Rheumatoid arthritis (RA) is a type of autoimmune disease. It causes chronic inflammation in the joints, which can lead to symptoms such as joint pain and swelling, as well as fatigue. This can interfere with a person’s day-to-day activities and quality of life.
If RA is untreated or undertreated, it can progress over time and lead to joint damage and deformity.
First-line RA medications include nonsteroidal anti-inflammatory drugs, which are sometimes called NSAIDs, and some examples are aspirin and ibuprofen (Advil). These drugs can help reduce inflammation and relieve pain.
A person may also use corticosteroids, briefly, to gain quick control over an RA flare. However, neither of these types of medications slows or stops the progression of the disease.
To help prevent disease progression, it is important to also treat RA with:
- traditional disease-modifying antirheumatic drugs (DMARDs), such as methotrexate (Trexall)
- biologic drugs, such as tumor necrosis factor (TNF) inhibitors
- Janus kinase inhibitors, such as tofacitinib (Xeljanz)
These medications each work in a different way to curb disease activity and suppress the overactivity of the immune system that is thought to be involved in RA.
Doctors may even prescribe some of these drugs in tandem to help gain optimal control of RA.
Below, we explore why many people with RA have unmet needs, despite access to these therapies.
Though disease-modifying therapies are available, many people with RA are dissatisfied with their current treatment. They often face challenges related to pain, fatigue, physical function, or mental health, even when they take their treatment exactly as prescribed, according to reviews published in 2016 and 2020.
“Persons with RA often continue to experience significant fatigue and sometimes poor sleep or low mood, despite treatment with DMARDs,” Dr. Jennifer Barton, an associate professor of medicine at Oregon Health & Science University, in Portland, told Medical News Today.
“We know there is a higher prevalence of depression among persons with RA, and they tend to have less of a response to biologic DMARD therapy, like TNF inhibitors,” she said.
One web-based survey published in 2019 evaluated 258 people with RA who were taking one or more disease-modifying therapy. Only 26% of respondents were satisfied with their treatment. Many said that fatigue, pain, or other symptoms still had a moderate-to-severe impact on their lives.
Multiple factors may contribute to persistent symptoms and low treatment satisfaction among people with RA.
Current treatment guidelines recommend a treat-to-target approach for RA. With this approach, healthcare providers use tests to regularly assess disease activity. If certain targets are not met, they recommend adjustments to the person’s treatment plan.
The treat-to-target approach often helps improve treatment outcomes for people with RA, researchers reported in 2019.
However, a treatment plan does not always meet all of a person’s needs. Moreover, some symptoms and their impact on daily living may not be well captured by the assessments that providers use in their treat-to-target approach, according to a 2020 review.
For example, test results might indicate that a person has low levels of inflammation in their joints, leading the doctor to conclude that the treatment plan is working well.
However, the person might still be experiencing joint pain or fatigue and find it hard to do activities that matter to them. This can leave them dissatisfied.
“Many times, we may not realize that the patient is unhappy,” Dr. Nilanjana
Bose, a rheumatologist at the Rheumatology Center of Houston, told MNT.
“We may be happy with the outcome because we find that their joints are doing better and their lab [results] are looking better,” she said. “But if the patient is dissatisfied, then it would be helpful to let the doctor know.”
Trust, open communication, and shared decision making are important for ensuring that a person’s needs are met, Dr. Bose noted. But that kind of relationship can take time and effort to build. “You don’t form a relationship in 1 day or 2 days,” she told MNT. “It takes time, it takes patience, it takes commitment from both sides.”
When symptoms persist despite treatment, it is sometimes because RA is still active. Testing may indicate that inflammation is still present in the joints.
If following a treatment plan is challenging, the medication might not be working as well as it could. This can happen if a person is not taking the medication consistently or taking the wrong dosage.
If a person is following their treatment plan exactly as prescribed, the medication might simply need more time to work. “I will give most drugs at least a 3- to 4-month solid trial, that is, if it is used at the right dosage and in the right way,” said Dr. Bose.
If the disease is still active after this trial period, it may be time to try another treatment. People with RA may need to try more than one drug, or a combination, to find what works best for them.
Some people may be reluctant to change their treatment due to a fear of side effects or other concerns, the authors of a 2020 review report. Speak with the doctor to learn more about the potential benefits and risks of adjusting the treatment plan.
Lifestyle habits may also contribute to persistent RA symptoms.
“Anxiety, stress, poor diet, lack of exercise — all these things in conjunction can lead to a poor outcome,” said Dr. Bose. “A person could be on the best treatments and not achieve good results if we’re not optimizing the lifestyle measures as well.”
To learn whether lifestyle changes may help, a person should speak with their doctor. “We as rheumatologists need to do better to talk about sleep, mood, and physical activity with our patients,” Dr. Barton urged, “and patients should feel they have the opportunity to focus on things that matter to them.”
In some cases, a person’s doctor might refer them to another specialist. “It may be appropriate to refer patients for physical or occupational therapy, or aqua therapy, if available,” said Dr. Barton. “The primary care clinician may also recommend a referral to a mental health provider.”
Symptoms that persist, even though the person is following their treatment plan, may stem from a related complication or another condition altogether.
People with RA may develop permanent joint damage as a complication of the disease. This may contribute to pain and disability, even after treatment brings RA under control.
People with RA also have an increased risk of developing certain health issues. For example, when investigators combined the results of multiple studies, they found that fibromyalgia affects 21% of people with RA, and fibromyalgia can also cause pain and fatigue.
To learn more about what might be causing symptoms, people with RA should speak with their healthcare team.
It might help to ask:
- Could these symptoms be caused by something other than RA?
- What are the other potential causes?
- What types of testing can help determine any related causes?
Researchers continue to develop and test new approaches to RA treatment. These therapies, once realized, may help address needs that are currently unmet.
Some medications under evaluation target immune cells that are not targeted by existing treatments. Others represent “new generations” of existing classes of drugs.
To learn which treatments are most likely to benefit which people, researchers are also working to identify specific genetic biomarkers of RA.
So far, scientists have found no strong, consistent links between genetic variants and improved treatment responses, experts report in Autoimmunity Reviews. However, the investigations continue.
While various treatment options are available, many people with RA are dissatisfied by how well their medication is controlling their disease.
It is essential for people with RA to take their medications as prescribed and give them time to work. It is also important for doctors and patients to cultivate a relationship, as open communication and shared decision making can help address issues and improve outcomes.
In some cases, a doctor may recommend changes to a person’s treatment plan or lifestyle habits. This might help bring RA under control or address other underlying health issues.
Ongoing research may help improve treatment options in the future.