Rheumatoid arthritis: Medication to prevent joint damage (2023)

Rheumatoid arthritis can lead to permanent damage in the affected joints. "Disease-modifying" medications can slow down or stop the progression of the disease. They also relieve the pain and swelling.

Disease-modifying drugs reduce the inflammation in the joints, which helps to prevent joint damage. They are used regularly and continuously – in other words, even during symptom-free phases. It takes several weeks or months for them to start having a noticeable effect. These drugs are also known as DMARDs ("Disease-modifying anti-rheumatic drugs“).

There are two main groups of disease-modifying drugs: conventional DMARDS and biologic DMARDs (biologics).

What are conventional disease-modifying drugs?

When disease-modifying treatment is started, conventional DMARDs are used at first. These include:

  • Methotrexate (MTX)

  • Leflunomide

  • (Hydroxy)chloroquine

  • Sulfasalazine

Methotrexate is considered to be the best tolerated of these drugs in the long term, so it is typically the first medication that is tried out. Methotrexate can be taken once a week as a tablet or injected as a solution. The dose is usually between 15 and 25 mg, depending on the person's body weight, and it is gradually increased over the first few weeks of treatment.

The various conventional DMARDs work in different ways, and can have different effects in different people. So if one medication doesn't help or isn't well tolerated, other medications can be tried out.

How are the medications used?

The choice of drug depends on various factors, including how doctors think the condition will develop, how far it has progressed, and whether certain medications can't be used, for instance because the person has other medical conditions.

Generally speaking, treatment is started using methotrexate as a basic therapy. Because it can take a while for methotrexate to start working, it is often combined with the steroid medication prednisolone at first. After a few weeks you have an appointment with the doctor to see whether the treatment is helping. The appointment involves physical examinations, blood tests and sometimes x-rays too.

After six months, the goal of treatment should be reached: a complete – or at least very noticeable – reduction in inflammation. If that hasn’t happened, methotrexate can be combined with a different conventional disease-modifying drug or with a biologic drug. If people have to stop using methotrexate because they don't tolerate it well, they can carry on using a biologic drug on its own.

The aim of long-term treatment with disease-modifying drugs is to prevent joint damage, or delay it for a long time, if possible. Some people switch to a different medication after a while, for example because they don't tolerate the first medication well or because it's no longer effective enough. In other people, the dose and number of medications can be reduced after a while. But disease-modifying drugs don't have a noticeable effect in some people, so they stop using them.

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How effective are drugs like methotrexate?

Research has shown that conventional disease-modifying drugs can prevent damage to joints and relieve symptoms. In research on medication for rheumatoid arthritis, a treatment is considered to work if it reduces swelling in the joints and at least three of the following improvements occur:

An analysis of methotrexate studies that lasted one year found the following:

  • Symptoms were reduced by at least a half in 23 out of 100 people who took methotrexate.

  • Symptoms were reduced by the same amount in 8 out of 100 people who took a placebo (fake drug) for comparison.

So treatment with methotrexate helped 15 out of 100 people to feel significantly better. Symptoms like morning stiffness also improved in a lot more people who took a conventional disease-modifying drug.

There hasn't yet been any good-quality research looking into whether one particular conventional disease-modifying drug is more effective than any of the others.

What are the possible side effects?

Methotrexate is the most commonly used conventional DMARD because it is usually well tolerated. But it can still cause various side effects. These include:

  • Gastrointestinal (stomach and bowel) problems and nausea: in about 5 out of 100 people – particularly at the start of the treatment.

  • Upper airway infections: About 12 out of 100 people had more colds or acute bronchitis infections within the first year.

  • Hair loss: in about 5 out of 100 people.

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  • Inflammations of the membranes lining the inside of the mouth: in about 4 out of 100 people.

Most people can cope well with the side effects. But in about 3 out of 100 people the side effects are so bad that they stop the treatment.

Leflunomide, hydroxychloroquine and sulfasalazine can also cause side effects such as gastrointestinal problems and nausea. As well as that, leflunomide can lead to weight gain and an increase in blood pressure, sulfasalazine can cause allergic skin reactions, and hydroxychloroquine can lead to vision problems.

Many people accept mild side effects because the treatment is effective and helps them cope better with the disease in everyday life. And mild side effects are often only temporary. That was also shown in research: People who took these medications were more likely to continue treatment than those who used a placebo containing no active ingredient.

What can you do about the side effects?

Some of methotrexate's side effects occur because it interferes with the effect that folic acid has in the body. The risk of these side effects can be lowered by also taking low-dose folic acid (5 to 10 mg) once a week. Studies have shown that this helped more than half of the people who had side effects to continue their treatment with methotrexate.

It is also possible to inject the medication under the skin or into a muscle instead: When the medication is given in this way, side effects such as nausea, diarrhea and inflammations of the membranes lining the mouth are less common.

Because of the increased risk of infections, pneumonia is more likely to develop. In very rare cases the medications can cause other serious side effects too, such as liver damage or changes in blood cell count. In order to detect these kinds of serious side effects earlier, blood and urine samples are tested regularly during the treatment. It's generally always important to talk to a doctor if side effects occur.

When deciding which medication to use, it's also important to take other medical conditions into account. For instance, in very rare cases hydroxychloroquine can damage the retina (lining of the back of the eye) so it isn't suitable for people who have a retinal disease. Because sulfasalazine can lead to allergic skin reactions, it shouldn't be used in people who have certain allergies.

When are biologics an option?

Biologic drugs are made from living cell cultures. They work by, for instance, interfering with certain chemical messengers in the body's immune system, and that influences the rheumatic inflammatory response. These drugs are sometimes also called biologic disease-modifying antirheumatic drugs (biologic DMARDs).

Biologics are considered as a treatment option for rheumatoid arthritis when conventional DMARDs haven't helped enough. Biologics are typically used in combination with methotrexate. People who don't tolerate methotrexate well can start treatment with a biologic only. All of the biologics approved in Germany so far are given as an injection or an infusion (a drip). It's also possible to inject the drug under your skin yourself.

The following biologic DMARDs have been approved for use in Germany and other countries:

  • Abatacept

  • Adalimumab

  • Anakinra

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  • Certolizumab pegol

  • Etanercept

  • Golimumab

  • Infliximab

  • Rituximab

  • Tocilizumab

Biologics can reduce pain, swelling and morning stiffness, and also help against fatigue. But they can have various side effects too. For example, skin rashes, itching or pain can occur where the injection or infusion needle was inserted. They may lead to infections of the airways as well.

If a biologic is used in addition to basic therapy with methotrexate, within one year an extra 16 out of 100 people are symptom-free or experience a clear improvement in symptoms. But an extra 9 out of 100 people develop an infection of the airways, and 2 out of 100 have a severe infection.

What should women be aware of if they're pregnant or trying for a baby?

Methotrexate and leflunomide can lead to the development of birth defects in an unborn baby. There is some evidence to suggest that these drugs might damage genetic material (genes) in men's sperm too. So it's important to use safe contraception if you are on these medications. It's still important to use safe contraception for some time afterwards as well: for six months after stopping treatment with methotrexate, and even for two years after treatment with leflunomide. Women who are breastfeeding also shouldn't use methotrexate or leflunomide during that time.

Ideally, women who have rheumatoid arthritis and would like to have children should talk to their doctor before they get pregnant. Otherwise, they should do so as soon as they find out that they are pregnant.

There is also some evidence to suggest that methotrexate can reduce women's and men's fertility while they are taking them. Sulfasalazine can reduce men's sperm count too.


  • Götestam Skorpen C, Hoeltzenbein M, Tincani A, Fischer-Betz R, Elefant E, Chambers C et al. The EULAR points to consider for use of antirheumatic drugs before pregnancy, and during pregnancy and lactation. Ann Rheum Dis 2016; 75(5): 795-810. [PubMed: 26888948]

  • Institute for Quality and Efficiency in Health Care (IQWiG, Germany). Biologic medications as second-line therapy for rheumatoid arthritis: Final report; Commission A10-01. June 28, 2013. (IQWiG reports; Volume 180).

    (Video) Rheumatoid Arthritis Success! Pain Relief After 20 Years | Daniel Ganu, DrPH
  • Institute for Quality and Efficiency in Health Care (IQWiG, Germany). Biotechnologically produced drugs for the treatment of rheumatoid arthritis : Final report; Commission A16-70. July 23, 2019. (IQWiG reports; Volume 795). [PubMed: 31738499]

  • Ledingham J, Snowden N, Ide Z. Diagnosis and early management of inflammatory arthritis. BMJ 2017; 358: j3248. [PubMed: 28751303]

  • Liu L, Liu S, Wang C, Guan W, Zhang Y, Hu W et al. Folate Supplementation for Methotrexate Therapy in Patients With Rheumatoid Arthritis: A Systematic Review. J Clin Rheumatol 2019; 25(5): 197-202. [PubMed: 29975207]

  • Lopez-Olivo MA, Siddhanamatha HR, Shea B, Tugwell P, Wells GA, Suarez-Almazor ME. Methotrexate for treating rheumatoid arthritis. Cochrane Database Syst Rev 2014; (6): CD000957. [PMC free article: PMC7047041] [PubMed: 24916606]

  • Shea B, Swinden MV, Tanjong Ghogomu E, Ortiz Z, Katchamart W, Rader T et al. Folic acid and folinic acid for reducing side effects in patients receiving methotrexate for rheumatoid arthritis. Cochrane Database Syst Rev 2013; (5): CD000951. [PMC free article: PMC7046011] [PubMed: 23728635]

  • Smolen JS, Landewé RB, Bijlsma JW, Burmester GR, Dougados M, Kerschbaumer A et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. Ann Rheum Dis 2020 [Epub ahead of print].

  • IQWiG health information is written with the aim of helpingpeople understand the advantages and disadvantages of the main treatment options and healthcare services.

    Because IQWiG is a German institute, some of the information provided here is specific to theGerman health care system. The suitability of any of the described options in an individualcase can be determined by talking to a doctor. We do not offer individual consultations.

    (Video) Rheumatoid Arthritis Flare: Causes, How to Prevent and Treat

    Our information is based on the results of good-quality studies. It is written by ateam ofhealth care professionals, scientists and editors, and reviewed by external experts. You canfind a detailed description of how our health information is produced and updated inour methods.


How can you prevent joint damage from rheumatoid arthritis? ›

Here's how to keep your joints healthy as you age:
  1. Stay at a healthy weight. Extra pounds put pressure on weight-bearing joints like hips and knees. ...
  2. Control your blood sugar. ...
  3. Exercise. ...
  4. Stretch. ...
  5. Avoid injury. ...
  6. Quit smoking. ...
  7. Eat fish twice a week. ...
  8. Get routine preventive care.

What is the most effective medication for rheumatoid arthritis? ›

Methotrexate is usually the first medicine given for rheumatoid arthritis, often with another DMARD and a short course of steroids (corticosteroids) to relieve any pain. These may be combined with biological treatments.

What is the best and safest drug for rheumatoid arthritis? ›

Methotrexate is widely regarded as one of the safest of all arthritis drugs, though it carries some potential downsides. Gastrointestinal symptoms such as nausea and vomiting are its most frequent side effects.

What is the new pill for rheumatoid arthritis? ›

The newest drugs for the treatment of rheumatoid arthritis are the Janus kinase (JAK) inhibitors, which are FDA approved under the brand names Rinvoq, Olumiant, and Xeljanz.

Does methotrexate prevent joint damage? ›

Methotrexate is one of a group of medications called disease‐modifying antirheumatic drugs (DMARDs) and it is the most common treatment for rheumatoid arthritis. Methotrexate helps prevent further permanent damage that can happen if rheumatoid arthritis is not treated.

What stops joint damage? ›

Movement and Exercise

First and foremost, movement and regular exercise are vital in preventing permanent joint damage.

What is the first choice drug to treat rheumatoid arthritis? ›

Methotrexate is often the first drug prescribed for people newly diagnosed with rheumatoid arthritis. RA patients take this medication weekly, alone or in combination with other medications. High dose methotrexate is also used to treat some cancers.

What can I take instead of methotrexate for RA? ›

Leflunomide (Arava®) Leflunomide is also an effective DMARD. Its efficacy is similar to methotrexate in terms of signs and symptoms, and is a viable alternative to patients who have failed or are intolerant to methotrexate. Leflunomide has been demonstrated to slow radiographic progression.

Which is better methotrexate or hydroxychloroquine? ›

Methotrexate is a common treatment for some types of cancer, rheumatoid arthritis, and psoriasis, but it can have many side effects. Hydroxychloroquine (Plaquenil) is an effective medication for autoimmune conditions (such as rheumatoid arthritis and lupus) and certain types of malaria.

What is the safest anti-inflammatory drug for arthritis? ›

For example, celecoxib is considered safe for treating long-term arthritis pain. It's generally less damaging to the stomach than other NSAIDs.

What is the best climate for rheumatoid arthritis? ›

Just as the effects of weather vary, the best climate may not be the same for all people. But based on research, it appears that for most people with arthritis, a warmer, drier climate may be optimal, such as that in parts of Texas, Arizona, Nevada and the Eastern Sierra region of California.

Is there one pill a day for rheumatoid arthritis? ›

Olumiant is a once-daily pill to treat adults with moderately to severely active rheumatoid arthritis (RA) who didn't find relief from biologic medicines called tumor necrosis factor (TNF) blockers, such as Humira® (adalimumab), Enbrel® (etanercept), and Remicade® (infliximab).

What is the gold standard drug for rheumatoid arthritis? ›

Methotrexate was introduced for treatment of cancers more than 50 years ago due to its antiproliferative action but it has become the DMARD of choice for rheumatic diseases owing to its anti-inflammatory activities.

What is the new arthritis medication in 2023? ›

Several biosimilars for the world's best-selling drug are set to launch in the U.S. in 2023. Adalimumab — commonly known by its brand name, Humira — is getting more competition this year. Its first “biosimilar” came on the market at the end of January and at least eight more are expected in 2023.

What is the gold standard for rheumatoid arthritis? ›

The current gold standard treatment for rheumatoid arthritis combines a monoclonal antibody and TNF (tumor necrosis factor) inhibitor called adalimumab with a folic acid antagonist called methotrexate.

Why should you not touch methotrexate? ›

Even touching or inhaling the dust from the tablet can allow the medicine to get into the body. Methotrexate goes into sperm, so it's important that a man taking it doesn't get his partner pregnant. Whether you're male or female, you must use birth control while taking methotrexate.

Why people stop taking methotrexate? ›

The main reasons for discontinuation were adverse effects. Taken over a long period of time, methotrexate can lead to a different set of side effects. “Long term, there is a risk of liver toxicity,” Kaye says.

What are the disadvantages of methotrexate? ›

Methotrexate may cause side effects. Tell your doctor if any of these symptoms are severe or do not go away:
  • dizziness.
  • drowsiness.
  • headache.
  • swollen, tender gums.
  • decreased appetite.
  • reddened eyes.
  • hair loss.
Apr 15, 2017

What vitamin is good for joint repair? ›

Glucosamine and chondroitin are two of the most commonly used supplements for arthritis. They're components of cartilage—the substance that cushions the joints. Research on these supplements has been mixed, in part because studies have used varying designs and supplement types.

Can you reverse the joint damage of arthritis? ›

Is it possible to reverse arthritis? A person cannot reverse arthritis, but they can manage their symptoms. Arthritis commonly causes joint inflammation with swelling, pain, and stiffness. According to the Arthritis Foundation, almost 60 million adults and 300,000 children have some form of arthritis.

What medication is used to slow the progression of rheumatoid arthritis? ›

Conventional DMARDs .

These drugs can slow the progression of rheumatoid arthritis and save the joints and other tissues from permanent damage. Common DMARDs include methotrexate (Trexall, Otrexup, others), leflunomide (Arava), hydroxychloroquine (Plaquenil) and sulfasalazine (Azulfidine).

Is there a natural alternative to methotrexate? ›

A 2015 study of 207 patients with rheumatoid arthritis showed that Tripterygium wilfordii Hook F (TwHF), an herb used in Chinese traditional medicine, was superior to methotrexate monotherapy - as either a monotherapy itself or in combination with methotrexate.

What is the once a week drug for rheumatoid arthritis? ›

When methotrexate is used for rheumatoid arthritis, it is taken either once a week or in three divided doses over 36 hours once a week. Folic acid is normally prescribed to be taken on a different day to methotrexate.

What is the best RA medication with the least side effects? ›

The RA drug with the least side effects is hydroxychloroquine (Plaquenil). “We don't consider it immunosuppressive, and it doesn't cause elevated liver markers or kidney issues like some of the other drugs,” says Dr. Sharmeen.

Can you manage rheumatoid arthritis without medication? ›

Regular physical activity can help relieve adult arthritis pain as effectively as over-the counter medications. Physical activity has many additional benefits, including improved physical function and mood, decreased disability and reduced anxiety.

What is an alternative to hydroxychloroquine for RA? ›

  • Prednisone.
  • Meloxicam.
  • Celebrex.
  • Remicade.
  • Plaquenil.
  • Cimzia.

What is safer than methotrexate? ›

While there is no ideal alternative to methotrexate that works as quickly, rheumatologists say another oral medication, leflunomide, has comparable efficacy and safety rates as methotrexate (MTX).

Does methotrexate make you gain weight? ›

A side effect, in this case, is weight gain. Studies have proved that methotrexate can cause a small amount of weight gain in people with rheumatoid arthritis, especially if they have lost weight due to the ailment.

Does hydroxychloroquine slow down rheumatoid arthritis? ›

Hydroxychloroquine (Plaquenil) is a disease-modifying anti-rheumatic drug (DMARD). It can decrease the pain and swelling of arthritis which can prevent joint damage leading to long-term disability.

What is the strongest natural anti-inflammatory? ›

1. Omega-3 fatty acids. Omega-3 fatty acids , which are abundant in fatty fish such as salmon or tuna, are among the most potent anti-inflammatory supplements. These supplements may help fight several types of inflammation, including vascular inflammation.

What is the number one anti-inflammatory drug? ›

Research shows diclofenac is the strongest and most effective non-steroidal anti-inflammatory medicine available.10 Diclofenec is sold under the prescription brand names Cambia, Cataflam, Zipsor, and Zorvolex. It is also available as a topical gel, Voltaren, which is available over the counter.

Is CBD good for arthritis? ›

Cannabidiol (CBD) is a non-psychoactive cannabinoid that has shown promise in preclinical studies to reduce inflammation and pain associated with arthritis.

Is sun good for rheumatoid arthritis? ›

Sun helps the body synthesize vitamin D, which is essential for bone health and a well-functioning immune system; vitamin D deficiency has been linked to autoimmune diseases, including rheumatoid arthritis (RA). Plus, sunshine boosts mood by raising levels of the neurotransmitter serotonin in the brain.

Does air conditioning make rheumatoid arthritis worse? ›

Temperature plays a large role in the pain relief cycle, thus the use of air conditioning can in fact help elevate some of the symptoms of arthritis.

Is heat or ice better for rheumatoid arthritis? ›

Heat therapy may be used to relieve muscle and joint stiffness, help warm up joints before activity, or ease a muscle spasm. Cold can reduce inflammation, swelling, and pain related to arthritis and activity. (It is also recommended to treat many acute injuries.)

What is the over the counter substitute for prednisone? ›

You can hardly find prednisone cream over the counter, but an OTC 1% hydrocortisone cream may be an alternative, for example, if you have a severe allergic rash.

Is ibuprofen 800 good for rheumatoid arthritis? ›

Descriptions. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) used to treat mild to moderate pain, and helps to relieve symptoms of arthritis (osteoarthritis, rheumatoid arthritis, or juvenile arthritis), such as inflammation, swelling, stiffness, and joint pain.

How long does it take for rheumatoid arthritis to damage joints? ›

Bone erosion and destruction of cartilage can happen quickly within the first two years that you have rheumatoid arthritis, and the damage may continue to develop over time.

Can joint damage from arthritis be reversed? ›

Is it possible to reverse arthritis? A person cannot reverse arthritis, but they can manage their symptoms. Arthritis commonly causes joint inflammation with swelling, pain, and stiffness. According to the Arthritis Foundation, almost 60 million adults and 300,000 children have some form of arthritis.

What causes joint damage in rheumatoid arthritis? ›

In a joint with RA, the lining of the joint becomes inflamed, causing damage to joint tissue. This tissue damage can cause long-lasting or chronic pain, unsteadiness (lack of balance), and deformity (misshapenness).

What causes most of the joint damage in RA? ›

In rheumatoid arthritis, your immune system attacks healthy tissue in your joints. It can also cause medical problems with your heart, lungs, nerves, eyes and skin. Doctors don't know what starts this process, although a genetic component appears likely.

What is the average lifespan of someone with rheumatoid arthritis? ›

In the study, the median survival rate for healthy adults was approximately 82 years while the median survival rate for people with RA was approximately 77 years.

Can rheumatoid arthritis go into remission? ›

With aggressive treatment, RA can go into remission (no visible signs or symptoms. Learn if it's possible to take less medication or even a drug holiday. There is no cure for rheumatoid arthritis (RA), but remission can feel like it.

Is my life over if I have rheumatoid arthritis? ›

RA doesn't directly shorten your life. But it does raise your odds of getting some serious health conditions (your doctor will call them complications) that could affect your health and life expectancy: Heart disease. RA makes you more likely to develop cardiovascular disease.

Can vitamin D reverse rheumatoid arthritis? ›

Another study revealed that a higher intake of vitamin D and omega-3 fatty acids may be associated with better treatment results in patients with early rheumatoid arthritis.

How do you put RA in remission naturally? ›

Natural remedies
  1. Stretching. Stretching the muscles around the affected joints can provide some relief from RA symptoms. ...
  2. Exercise. ...
  3. Heat and cold. ...
  4. Balanced rest. ...
  5. Stress relief. ...
  6. Cognitive behavioral therapy. ...
  7. Support groups. ...
  8. Assistive devices.

Can you stop rheumatoid arthritis from progressing? ›

Many people with rheumatoid arthritis (RA) can silence their symptoms and halt progression of the disease thanks to biologics, targeted DMARDs and more aggressive treatment approaches. Yet some patients who achieve remission struggle to sustain it.

What is the least affected joint in rheumatoid arthritis? ›

The shoulders, elbows, knees, and ankles are also affected in many patients. The distal interphalangeal (DIP) joints are generally spared. With the exception of the cervical spine, the spine is unaffected.

What is the most affected joints in rheumatoid arthritis? ›

The joints most often affected by RA are in the hands, wrists, feet, ankles, knees, shoulders, and elbows. Symptoms may include joint pain, stiffness, and swelling; decreased and painful movement; bumps over small joints; and fatigue or fever.

What can be mistaken for rheumatoid arthritis? ›

Conditions That Can Look Like RA
  • Lyme Disease.
  • Psoriatic Arthritis.
  • Sjögren's Syndrome.
  • Gout.
  • Fibromyalgia.
  • Lupus.
Sep 4, 2022


1. Science Reports Successful Treatment for Arthritis, Joint Pain, & Rheumatoid Arthritis
(Bob & Brad)
2. Best Tip For Rheumatoid Arthritis – Joint Pain Relief By Dr.Berg
(Dr. Eric Berg DC)
3. HOW TO TREAT RHEUMATOID ARTHIRITIS. RA Signs and Symptoms and Management.
4. Rheumatoid Arthritis Joint Damage Explained | Biologic Medicine | Dr. Lia Jamian
(AmeriStaff Nursing Services)
5. 1 Cup a Day Takes Joint Pain Away | Dr. Mandell
6. Inflammatory Arthritis Medications Simplified
(Arthritis Society Canada)


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