Early treatment for rheumatoid arthritis prevents joint damage

The Medicine Cabinet: Ask the Harvard Experts

Q: I was just diagnosed with rheumatoid arthritis. The doctor wants to me start medication now. What is the harm in waiting to see if it gets better on its own?

A: For someone newly diagnosed with rheumatoid arthritis, waiting to start treatment is usually not a good idea. That’s because it rarely gets better on its own and permanent joint damage may develop early in the disease course.

Rheumatoid arthritis is quite different from more common types of joint disease such as osteoarthritis. With osteoarthritis, there is degeneration in the cartilage lining the joint. Osteoarthritis is largely age-related, can run in families, and, is usually treated with mild pain relievers, exercise and, when severe, joint replacement.

Rheumatoid arthritis is considered an autoimmune disease — that is, it’s thought to develop because the immune system (the body’s defense system) mistakenly attacks the joints and other parts of the body. In addition to joint involvement, it may cause inflammation of the eyes, lungs, and lining of the heart.

The reason the immune system “misfires” is unknown; as a result, there is no known way to prevent or cure it. However, a number of highly effective treatments are available. When started early, permanent joint damage can be minimized or even prevented.

In most cases, the first-line treatment is methotrexate (Folex, Rheumatrex). A number of other oral medications are also available, including hydroxychloroquine, sulfasalazine, and leflunomide. If these don’t work well enough, one of the injectable “biologics” or a newer oral biologic may be recommended.

While medications can improve symptoms and help protect the joints from damage, additional treatments may be necessary to improve dexterity, strength, balance and stamina. In addition, there are other aspects of health — such as depression and excess weight — that may not be addressed by medications for rheumatoid arthritis. So, other therapies are usually encouraged include exercise, splinting, loss of excess weight, and smoking cessation. The role of dietary modifications, heat or cold therapy and other alternative treatments is uncertain.

Patient preference is an essential part of choosing treatment for rheumatoid arthritis. For example, some prefer to avoid any injectable medication. Others prefer a weekly injection or an intravenous treatment every two months rather than having to take multiple pills each day. The expense of these medications and health insurance coverage are also important considerations.

While there is no single best treatment for every person with rheumatoid arthritis, putting off treatment with the hope that the condition will improve on its own is unlikely to go well.

(Robert H. Shmerling, M.D., is associate professor of Medicine at Harvard Medical School and clinical chief of Rheumatology at Beth Israel Deaconess Medical Center in Boston. For additional consumer health information, please visit www.health.harvard.edu.)