthritis. These mutations—which include the HLA-class II histocompatibility variants—often interact with environmental and other genetic risk factors to raise the risk of RA even higher.

Many non-HLA gene variants have also been linked to the development of RA. These include protein tyrosine phosphatase non-receptor type 22 (PTPN22), cytotoxic T-lymphocyte associated protein 4 (CTLA4), and protein-arginine deiminase type-4 (PADI4).

Initiating factors that may increase RA risk

Not all people with susceptibility factors develop rheumatoid arthritis. These often interact with other risk factors, called initiating factors, to cause the disease. An initiating factor is something from a patient’s environment (whether external to their body or another disease they are experiencing) that sets in motion the development of RA. These initiating factors might include:

Gut dysbiosis and RA risk

There are trillions of tiny organisms that live in your digestive tract, including bacteria, fungi, parasites, and viruses. Some of these microbes protect your health while others harm it. Gut dysbiosis occurs when the beneficial and harmful microbes become unbalanced. It has been linked with a higher risk of rheumatoid arthritis as well as other related conditions, such as psoriatic arthritis (PsA).

This relationship between gut dysbiosis and joint disease is known as the gut-joint axis. One type of gut dysbiosis associated with RA involves lower levels of anti-inflammatory butyrate-producing bacteria (such as faecalibacterium) and higher levels of inflammatory causing bacteria (such as streptococcus). Gut microbiota imbalances such as these can affect the functions of the intestines as well as your joints and other organs.

Periodontal disease and RA risk

Periodontal disease (PD) may also raise the risk for rheumatoid arthritis. PD includes:

• Gingivitis, an early form of gum disease that causes inflammation of the gingiva or gums
• Periodontitis, more advanced gum disease that can erode the tissue and bones that support your teeth

People with moderate to severe PD are more prone to RA, according to a 2022 review of studies published in Frontiers in Immunology. This may also involve an imbalance in the microbes that live in your mouth.

The authors of the review pointed to a potential two-way relationship between PD and RA. People with PD are more likely to develop RA, while those with RA are more likely to develop and experience more severe PD. But it remains unclear whether or how one condition causes the other.

Smoking tobacco and RA risk

Smoking tobacco is a well-established risk factor for rheumatoid arthritis, In fact, people who currently smoke or who quit smoking have a 40 percent higher risk of RA compared to people who have never smoked, according to a 2022 review and analysis of studies published in PLoS One.

Around 20 percent of all RA cases and 35 percent of a type of RA called ACPA-positive RA have been attributed to smoking, according to a 2022 review of studies published in the Journal of Clinical Medicine.

Some research suggests that secondhand smoke exposure during childhood may also raise the risk of developing RA in adulthood, but the effect of secondhand smoke exposure during adulthood remains unclear.

Stress and RA risk

Heightened or chronic psychological and emotional stress or trauma may contribute to the onset of RA. Events that have a significant impact on your mental health may include divorce, grief, or work-related stress.

Excess weight and RA risk

Excess weight as determined by body mass index (BMI) can raise the risk of rheumatoid arthritis. The more excess weight a person carries, the higher the risk for the disease. BMI is one screening tool that your healthcare provider (HCP) may use to determine whether your weight falls within the typical range for your height, or whether you’re underweight, overweight, or obese based on these parameters. It measures body fat based on your height and weight, although it’s only one measure commonly used for this purpose and is not always a perfect measure of one’s overall health.

In general, the risk of RA goes up by 30 percent if you have a BMI greater than 30, which is considered obese per the standard BMI chart. The risk goes up by 15 percent if your BMI falls between 25 to 29.9, which is classified as overweight.

These findings were supported by a 2022 study published in Rheumatology. The study followed 108,505 nurses assigned female at birth (AFAB), age 25 to 42, from the Nurses’ Health Study II over a period of nearly 26 years. The results point to long-term weight gain during adulthood as a major risk factor for RA in people AFAB.

Those who gained a minimum of 20 kilograms (around 44 pounds) over the study period had nearly four times the risk of developing RA. The risk of RA began rising with a weight gain of 2 to 10 kilograms (around 4.4 to 22 pounds).

Like RA, being overweight or obese boosts inflammation in the body. The processes involved in RA and obesity may interact to further boost the levels of inflammatory substances produced by the body. These may include TNF, IL-6, and C-reactive protein (CRP), according to the authors of a 2023 study published in Nutrients.

Diet and RA risk

Certain eating habits may trigger and worsen rheumatoid arthritis symptoms and decrease the chances of achieving and sustaining remission of the disease. RA has been associated with a Western eating style. This diet typically involves higher consumption of processed and refined foods, saturated fats, and added sugars, with less fiber and other beneficial nutrients than other eating styles. Poor eating habits may also lead to excessive weight gain, which can contribute to RA risk.

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The different types of rheumatoid arthritis include:

• Seropositive RA
• Seronegative RA
• Juvenile idiopathic arthritis (JIA)

Seropositive RA vs. seronegative RA

The two main RA subtypes in adults are seropositive RA and seronegative RA. People with seropositive RA will test positive on blood tests for rheumatoid factor (RF) and/or anti-citrullinated protein antibodies (ACPA), also called anti-cyclic citrullinated peptides (ACCP). These antibodies won’t be detected in people with seronegative RA.

Anti-CCP tests are currently the most widely used tests for measuring ACPA. They have high levels of sensitivity (60 to 78 percent) and specificity (86 to 99 percent) for RA.

Sensitivity describes how well the test can correctly identify the presence of a disease or illness. A test with high sensitivity is more likely to give a true positive result and correctly detect the disease or illness when it’s present.

Specificity indicates how well the test can correctly identify the absence of a disease or illness. A test with high specificity is more likely to give a true negative result and correctly identify when the disease or illness isn’t present.

RF tests can be slightly more sensitive (60 to 90 percent). They lag behind CCP tests, however, when it comes to how specific they are to RA (85 percent at best). The reason for this is that rheumatoid factor may also be present in other conditions such as Sjögren’s syndrome, lupus, hepatitis C, tuberculosis, and leukemia.

Seropositive RA has been associated with more severe rheumatoid arthritis symptoms and worse outcomes than seronegative RA, but these differences remain unclear. Moreover, around 20 to 30 percent of people don’t have ACPA or RF, according to a 2022 study published in Frontiers in Medicine. Still, joint damage and bone erosion due to RA can occur even without these antibodies present.

Juvenile idiopathic arthritis

JIA is a form of rheumatoid arthritis that occurs in children ages 16 and younger. The condition was formerly referred to as “juvenile rheumatoid arthritis” in the U.S. and “juvenile chronic arthritis” in Europe.

JIA is the most common type of childhood arthritis, according to the CDC. Like adult RA, it also causes joint inflammation, pain, and stiffness that feels worse upon waking in the morning or after a nap and may last for days or months.

JIA can also cause broader, nonspecific symptoms such as:

• Decreased appetite
• Eye inflammation
• Fatigue
• High fever and rash
• Poor weight gain and slow growth
• Swollen lymph nodes

Like adults with RA, children with JIA may experience rheumatoid arthritis symptoms that come and go. But unlike adults with RA, some children may eventually experience permanent remission from symptoms—although many have RA symptoms into adulthood.

Like adult RA, the causes and risk factors for JIA often involve both genetic and environmental aspects. Around 20 percent of JIA cases are also attributed to HLA gene variants, according to a 2023 review of studies published in the International Journal of Molecular Sciences.

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The damage to your body caused by rheumatoid arthritis may not be limited to your joints, especially as the disease progresses. RA can also affect your:

Bones and RA

As many as 30 percent of people with RA develop osteoporosis. Circulating autoantibodies such as ACPA and inflammatory cytokines such as TNF, IL-1, and IL-6 can cause the bones of people with RA to become fragile. This can erode bone, cause bone loss, and raise the risk of fractures.

Cancer risk and RA

People with RA are about twice as likely to develop lymphoma, a group of cancers that start in the part of the immune system called the lymphatic system. This is likely due to the effects of chronic inflammation on your immune system.

B cells and T cells are types of WBCs called lymphocytes that produce inflammation as part of the immune response. But these same cells are more likely to become cancerous in people with RA due to increased autoimmune activity. Poorly controlled inflammation amplifies the risk of lymphoma.

Some medicines used to treat RA may also raise the risk of lymphoma. These include less commonly used medicines such as cyclophosphamide and azathioprine, as well as a widely used RA treatment called methotrexate.

Methotrexate and biologic drugs may also slightly increase the risk of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), which are two common but usually not life-threatening forms of skin cancer.

Cardiovascular system and RA

Around 30 to 60 percent of people with rheumatoid arthritis develop cardiovascular disease (CVD), an umbrella term to describe diseases that affect the heart and blood vessels. Although RA can cause debilitating complications, the main cause of death in people with RA is CVD, particularly heart failure.

Heart and RA

Some of the main RA complications affecting the heart include:

Pericarditis: This condition causes inflammation of the sac-like tissue surrounding your heart (called the pericardium) and the lining of your chest cavity, which can cause symptoms such as chest pain and shortness of breath.

Myocarditis: This condition causes inflammation of the heart muscle, or the middle muscle layer of the heart wall. It can weaken the heart and its electrical system, thereby reducing the heart’s ability to pump blood.

Cardiac arrhythmia: Abnormal heart rhythms may stem from issues with the heart’s electrical system. These can cause rheumatoid nodules, as well as cardiac ischemia (decreased blood flow and oxygen to the heart) and amyloidosis (buildup of abnormal amyloid protein deposits in the heart).

Coronary artery disease (CAD): This is likely due to atherosclerosis (the buildup of waxy, fatty deposits called plaques in the arteries) tied to RA inflammation.

Heart failure: People with RA are twice as likely to have heart failure compared to the general population, with more people assigned female at birth developing the disease than people assigned male at birth. Systemic inflammation due to elevated levels of inflammatory substances such as CRP, RF, ACPA, and cytokines may worsen heart failure in people with RA.

Blood vessels and RA

Vasculitis, also called angiitis or arteritis, is a rare but serious complication of rheumatoid arthritis. It’s an autoimmune condition that causes inflammation in your blood vessels. The narrowing of blood vessels due to inflammation can impede blood flow and affect multiple organs and body systems. It may also raise the risk of other health issues such as leg ulcers and blood clots that form in veins (deep vein thrombosis), or that travel to your lungs (pulmonary embolism) or brain (stroke).

Vasculitis can occur by itself or alongside rheumatic diseases such as RA and lupus. It can also be triggered by infections such as hepatitis B or hepatitis C.

Eyes and RA

Eye inflammation associated with RA can cause eye pain, redness, and vision problems. You may also experience Sjögren's syndrome, an autoimmune disease that attacks your salivary and tear glands, causing dry eyes and mouth. You may also develop rheumatoid nodules in your sclera, the white portion of the eyeballs.

Lungs and RA

Rheumatoid lung disease describes a group of lung conditions associated with rheumatoid arthritis. These include:

• Bronchiolitis obliterans (blockage of the small airways)
• Pleural effusions (fluid in the chest, which can leak out)
• Pulmonary hypertension (high blood pressure in your lungs)
• Pulmonary fibrosis (scarring of lung tissue)
• Rheumatoid nodules in your lungs

Mental health and RA

People living with rheumatoid arthritis are twice as likely to experience depression compared to the general population, according to a 2020 review of studies published in Rheumatology and Therapy. Up to 48 percent of people with RA have depression, almost 17 percent of which involves major depressive disorder.

In addition to feeling depressed, people with RA often report feeling tearful, irritable, frustrated, and anxious. The psychological impact of the disease may be associated with the stress of coping and trying to manage RA symptoms over the long term. Mental and emotional stress can also interfere with immune function, and chronic inflammation can influence your mood and mental well-being through its effects on your central nervous system (CNS).

Muscles and RA

Rheumatoid arthritis can weaken muscles around or close to your affected joints. Joint ankylosis may occur when joints fuse together, causing them to become stiff and rigid. Myositis (muscle inflammation) may also occur. All these issues can make it more challenging to move around and perform your daily tasks.

Certain medications used to treat RA may also contribute to muscle weakness, including corticosteroids and certain disease-modifying antirheumatic drugs (see more below).

Nervous system and RA

Rheumatoid arthritis can affect your CNS and peripheral nervous system (PNS), thereby potentially affecting your brain, spinal cord, and the many nerves that run through your brain and body. Neurological symptoms associated with RA can range from numbness or tingling in your hands and feet to sudden death due to issues such as stroke or compression of the medulla oblongata, the tail-like structure at the base of the brain that connects the brain to the spinal cord.

These symptoms are often due to compression of the nerves in the spinal cord caused by RA inflammation.

Central nervous system (CNS) complications of RA

Examples of complications involving the CNS include:

• Cervical myelopathy, which involves compression of the spinal cord in the neck. This is the most common CNS complication. Estimates of its occurrence range widely from 5 percent of people with RA up to 50 percent.
• Rheumatoid nodules within the CNS
• Progressive multifocal leukoencephalopathy, which affects the white matter of the brain and results in symptoms such as clumsiness, weakness, and changes to vision, speech, and personality. The use of biologic drugs to treat RA may also increase the risk of this complication.
• Quadriplegia (paralysis of the limbs)
• Vasculitis (inflammation of the blood vessels)
• Rheumatoid meningitis, which involves inflammation of the tissue that surrounds the brain and spinal cord and may result in stroke-like symptoms

A 2021 review and analysis of studies published in PLoS One also found a 36 percent higher risk of stroke in people with various arthritis types such as RA, PsA, and gout. The analysis found a 53 percent higher risk of ischemic stroke (which involves the death of brain tissue due to a lack of blood supply) and 45 percent higher risk of hemorrhagic stroke (bleeding in the brain due to blood vessel rupture) in people with RA, especially those younger than 45.

Peripheral nervous system (PNS) complications of RA

PNS complications occur in about 30 percent of people with RA. These can involve issues involving nerve compression such as carpal tunnel syndrome. Other examples include:

• Tarsal tunnel syndrome, which involves nerve compression or damage to the nerve that travels through the heel and sole of the foot called the posterior tibial nerve, causing burning, tingling, or shooting pain in the ankle, foot, and sometimes the toe)
• Small vessel vasculitis, which can cause nerve damage that may affect one’s ability to move or result in numbness, tingling, or a burning feeling
• Mononeuritis multiplex, which is caused by small vessel vasculitis, entails damage to two or more peripheral nerve areas. This may lead to symptoms such as numbness, tingling, lack or loss of sensation, loss of bowel or bladder control, and weakness or paralysis in one or more areas of the body.

The widespread use of biological disease-modifying antirheumatic drugs (DMARDs) to treat RA has also contributed to higher rates of Guillain-Barré syndrome (GBS) and other severe demyelinating diseases that affect the CNS and PNS. Demyelinating diseases such as GBS and multiple sclerosis occur due to the loss of myelin, the fatty tissue that surrounds and protects nerves.

Skin and RA

You may notice rheumatoid nodules appearing on your skin due to inflammation of small blood vessels. These are visible but often painless bumps that form beneath your skin at or near your joints.

RA skin nodules can be small like peas or grow as large as lemons. Some move easily when touched while others are stiff and attached to deeper tissues. They usually form on the elbow, underside of the forearm, and areas that experience more pressure or irritation such as your:

• Achilles tendon
• Back of your head
• Base of your spine
• Feet and heels
• Fingers
• Knees
• Tendons in your hand

Sleep and RA

More than 80 percent of people with rheumatoid arthritis experience sleep issues such as sleep latency (problems falling asleep), waking up multiple times at night, and waking up too early—all of which can lead to excessive daytime sleepiness. Sleep disorders such as sleep apnea, restless legs syndrome, and insomnia also occur in people with RA.

Short-term and chronic sleep disturbances and sleep deprivation increase inflammation, including blood markers associated with RA such as C-reactive protein (CRP), IL-6, and TNF. This may be a result of RA itself or due to the side effects of certain rheumatoid arthritis treatments.

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To help determine what’s causing your condition, your HCP will first discuss your symptoms and personal and family medical history. They will then likely conduct a physical exam to:

• Examine your joints
• Observe how you move or perform activities such as walking or bending
• Look for skin issues such as rashes or nodules
• Listen to your heart and lungs

Your HCP might also order lab and imaging tests to diagnose or rule out RA. It’s important to note that no single test can diagnose RA. Rather, the diagnosis is made based on the results of tests in addition to your symptoms, history, and findings from your physical exam.

Blood tests to help diagnose RA

The results of certain blood tests can help confirm or rule out a rheumatoid arthritis diagnosis. These include:

Antibody tests

These mainly involve testing for anti-CCP and RF, although your HCP may test for other autoantibodies.

Complete blood count (CBC)

A CBC measures the main components of your blood and may include:

• Red blood cells (RBCs), including the number of RBCs and mean corpuscular volume, which is the average size of your RBCs
• WBCs (and the various WBC types, if ordered by your HCP)
• Platelets
• Hemoglobin and hematocrit

The results of your CBC may indicate anemia (low RBC count), a common finding in people with RA.

Erythrocyte sedimentation rate (ESR)

An ESR measures how fast erythrocytes (another name for RBCs) sink to the bottom of the test tube. The faster the rate, the greater degree of inflammation present.

C-reactive protein (CRP)

This test measures how much CRP (made by your liver) is in your blood. Like ESR, the higher your CRP levels, the higher the inflammation level in your body tends to be.

Synovial fluid test

This involves removing and analyzing a sample of your synovial fluid to help distinguish between rheumatoid arthritis and other forms of arthritis.

Other blood tests for rheumatoid arthritis diagnosis

Your HCP may also order other lab tests to help diagnose RA or determine if an infection or other condition might be causing your symptoms. Examples include tests to check your:

• Electrolytes (essential minerals found in your body fluids)
• Kidney function
• Liver function
• Thyroid function
• Muscle enzymes (such as creatine phosphokinase and aldolase)
• Other autoimmune disease markers

Imaging scans to help diagnose rheumatoid arthritis

Imaging scans may also be ordered to check for joint damage. These include:

X-ray: Joint or bone damage may not occur in the early stages of RA. Therefore, X-rays may be used to monitor the progression of the disease or to determine or rule out other causes for your joint symptoms.

Magnetic resonance imaging (MRI) or ultrasound (US): An MRI or US can help diagnose RA in the early stages of the disease. These imaging scans can show the extent and severity of joint damage, including joint inflammation and fluid buildup, as well as bone erosion.

Other imaging tests: If additional imaging tests are needed to evaluate the extent of joint or bone damage, your HCP might also recommend a computed tomography (CT), positron emission tomography (PET), or dual-energy X-ray absorptiometry (DEXA) scan to measure bone mineral density.

Rheumatoid arthritis diagnostic criteria

In general, your HCP may make a rheumatoid arthritis diagnosis based on these findings:

• Signs of inflammation in three or more joints, lasting for six weeks or longer
• Positive RF or anti-CCP test results
• Elevated CRP or ESR

Conditions with symptoms similar to rheumatoid arthritis

Certain health conditions may have symptoms that overlap with those seen with RA. To confirm a rheumatoid arthritis diagnosis, your HCP will likely rule out these and other conditions that produce similar symptoms:

• Other arthritis types, including OA, PsA, and gout
• Other autoimmune diseases such as Sjögren's syndrome, scleroderma, and lupus
• Other inflammatory conditions such as Lyme disease, bursitis, reactive arthritis, polymyalgia rheumatica, giant cell arteritis, and sarcoidosis
• Other chronic pain conditions such as fibromyalgia
• Viral infections such as hepatitis B and C, rubella, and HIV

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It’s best to seek prompt medical care for persistent or severe RA symptoms such as joint pain and swelling, especially if these have lingered for more than a few weeks and are accompanied or preceded by systemic symptoms such as low-grade fever and fatigue.

Questions to ask your HCP about RA

If a rheumatoid arthritis diagnosis is confirmed, a few helpful questions to ask your HCP about RA include:

• Will I need to see other healthcare specialists who treat RA, such as a rheumatologist, physiatrist, or orthopedic surgeon?
• Which rheumatoid arthritis treatments work best for my RA type? What are the benefits, risks, and side effects of each treatment?
• How do I prevent and relieve rheumatoid arthritis flare-ups?
• Are there any lifestyle interventions that complement my rheumatoid arthritis treatment plan?
• What’s my prognosis and is there anything I can do to improve it?

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Your HCP will work with you to develop a comprehensive rheumatoid arthritis treatment plan. This will be designed to help:

• Alleviate symptoms such as pain and inflammation
• Maintain and maximize your ability to perform your daily activities
• Prevent, slow, or stop complications such as joint and organ damage

Your RA treatment plan may include medicines, physical therapy (PT) and occupational therapy (OT), and lifestyle strategies. Surgery may also be considered to help restore joint function.

Joint damage can begin within the first few years of having the disease and the damage may be permanent. Your rheumatoid arthritis treatment plan will therefore include early and aggressive measures to quickly reduce and stop inflammation before joint damage and other complications set in.

What medications treat rheumatoid arthritis?

Medicines are fundamental to preventing and treating symptoms and flares and achieving and maintaining RA remission. Several medicines used to manage rheumatoid arthritis will likely be included as part of an effective treatment plan.

Non-steroidal anti-inflammatory drugs (NSAIDs)

NSAIDs help with pain and mild inflammation. Although these medicines can be purchased over the counter (OTC), your HCP may prescribe a higher dose than available with OTC NSAIDs.

NSAIDs commonly used for rheumatoid arthritis treatment include:

• Aspirin
• Celecoxib
• Ibuprofen
• Naproxen

Corticosteroids (also called glucocorticoids or steroids)

Corticosteroids can quickly decrease joint swelling, stiffness, pain, and tenderness. They may be an option if RA symptoms severely limit your ability to carry out your usual daily activities.

A short course of steroids may be added to your rheumatoid arthritis treatment plan to help manage symptoms until slower-acting RA medicines start to take effect. If needed, low-dose steroids are used alongside disease-modifying antirheumatic drugs (DMARDs) to prevent and ease RA symptoms and flares and to keep the disease from progressing.

Because of their potential for serious side effects—such as bone loss, worsening diabetes, insomnia, and higher risk of infection—the goal of steroid therapy is to use the lowest dose possible or the shortest duration. Examples of steroids used to treat RA include:

• Oral steroids: prednisone and prednisolone
• Injectable steroids: hydrocortisone, methylprednisolone acetate, and triamcinolone

Conventional disease-modifying antirheumatic drugs (DMARDs)

Conventional DMARDs (also called traditional DMARDs) are prescribed for most people with RA. These medicines modify your immune system to significantly reduce inflammation, lessen and prevent joint damage, and preserve joint structure and function.

Although some DMARDs act slowly, adding these to your RA treatment plan may facilitate taking a lower dose of steroids to ease pain and inflammation. Conventional DMARDs used to treat RA include:

• Methotrexate
• Hydroxychloroquine
• Leflunomide
• Sulfasalazine
• Janus kinase (JAK) inhibitors such as tofacitinib and baracitinib (JAK inhibitors can be used if other DMARDs don’t improve RA symptoms.)

Biologics (also called biologic DMARDs)

Your HCP may recommend adding biologics to your rheumatoid arthritis treatment plan, if conventional DMARDs alone aren’t sufficient to control your RA. For some people, biologics may be more effective at treating the disease because they target the specific molecules in the body causing joint inflammation.

Biologics can take effect quickly, often within two to six weeks. Those used for rheumatoid arthritis treatment include:

• Abatacept
• Adalimumab
• Anakinra
• Certolizumab
• Etanercept
• Golimumab
• Rituximab
• Tocilizumab

What is the safest medicine for rheumatoid arthritis?

In general, the safest RA medicine for you is the one that confers the most benefit with the fewest side effects. This can vary and change over time, depending on the severity of your symptoms, health history, and current health status (for example, whether you have other health conditions or complications). In most cases, your HCP will recommend a combination of RA treatments to help boost treatment effectiveness while minimizing side effects.

If you take medicines to control and treat RA, it’s important that you keep follow-up appointments with your HCP. During these appointments, your HCP will discuss your current symptoms and whether your treatment plan is working well or needs to be adjusted. They’ll also go over any follow-up test results that were ordered to monitor disease activity and complications associated with RA medicines you’re taking.

Can physical and occupational therapy relieve RA symptoms?

Physical therapy and occupational therapy can help you manage your rheumatoid arthritis symptoms, improve your ability to perform daily activities, and maintain your independence. Physical therapists (PTs) employ techniques to help preserve and restore muscle strength and joint function, including range of motion and flexibility—all of which can help ease RA symptoms.

Occupational therapists (OTs) work with you to maximize your ability to carry out your daily activities at home or work. These strategies might entail making modifications that help you complete activities within your physical capabilities without making your symptoms worse.

Examples of strategies PTs and OTs might employ to help with your arthritis symptoms include:

• Tailored exercise program: This might include aerobic, strength, flexibility, and balance and mobility training (to prevent falls).
• Functional training and activity modifications: These help you engage in desired activities at home, work, and in your community.
• Splints and braces: These devices support and immobilize joints, which can help ease joint pain and prevent injury.
• Orthotics: Custom-made foot and/or ankle orthotics help improve the way you walk, reduce pain and pressure in your foot and ankle, and prevent further joint damage or deformities in these areas from getting worse. Your PT or OT can also recommend certain types of shoes that provide proper support.
• Assistive devices: Lifestyle modifications or certain assistive devices can help make challenging tasks easier, such as opening a jar or walking long distances or uphill and downhill.
• Self-management plans: These can help you better manage symptom and flare-ups and optimize home- and work-based tasks.
• H3: When is surgery used to treat rheumatoid arthritis?

Your HCP may discuss surgical options for severe rheumatoid arthritis symptoms and complications that aren’t well-controlled with other RA treatments. Though surgery may help correct severe joint deformities and restore function to damaged joints, no surgical option can cure RA. Over time, symptoms may once again affect the surgically repaired or reconstructed joint.

What are the types of surgery for rheumatoid arthritis?

Examples of surgeries used to help repair or reconstruct joints damaged by RA include:

• Joint fusion: This involves removing a joint and fusing together the ends of the two bones that meet at the joint, effectively creating one large bone and limiting joint movement.
• Joint arthroplasty (replacement): This involves replacing the damaged joint with healthy tissue (such as tendons) from another part of your body or an artificial joint made from metal, plastic, or silicone rubber. Common types performed on people with RA include knee replacement and hip replacement. 
• Surgical cleaning: This involves removing inflamed and damaged joint tissue to ease pain and improve joint function.

Can dietary changes help with rheumatoid arthritis?

Although diet and nutrition strategies won’t cure RA, healthy eating habits can ease RA symptoms such as pain and swelling, nourish and strengthen your body, and help you keep your weight within a healthy range. This includes choosing healthy foods for rheumatoid arthritis and limiting or avoiding certain foods that may trigger RA symptoms or make them worse.

There isn’t a one-size-fits-all eating plan for RA, but studies have shown that the Mediterranean diet can ease and prevent inflammation. It can also help you prevent or better manage conditions tied to RA such as obesity and cardiovascular disease.

This plant-based eating style emphasizes fresh fruits, vegetables, nuts, seeds, and legumes, with olive oil as your main source of healthy fat. It also includes fish rich in omega-3 fatty acids like salmon, sardines, and tuna, and other lean protein sources. And it includes moderate amounts of dairy products such as milk and cheese and limited amounts of saturated fats from animal products like red meat.

Other foods to limit or avoid include:

• Added sugars, including high-fructose corn syrup
• Alcohol
• Processed meats
• Refined carbohydrates (such as processed foods with added sugar or flour)
• Sodium

A 2021 review and analysis of studies published in Nutrients also found that the Mediterranean diet helps improve pain and inflammation in people with RA, even more so than a vegan or vegetarian diet. The authors of the analysis recommend using caution when adding the diet to your rheumatoid arthritis treatment plan, however. The Mediterranean diet tends to include high amounts of whole grains, which may contain gluten, and gluten sensitivity is common in people with rheumatic diseases like RA.

Talk with an HCP or registered dietitian nutritionist (RDN) before making significant changes to your eating habits, especially if you have allergies or sensitivities to gluten and other foods. An RDN can help you create a safe and effective eating plan to better manage your RA symptoms and help you meet your health goals.

Can complementary and alternative medicine ease RA symptoms?

While some complementary and alternative medicine (CAM) approaches might help with certain rheumatoid arthritis symptoms, these should not be used in place of standard medical treatments for the disease. It’s best to talk with your HCP before trying any CAM approach, as some may not be safe for your condition while others, such as some herbal remedies, may interact with medicines you take for RA.

A few CAM approaches that might offer benefits for people with RA and are unlikely to cause harm include:

• Balneotherapy: This spa therapy involves soaking in a mineral water or mud bath to ease joint symptoms.
• Massage therapy: This relaxation therapy helps relieve muscle stiffness and joint inflammation and pain by boosting blood flow to affected areas.
• Mind-body techniques: These include techniques such as meditation and biofeedback to improve RA symptoms and ease stress and anxiety.

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You may not be able to prevent rheumatoid arthritis, especially since the specific cause of the disease isn’t known. But you can take steps to ease symptoms, prevent RA flare-ups, and improve your quality of life.

In addition to sticking with your rheumatoid arthritis treatment plan, you can adopt certain lifestyle strategies to help ease RA, such as:

Balancing rest and exercise

It’s important to stay physically active on a regular basis when you have RA, but it’s just as important to rest your body when your symptoms flare up. In general, shorter rest breaks are more beneficial than extended periods lying or sitting down.

Exercise helps ease pain, strengthen your bones and muscles, preserve joint mobility, improve balance and flexibility, boost energy, and reduce stress. Rest helps ease RA symptoms such as pain, inflammation, and fatigue (to some degree).

The CDC recommends adults with arthritis get at least:

• 150 minutes a week of moderate-intensity cardio such as brisk walking, or
• 75 minutes a week of vigorous-intensity cardio, such as cycling at a rate of at least 10 miles per hour, or
• An equal combination of moderate and vigorous cardio each week

It’s also important to add activities that improve balance such as standing on one foot while performing certain exercise moves, as well as a minimum of two days a week of strength exercises such as lifting weights.

Change the types and amounts of activity based on your symptoms, and if you haven’t worked out in a while, slowly build up your endurance, strength, and flexibility. Low-impact exercises for rheumatoid arthritis may be a good place to start, as these place less stress on your joints.

Examples of low-impact activities include:

• Brisk walking
• Cycling
• Light gardening
• Swimming
• Water aerobics
• Yoga
• Tai chi

Protecting your joints

This might involve:

• Wearing a splint or brace around your wrists and hands or feet and ankles, as instructed by your HCP, PT, or OT
• Using assistive devices such as items with large grips, zipper pullers, or shoehorns with long handles
• Using tools and devices to help with basic daily activities, such as an adaptive toothbrush or silverware
• Using devices to help you safely get in and out of bed and on and off chairs and toilet seats, such as grab bars or a front-wheel walker, as instructed by your PT or OT
• Keeping to a healthy weight to help ease the stress placed on your joints

Staying away from tobacco smoke

Smoking tobacco can make RA worse and raise your risk of other health conditions associated with RA such as CVD. Therefore, quitting smoking for good is essential to an effective rheumatoid arthritis treatment plan. If you need help quitting, be sure to talk with your HCP about your options.

Managing stress and your mental health

The stress of living with rheumatoid arthritis can feel overwhelming at times. You may sometimes feel anxious, depressed, isolated, and alone. But rather than feeling stuck with these emotions or withdrawing from others, it’s important to find healthy ways to cope with your thoughts, concerns, and emotions.

Aim to:

• Relax with stress-management techniques such as deep breathing, meditation to build resilience, listening to soothing sounds or feel-good music, journaling, or engaging in a peaceful hobby.
• Balance your mind and body with movement-based techniques such as yoga or tai chi.
• Stay socially engaged to boost your mental and physical well-being.
• Reach out to trusted friends, family members, or spiritual advisors for support.
• Seek professional support from a licensed mental health provider or join an online or in-person rheumatoid arthritis support group.

Joining a self-management education class

The CDC also recommends joining an RA self-management workshop. These interactive, community-based programs teach people with RA how to control their symptoms more effectively and how to live better every day with a chronic condition.

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Living with a chronic condition like rheumatoid arthritis can involve highs and lows. There may be times when your symptoms feel like they’ve taken control of your life and other times you’re able to manage your RA and stay in remission.

Taking the time to learn as much as you can about RA and how to navigate its ups, downs, and various treatment and management strategies is worth your effort. Thanks to advanced treatments, a wide selection of assistive devices, and a greater understanding of how lifestyle measures can impact RA, many people are able to stay active and productive and live longer, more fulfilling lives with RA.

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