The incidence of rheumatoid arthritis (RA) in 2017 was 23.4 cases per 100,000 people, up from 19.3 per 100,000 in 1990 (a 21 percent jump), according to a report published in September 2019 in the Annals of Rheumatic Diseases.

Overall, it affects about 1.35 million people in the United States, according to a report published in September 2017 in the journal Rheumatology International.

There's no known cure for this condition. Treatment instead focuses on effectively stopping the progression of the disease in the following ways:

Reducing symptoms and long-term complications, such as pain and joint swelling
Getting joint inflammation under tight control or stopping it altogether (putting the disease in remission)
Minimizing joint and organ damage
Improving physical function and quality of life

Achieving RA remission is a lot easier for people who don't have high disease activity — that is, people who don't have inflammation that affects numerous joints, evidence of bone erosion, rheumatoid nodules, or blood that's positive for certain inflammation-related antibodies, among other things.

Drugs, physical therapy, and surgery are proven therapies for rheumatoid arthritis.

Treat-to-Target for Rheumatoid Arthritis

Treat-to-target is a new treatment paradigm for rheumatoid arthritis that involves doctors and patients having an open and ongoing discussion about the target for treatment. This is important for shared decision-making.

This process involves patients describing their treatment goals, acceptable pain levels, and requirements for conducting daily functions. From there, the patient and doctor come up with a reasonable disease target — high, moderate, or low disease activity or full remission — and determine how to get there.

Low disease activity may be the ideal initial goal for most people, the American College of Rheumatology (ACR) declared in guidelines published in Arthritis Care & Research in July 2021. The panel noted that remission can be difficult to achieve, especially for people with moderate or severe disease.

The physician continually monitors (using standardized tools) disease activity and explains why specific therapies are being used, and the patient shares his or her symptoms and experiences. For optimized care, the physician will adjust the medications and therapies accordingly on an ongoing basis.

Research suggests treat-to-target is more effective than routine care, the Arthritis Foundation notes.

For instance, in one study researchers found that patients with long-standing RA who underwent treat-to-target care achieved remission more quickly than those on routine care, and they were also less likely to drop out of the study.

Though treat-to-target yields superior outcomes to standard RA care, its implementation in clinics is far behind expectations, and it hasn't yet been widely adopted, according to a study published in 2019 in the journal Nature Reviews Rheumatology.

Medication for Treating Rheumatoid Arthritis

Early, aggressive treatment of RA can help control symptoms and complications before the disease significantly worsens, by reducing or altogether stopping inflammation as quickly as possible. It's key to preventing disability.

This strategy essentially amounts to treatment with anti-inflammatory drugs, and sometimes more than one medication at a time.

There are three main categories of medication for rheumatoid arthritis:

Disease-modifying antirheumatic drugs (DMARDs), including biologic DMARDs and targeted synthetic DMARDs called JAK inhibitors
Corticosteroids
Nonsteroidal anti-inflammatory drugs (NSAIDs)

As their name implies, DMARDs can slow the progression of RA. Corticosteroids and NSAIDs, on the other hand, can help with acute pain and inflammation but do not stop or slow the progression of RA; though corticosteroids, such as prednisone and prednisolone, may help preserve function until DMARDs can start taking effect.

Disease-Modifying Antirheumatic Drugs for RA

Doctors usually prescribe DMARDs very early in the course of the RA disease, sometimes right after a diagnosis is made. The goal is to try to prevent cartilage damage and bony erosions, which can develop within the first two years of the disease, according to the Johns Hopkins Arthritis Center.

These drugs each work differently, but ultimately alter or slow the course of RA by suppressing the body's overactive immune system or inflammatory processes.

The most frequently used DMARD for RA is Trexall (methotrexate). Up to 90 percent of people take methotrexate at some point during RA treatment, according to the Arthritis Foundation.

Because of the side effects (upset stomach, aching muscles, thinning hair, and sore mouth) around 20 percent of patients eventually stop taking methotrexate.

In its 2021 guideline for the treatment of RA, the American College of Rheumatology (ACR) recommends maximizing the use of methotrexate. This is because the drug has a long history of use and a lot of research documenting its effectiveness. If methotrexate alone ultimately proves insufficient to control RA symptoms, the ACR recommends doctors find a methotrexate regimen that does work, including by pairing it with other DMARDs.

A class of DMARDs called biologics work by targeting the specific steps in the inflammatory process. Biologic DMARDs work faster than conventional DMARDs — some within two weeks, while conventional DMARDS may take a few months. Biologics are created from living cells and are usually used to treat moderate to severe RA, as well as patients who have not responded well to conventional DMARDs or other treatments.

The first conventional biologics that became available work to inhibit tumor necrosis factor (TNF) alpha, a pro-inflammatory substance in the immune system. Anti-TNF drugs, or TNF inhibitors, include:

Enbrel (etanercept) — self-injection
Remicade (infliximab) — infusion
Humira (adalimumab) — self-injection
Cimzia (certolizumab) — self-injection
Simponi (golimumab) — self-injection

JAK inhibitors are for difficult-to-treat RA, and they work by blocking another part of the body's immune response: Janus kinase (JAK) pathways.

JAK inhibitors include tofacitinib (Xeljanz, Jakvinus), baricitinib (Olumiant), and upadacitinib (Rinvoq). In September 2021, the FDA announced that JAK inhibitors should be used to treat RA only in people who didn’t respond to or could not tolerate one or more TNF blockers. In addition, the agency stressed that JAK inhibitors can increase the risk of serious heart-related events like heart attack or stroke, as well as the risk of cancer, blood clots, and death, especially for past or current smokers and those with existing heart conditions.

While past research suggested certain biologics increased a person's risk of developing lymphomas (cancer of the lymph nodes), more recent studies have suggested otherwise. The increased risk of lymphomas for RA patients likely has to do with RA-related inflammation.

In its earlier guidelines from 2015, the ACR recommended triple therapy — a combination of methotrexate and two other DMARDs, sulfasalazine and hydroxychloroquine — before starting a biologic in patients whose disease was uncontrolled. In its new guidelines, the ACR now recommends adding a biologic or JAK inhibitor instead of switching to triple therapy.

Neither conventional nor biologic DMARDs are meant to be pain relievers.

Your doctor may prescribe corticosteroids and NSAIDs in the meantime to help with acute pain and inflammation. The doctor may also prescribe corticosteroids while waiting for your DMARD to start working. But the ACR recommends prescribing corticosteroids as infrequently as possible and at the lowest effective dose, due to the drugs' risks, including infection, weight gain, bone fractures, and osteoporosis.

All DMARDs and biologics can become less effective over time and may even stop working, usually because the immune system starts to recognize the medicine as foreign (and subsequently attacks it). Often, doctors prescribe a combination of two or three DMARDs, which makes treatment more effective and the body less likely to form antibodies against the drugs.

Physical and Occupational Therapy for Rheumatoid Arthritis

Your doctor may prescribe physical and occupational therapy along with medication to help relieve pain and joint stress, reduce inflammation, and preserve joint structure and function.

An occupational therapist can teach you how to modify your home and workplace and better navigate your surroundings to effectively reduce strain on your joints and prevent further aggravation of the inflammation during your day-to-day activities. Additionally, they can teach you how to perform regular tasks in different ways to better protect your joints.

Occupational therapists may also provide splints or braces that help support weakened and painful joints, and recommend devices to help you with daily tasks, such as bathing. They can help you be able to work or participate in recreational activities, paying special attention to help you maintain good function of the hands and arms.

A physical therapist can show you exercises to strengthen your muscles and keep your joints movable and flexible. Range-of-motion exercises, strengthening exercises, and low-impact endurance exercises (walking, swimming, and cycling) all can help you preserve the function of your affected joints.

They'll teach you joint protection techniques, such as how to maintain proper body position and posture, body mechanics for specific daily functions, and how to distribute pressure to minimize stress on individual joints.

A physical therapist may use hot or cold packs to temporarily reduce pain and stiffness in your joints. They may recommend a podiatrist (foot specialist) to help you find supportive footwear and use orthotics, or devices that keep your feet in the correct positions.

Occupational and physical therapists can also teach you about the hand exercises that are best for you.

The Importance of Hand Exercises and Rest

The joints of the hands are among the first to be affected by RA, and over time inflammation can cause carpal tunnel syndrome and loss of hand and finger function.

Research published in July 2017 in the journal Arthritis Care & Research found that grip strength initially increased in study participants with early RA within their first year of diagnosis. This early improvement was likely due to anti-rheumatic treatments.

But the participants' grip strength was lower than expected five years after diagnosis, even for people who were in remission or had limited disability.

In a July 2018 report in the Cochrane Database of Systematic Reviews, researchers found that it's unclear whether exercise improves hand function or pain in the short term. And while hand exercises "probably" slightly improve function in the medium and long term, it has little or no difference on pain at these time scales.

But some hand exercises may improve grip strength and finger range of motion for RA patients. These exercises can include, among others:

Opening and closing your hands repeatedly
Pinching your fingers together (touching your thumb to the tips of your other fingers)
Touching your thumb to the base of your other fingers
Making a loose fist by drawing your fingers to the center of your palms
Moving your wrists up and down
Moving your hands in nice, easy circles
Putting your hands flat on a table and raising your fingers up individually

These exercises should be interspersed with hand rest.

Vagus Nerve Stimulation for Rheumatoid Arthritis

Though not yet ready for clinical use, recent small pilot studies suggest vagus nerve stimulation, in which an implanted electronic device delivers electrical pulses to the vagus nerve (a cranial nerve), may help relieve RA symptoms.

In a proof-of-concept study published in July 2016, researchers used reprogrammed epilepsy stimulators on 17 patients with RA. They found that the vagus nerve treatment reduced markers of systemic inflammation as well as RA signs and symptoms.

In a follow-up pilot placebo-controlled study, presented at the Annual European Congress of Rheumatology in June 2019, researchers had similar success when they employed a novel miniaturized neurostimulator called a MicroRegulator on 14 RA patients who were unresponsive to at least two biologics.

Another study, published in July 2020 in the Lancet Rheumatology, found that the neurostimulator was safe, well tolerated, and reduced RA signs and symptoms in people whose disease was resistant to multiple drugs.

More research is still needed before the device is ready for use.

Rheumatoid Arthritis and Diet Considerations

When it comes to the connection between diet and rheumatoid arthritis improvement, much of the scientific evidence is inconclusive, and the clinical studies haven't been very large. But some people claim that certain dietary modifications have helped relieve their RA symptoms. It's important to check with your doctor before you make any significant changes to your dietary habits.

Some people with RA follow a vegetarian or vegan diet to help reduce RA symptoms. Research suggests the diet can help some people with RA, but responses to it are highly individualized, according to a June 2020 literature review in the journal Nutrition Reviews. Fasting, sometimes followed by a vegetarian or vegan diet, can produce significant but temporary improvement in subjective symptoms, such as morning stiffness.

And some people report a beneficial effect from excluding certain food groups from their diet, going gluten-free or lactose-free. Lately, the ketogenic (keto) diet — a high-fat, very low-carb diet — has gained popularity, and while it may help you lose weight, it's not recommended for those with RA because it's high in fats that promote inflammation and it is low in grains, fruit, and many vegetables that help reduce inflammation. The few studies that have examined the effect of elimination diets on RA symptoms have found mostly short-term benefits, according to the Johns Hopkins Arthritis Center.

The 2020 literature review found that responses to elimination diets are highly individualized, but vitamin D supplementation and reduced sodium intake can help reduce symptoms.

Research suggests that following an anti-inflammatory Mediterranean diet — high in fiber and rich in omega-3 fatty acids from seafood and healthy fats from olive oil — may help control RA symptoms.

Fish oil — high in anti-inflammatory omega-3 fatty acids — has been shown to be helpful in reducing joint swelling and pain. And a study published in the journal Annals of the Rheumatic Diseases found that RA patients who took fish oil supplements in addition to DMARDs had a higher rate of remission than those who took only DMARDs. Overall, the research suggests omega-3 fatty acids, at high doses, can reduce RA disease activity and the rate of failure of RA drugs.

Are there specific foods that can help relieve symptoms? A study published in the journal Frontiers in Nutrition notes that raw or moderately cooked vegetables, seasonal fruits, probiotic yogurt, and spices such as turmeric and ginger can be beneficial.

Foods you should limit or avoid include processed foods and those high in salt, oil, butter, and sugar, which cause inflammation.

Learn More About Rheumatoid Arthritis and Diet

Complementary and Alternative Remedies for Treating Rheumatoid Arthritis

In addition to conventional treatments — medication, physical therapy, and, if necessary, surgery — some lifestyle changes and home remedies may be beneficial. Alternative therapies that fall outside of conventional Western medicine may provide additional relief. It's also important to pay attention to your mental health and to work to reduce the stress of living with RA. Relaxation techniques, visualization exercises, group counseling, and psychotherapy are worth considering.

Some complementary or alternative therapies, such as homeopathy, hydrotherapy, or cryotherapy, might help relieve RA symptoms, though the clinical evidence supporting these methods has been inconclusive. You might want to explore therapies such as acupuncture, tai chi, and yoga. While some people have found these approaches helpful, the research overall hasn't found clear, definitive benefits.

You should always check with your medical provider before trying any complementary or alternative therapies.

You'll also want to check with your doctor before using home remedies to relieve the pain and inflammation from a flare-up. At-home treatments that may help soothe pain and stiffness include hot or cold treatments, over-the-counter topical pain relievers, and braces or splints that support the joints.

Learn More About Alternative Therapies and Home Remedies for Rheumatoid Arthritis

Joint Surgery for Treating Rheumatoid Arthritis: A Last Resort

For many people, medication and therapy are enough to keep RA under control. But if you experience severe joint damage that limits your ability to carry out daily functions, surgery may be an option for you.

Joint surgery is only conducted after careful consideration, and can help reduce pain, improve joint function, and improve your quality of life.

A surgeon may operate to:

Clean out inflammation-causing bone and cartilage fragments from the joint, fix tears in soft tissues around joints, or repair damaged cartilage and ligaments (arthroscopy)
Remove some or all of the inflamed joint lining (synovectomy)
Fuse a joint (arthrodesis) so that it no longer bends and is properly aligned and stabilized
Replace a joint (arthroplasty), particularly of the ankles, shoulders, wrists, and elbows, with an artificial one made of plastic, ceramic, or metal
Remove only a certain section of a damaged and deformed knee joint (osteotomy)

Pain Management for Rheumatoid Arthritis

Treating pain and discomfort related to RA won't stop the progression of disease, but it can help you live more comfortably.

While DMARDs slow disease progression and reduce inflammation, they're not used to treat acute pain management. Instead, doctors typically recommend nonsteroidal anti-inflammatory drugs (NSAIDs), such as Aleve (naproxen sodium) and prescription Diflunisal (dolobid), and, for a brief duration, corticosteroids, such as prednisone and prednisolone.

Medical marijuana is frequently prescribed for chronic pain, but the research is lacking when it comes to treating RA pain. It's generally a matter of weighing the benefits and risks of medical marijuana for RA — it does reduce pain and has anti-inflammatory effects, but some doctors hesitate to prescribe it for rheumatic conditions because of the mental and cardiac-related side effects.

Exercise for RA Pain Management

RA pain can lead to a frustrating cycle: the pain causes people to become less active, but diminished physical fitness can then worsen symptoms. Inactivity can result in contractions and loss of joint motion and muscle strength.

An experienced physical or occupational therapist can create an exercise plan to help you relieve RA symptoms. The exercise regimen for RA should be a mix of low-impact aerobic exercises and those that target flexibility, strengthening, and body awareness, according to the American College of Rheumatology. Range-of-motion exercises can help preserve and restore joint motion and activities like walking, swimming, and cycling can increase endurance.

Learn More About Rheumatoid Arthritis Pain Management

Editorial Sources and Fact-Checking

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Rheumatoid Arthritis Treatment. Johns Hopkins Arthritis Center.
Combating High Disease Activity in Early RA. Arthritis Foundation.
Fraenkel L, Bathon JM, England B, et al. 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis & Rheumatology. June 08, 2021.
Treat to Target Approach Improves RA Outcomes. Arthritis Foundation.
Ronald van Vollenhoven. Treat-to-Target in Rheumatoid Arthritis — Are We There Yet? Nature Reviews Rheumatology. January 30, 2019.
Patient Education: Rheumatoid Arthritis Treatment (Beyond the Basics). UpToDate. December 5, 2019.
Understanding Methotrexate. Arthritis Foundation.
Kawalec P, Mikrut A, Wisniewska N, Pilc A. The Effectiveness of Tofacitinib, a Novel Janus Kinase Inhibitor, in the Treatment of Rheumatoid Arthritis: A Systematic Review and Meta-Analysis. Clinical Rheumatology. 2013.
FDA Requires Warnings About Increased Risk of Serious Heart-Related Events, Cancer, Blood Clots, and Death for JAK Inhibitors That Treat Certain Chronic Inflammatory Conditions. U.S. Food and Drug Administration. December 2021.
Mercer LK, Regierer AC, Mariette X, et al. Spectrum of Lymphomas Across Different Drug Treatment Groups in Rheumatoid Arthritis: A European Registries Collaborative Project. Annals of the Rheumatic Diseases. August 2017.
Occupational Therapy for Arthritis. Arthritis Foundation.
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Rheumatoid Arthritis (RA)

Treatment for Rheumatoid Arthritis: Medication, Alternative and Complementary Therapies, Surgery Options, and More