Everybody's different when it comes to rheumatoid arthritis (RA). Your symptoms may not be the same as those of a friend or neighbor who has the same disease. How your condition changes over time depends on such things as:
- How advanced your RA was when you learned you had it
- Your age when you were diagnosed
- How "active" your disease is
Stages of Rheumatoid Arthritis
There is a pre-RA stage, followed by four stages. Each stage has its own treatment options.
Pre-RA stage
The pre-RA stage happens before you have any symptoms or a diagnosis. A mix of genes and environmental factors changes your immune system in ways that put you at risk for RA. Your immune system starts making proteins called autoantibodies. These autoantibodies will eventually attack and damage your joints.
Stage 1
In the early stages, your joint lining, or synovium, becomes inflamed. If your doctor orders X-rays, they won’t see any damage in your joints yet. But the tissue around the joint may be swollen, making your joint stiff and painful.
Stage 2
In this moderate stage, inflammation damages your cartilage, the cushiony material that protects the ends of your bones. The joint will be stiff, and you won’t be able to move it as far as you used to. X-rays will show some damage to bones in the joint. The doctor will say you’ve lost range of motion.
Stage 3
This is the severe stage. Inflammation wears away cartilage and damages bones near your joints. Your doctor will see evidence of bone and joint damage on an X-ray. Your joints may become unstable and look deformed. You’ll have pain, stiffness, swelling, and loss of motion.
Stage 4
In end-stage RA, the damage to your joint continues. The joint might stop working. You’ll have more severe pain, swelling, stiffness, and lack of motion. Your muscles may be weak, too. You may need joint replacement surgery to restore movement to the damaged joint.
Treatment Based on RA Stages
Just as your condition changes over time, so will your treatment.
Early stage. A key focus is to control the inflammation. That’s especially important in the early phase of the disease to prevent joint damage. You may get:
- A low-dose steroid
- A disease-modifying antirheumatic drug (DMARD), such as methotrexate
- Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen, for pain
Quitting smoking and losing any extra weight also can help slow your RA.
Moderate stage. This is when you may have trouble with regular daily activities because of pain. You also may tire more easily. There are several options. Your doctor may have you try combining methotrexate with two other DMARD medications, sulfasalazine and hydroxychloroquine. Another option is a stronger form of DMARDs, called biologic DMARDs, including:
- Adalimumab (Humira)
- Certolizumab pegol (Cimzia)
- Etanercept (Enbrel)
- Golimumab (Simponi)
- Infliximab (Remicade)
Instead of a biologic, your doctor may recommend a JAK inhibitor, such as:
- Baricitinib (Olumiant)
- Tofacitinib (Xeljanz)
- Upadacitinib (Rinvoq)
If a certain joint is particularly inflamed, your doctor may give you steroid shots in that joint. Once your pain is under control, it’s important to exercise to keep ahead of your RA. You also may need physical therapy.
Severe stage. If a tumor necrosis factor (TNF) inhibitor doesn't improve your symptoms, your doctor may recommend you try a different TNF inhibitor or a different class of biologic. If you don’t respond to one, you may respond to another.
Surgery is a last resort for very severe RA. That includes when your joints are deformed and damaged, limiting your mobility. The three most common surgeries for RA are:
- Joint replacement, in which your surgeon replaces your damaged knee, hip, or other joints with man-made replacement parts
- Joint fusion, where two joints are fused and realigned
- Tendon repair, in which your surgeon fixes damaged tendons to ease pain and restore function
Signs Your RA Is Progressing
There's no easy way to tell if your RA is getting worse, but some general signs include:
- Flares that are intense or last a long time
- More stiffness and less range of motion in your joints
- Rheumatoid nodules — bumps under your skin, often around your elbows
- Active inflammation that shows up in tests of joint fluid or blood
- Damage on X-rays when you were diagnosed
- High levels of rheumatoid factor or citrulline antibody in blood tests
Rheumatoid Arthritis Remission
Remission means that your RA is under control and you have few to no symptoms. The definition of remission that doctors use is:
- One or fewer swollen joints
- One or fewer tender joints
- Arthritis activity of 1 or less on a scale of 1 to 10
- Little to no C-reactive protein, a marker of inflammation, on a blood test
Early and more aggressive treatment increases your chance of remission. You’re more likely to go into remission if you have low or good scores on these RA tests at diagnosis:
- Disease activity score (DAS) or other measures of disease activity use joint tenderness, signs of inflammation in your blood, and pain levels to rate your disease activity.
- The health assessment questionnaire (HAQ) shows how well you can do activities in eight daily life categories.
- C-reactive protein shows levels of this inflammatory marker in your blood.
Can you stop taking medicines when your RA is in remission?
After you’ve been in remission for a few months, your doctor may slowly lower your drug dose or stop your medicine entirely. “Drug holiday” is the term for taking a break from your medicine. Some people stay in remission for many months or years without medicine.
Because RA can flare up again, your doctor will closely track your condition. The doctor may restart your medicine if you relapse, which means your symptoms come back.
When to See Your Rheumatologist
Once you have an RA diagnosis, you’ll have regular visits with your rheumatologist. To monitor your disease progression, your doctor will do tests such as:
- Blood tests
- Urine tests
- X-rays or other imaging tests
At these visits, your doctor will:
- Check how well your medicine is controlling your RA
- Ask about any medicine side effects you’ve had
- Make changes to your treatment plan, if your disease isn’t under good control
Because RA can affect many parts of your body, your doctor might also check you for heart and lung problems and infections.
Between visits, tell your doctor if you have any new or worsening symptoms, such as:
- Joint swelling, stiffness, and pain
- Weakness
- Fever
- Rash
- Unexplained weight loss
Takeaways
RA progresses in stages from mild joint swelling and pain to severe joint damage. Once you get a diagnosis, plan regular follow-up visits with your rheumatologist so they can monitor your progress. Your doctor can adjust your treatment plan if your disease gets worse.
How quickly does RA progress?
Everyone with this disease is different. Some people’s symptoms progress faster than others. Usually, RA symptoms start slowly and progress over many weeks or months. In rare cases, the disease can start quickly and get worse within 1 or 2 days.
How do you stop rheumatoid arthritis from progressing?
You may not be able to stop RA, but you can slow its progression by taking the right medications and making lifestyle changes such as regular exercise.
What is the most aggressive form of rheumatoid arthritis?
RA comes in two types: seropositive and seronegative. People with seropositive RA have very high levels of antibodies called anti-cyclic citrullinated peptides (anti-CCPs). Some research has found that people with seronegative RA have more active disease and more inflammation. But other studies haven’t found any difference in severity between the two RA types.
When does rheumatoid arthritis start?
RA often starts between ages 30 and 60. Children and young adults can get the disease too, but not as often.
What are the signs rheumatoid arthritis is getting worse?
Signs that your RA is getting worse include:
- More joint stiffness and soreness
- Increased swelling in your joints
- Persistent tiredness
- Trouble with daily activities because of joint pain and other symptoms
