Newer "second-line" drugs for the treatment of rheumatoid arthritis include leflunomide (Arava) etanercept (Enbrel), infliximab (Remicade), anakinra (Kineret), and adalimumab (Humira.)
 
Leflunomide (Arava) is available to relieve the symptoms and halt the progression of the disease. It seems to work by blocking the action of an important enzyme that has a role in immune activation. Arava can cause liver disease, diarrhea, hair loss, and/or rash in some patients. It should not be taken just before or during pregnancy because of possible birth defects.
 
Other medications that represent a novel approach to the treatment of rheumatoid arthritis and are the products of modern biotechnology. Etanercept (Enbrel), infliximab (Remicade), and adalimumab (Humira, marketed as of January, 2003) intercept a protein (tumor necrosis factor, or TNF) that causes inflammation before it acts on its natural receptor to "switch on " inflammation.
 
 These medications are referred to as biological response modifiers. Symptoms can be significantly, and often rapidly, improved in patients using these drugs. Etanercept (Enbrel) must be injected subcutaneously twice a week. Infliximab (Remicade) is given by infusion directly into a vein (intravenously). Adalimumab (Humira) is injected subcutaneously either every other week or weekly.
 
Each of these medications will be evaluated by doctors in practice to determine what role they may have in treating various stages of rheumatoid arthritis. Recent studies demonstrate that biological response modifiers also prevent the progressive joint destruction of rheumatoid arthritis.
 
They are currently recommended for use after other medications have not been effective. The biological response modifiers (TNF-inhibitors) are expensive treatments. They are also frequently used in combination with methotrexate and other DMARDs.
 
Anakinra (Kineret) is another biologic treatment that is used to treat moderate to severe rheumatoid arthritis. Anakinra (Kineret) works by binding to a cell messenger protein (IL-1, a proinflammation cytokine). Anakinra (Kineret) is injected under the skin daily. Anakinra (Kineret) can be used alone or with other DMARDs.
 
The Prosorba column therapy involves pumping blood drawn from a vein in the arm into an apheresis machine, or cell separator. This machine separates the liquid part of the blood (the plasma) from the blood cells. The Prosorba column is a plastic cylinder about the size of a coffee mug that contains a sand-like substance coated with a special material called Protein A. Protein A is unique in that it binds unwanted antibodies from the blood that promote the arthritis.
 
 The Prosorba column works to counter the effect of these harmful antibodies. The Prosorba column is indicated to reduce the signs and symptoms of moderate to severe rheumatoid arthritis in adult patients with long standing disease who have failed or are intolerant to disease-modifying anti-rheumatic drugs (DMARDs). The exact role of this treatment is being evaluated by doctors.
 
There is no special diet for rheumatoid arthritis. Fish oil may have anti-inflammatory effects, but so far this has only been shown in laboratory experiments studying inflammatory cells. Likewise, the benefits of cartilage preparations remain unproven. Symptomatic pain relief can often be achieved with oral acetaminophen (Tylenol) or over-the-counter topical preparations, which are rubbed into the skin.
 
Antibiotics, in particular the tetracycline drug minocycline (Minocin), have been tried for rheumatoid arthritis recently in clinical trials. Early results have demonstrated mild to moderate improvement in the symptoms of arthritis. Minocycline has been shown to impede important mediator enzymes of tissue destruction, called metalloproteinases, in the laboratory as well as in humans.
 
The areas of the body, other than the joints, that are affected by rheumatoid inflammation are treated individually. Sjogren's syndrome  can be helped by artificial tears and humidifying rooms of the home or office. Regular eye check-ups and early antibiotic treatment for infection of the eyes are important.
 
Inflammation of the tendons (tendinitis), bursae (bursitis) and rheumatoid nodules can be injected with cortisone. Inflammation of the lining of the heart and/or lungs may require high doses of oral cortisone.
 
Proper, regular exercise is important in maintaining joint mobility, and in strengthening the muscles around the joints. Swimming is particularly helpful because it allows exercise with minimal stress on the joints.  Physical and occupational therapists are trained to provide specific exercise instructions and can offer splinting supports. For example, wrist and finger splints can be helpful in reducing inflammation and maintaining joint alignment. Devices, such as canes, toilet seat raisers, and jar grippers can assist daily living. Heat and cold applications are modalities that can ease symptoms before and after exercise.
 
Surgery may be recommended to restore joint mobility or repair damaged joints. Doctors who specialize in joint surgery are orthopedic surgeons. The types of joint surgery range from arthroscopy to partial and complete replacement of the joint.
 
Arthroscopy is a surgical technique whereby a doctor inserts a tube-like instrument into the joint to see and repair abnormal tissues. "Total joint replacement" is a surgical procedure whereby a destroyed joint is replaced with artificial materials. For example, the small joints of the hand can be replaced with plastic material. Large joints, such as the hips or knees, are replaced with metals.
 
Finally, minimizing emotional stress can help improve the overall health of the patient with rheumatoid arthritis. Support and extracurricular groups afford patients time to discuss their problems with others and learn more about their illness.
 
Scientists throughout the world are studying many promising areas of new treatment approaches for rheumatoid arthritis. These areas include treatments that block the action of the special inflammation factors, such as tumor necrosis factor (TNFalpha) and interleukin-1 (IL-1), as described above.
 
Many other drugs are being developed that act against certain critical white blood cells involved in rheumatoid inflammation. Also, new NSAIDs with mechanisms of action which are different from current drugs are on the horizon.
Studies involving various types of the connective tissue collagen are in progress and show encouraging signs of reducing rheumatoid disease activity. Finally, genetic research and engineering is likely to bring forth many new avenues of earlier diagnosis and accurate treatment in the near future.
 
Rheumatoid arthritis is an autoimmune disease that can cause chronic inflammation of the joints and other areas of the body. Rheumatoid arthritis can affect persons of all ages. The cause of rheumatoid arthritis is not known. Rheumatoid arthritis is a chronic disease, characterized by periods of disease flares and remissions. In rheumatoid arthritis, multiple joints are usually, but not always, affected in a symmetrical pattern.  Chronic inflammation of rheumatoid arthritis can cause permanent joint destruction and deformity. The "rheumatoid factor" is an antibody blood test that can be found in 80 % of patients with rheumatoid arthritis.
 
There is no known cure for rheumatoid arthritis. The treatment of rheumatoid arthritis optimally involves a combination of patient education, rest and exercise, joint protection, medications, and occasionally surgery.

 

There are a number of non-pharmacologic approaches. One is that people first have to acknowledge that medications alone cannot work and that they need to modify their activity. They need to learn to find how to offload inflamed joints and modify the way they do tasks to protect those joints.
 
A good example of that would be that if fingers are really sore, to find a way maybe to grasp which is different than just grasping or if someone has a problem with their wrist, perhaps use a splint which is a way of supporting that when they're doing a task that might irritate it, like vacuuming.
 
There are a number of other types of approaches, like using adaptive footwear, like shoe orthotics or adaptive shoes. And of course,there are a number of exercise-directed therapies which can really reduce muscle tension, improve sense of well-being and general conditioning
 
There are lots of different ways that people cope with pain which are kind of interesting. Some of these are sort of short-term interventions, and some are longer-term, but certainly distraction, and changing what you're doing, and changing your physical activity you're doing at a time is a good technique.
 
Sometimes people will meditate or pray. There's some pretty interesting research written about reflective writing, where people who are experiencing pain will write essays, and this activity often brings insight into the experiences people have but also reduce pain because it distracts the brain from really focusing on the pain itself.
 
Then the whole other question is how do we safely apply heat and cold? And there are many ways. You could use radiant heat from a heat lamp. You could use a moist heating pad. One can could use paraffin baths using paraffin wax that's heated. There are a lot of different ways to do this, and it's just a matter of what people find works for them.
The other thing is that often people have fatigue. And so if you control the disease process and you have less pain but also less fatigue, you'd be more likely to live a full life. Another important marker is sleeping. Often because people feel poorly, they have impaired sleep and, if you're tired and have pain and you don't sleep well at night, it's pretty tough to enjoy what you're doing
 
NSAIDs can be troublesome drugs for particular individuals, particularly elderly people or people with a past history of ulcers, and although the lower the dose that you use, the safer they are, the problem seems to be that sometimes people think if a little is good, then more is better. And so people adjust the doses up and take three tablets instead of two tablets like they're supposed to.
 
There can be a lot of problems with high blood pressure or edema, ulcers, kidney problems. These are difficult drugs to use, particularly if you push to higher doses. There's a subset or a group of patients who need to be worried. Those are the patients with edema or swelling, congestive heart failure, renal or kidney problems, people with stomach problems such as ulcer disease, and people who happen to be older. One of the problems is too often these are the same people that we take care of who have rheumatoid arthritis.
 
The other problem with the non-steroidals is that some patients and even sometimes their physicians will see a response and will think this is a sufficient therapy, and not realizing that the progression of the disease and the cartilage and bone wear continues despite these medications.
 
It's important from the beginning to help people understand what the goals are is to control symptoms and signs, and to try to prevent joint damage. To use the disease-modifying drugs is a continuous process that's necessary.