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Rheumatoid Arthritis Pain and Flare-Ups: What to Know and Do
Pain is the most common symptom of rheumatoid arthritis (RA), a chronic, inflammatory autoimmune disorder in which the body’s own immune system attacks the lining of the membranes that surround the joints (the synovium). Living with RA doesn’t have to mean living with pain forever. the goal of rheumatoid arthritis treatment is to live a full, asymptomatic life.
What Causes Pain in Rheumatoid Arthritis?
When you have rheumatoid arthritis, your immune system, which is supposed to protect against germs and foreign invaders, turns against the body and starts attacking the joints
Inflammation
Inflammation is the root cause of RA pain, the joint lining can get inflamed, thickened, and irritated, which causes pain, swelling, and stiffness in the joints.
Joint Erosion and Damage
RA pain can also be caused by joint erosion and damage. If you delay treatment, or your medication isn’t working well enough, and RA inflammation persists, it can cause permanent damage to the joints. Once a joint is damaged, even if the inflammation is controlled, it’s uncommon for that damage to repair and the pain might persist long-term.
Co-occurring Conditions
If RA patients have low levels of inflammation and few swollen joints but are still experiencing pain, this could indicate the presence of co-occurring conditions that can be common among RA patients, such as fibromyalgia or osteoarthritis. Mental health conditions like depression and anxiety may also play a role.
It’s important to remember that once you are diagnosed with RA, not all of your pain will necessarily be from rheumatoid arthritis; A rheumatologist’s job is to figure out if your pain is inflammatory triggered by the immune system or mechanical triggered by movements of the body.
Examples of mechanical pain that can affect those with RA include low back pain, carpal tunnel syndrome, muscle strains or sprains, tendinitis, and bursitis.
These things can happen to people with RA, but they aren’t necessarily caused by rheumatoid arthritis.
Some signs that indicate inflammatory pain instead of mechanical pain in rheumatoid arthritis include:
• Does your pain mostly affect the small joints, like fingers and toes?
• Is your stiffness, swelling, and pain worse with rest?
• Does your pain or stiffness last more than 30 minutes in the morning?
• Does your pain improve once you get moving?
• Does the area in pain look swollen or red, or feel warm?
• Is the pain happening in multiple joints, or is the pain symmetrical (the same on both sides), without the possibility of an overuse injury)?
RA Pain vs. RA Flare: What’s the Difference?
Everyday rheumatoid arthritis pain is different than the pain you feel during an RA flare. RA pain is a constant pain that is typically worse in the morning, while RA flare is severe sudden onset of diffuse widespread pain that, if not treated, can put you in bed all day.
RA pain is a symptom of an RA flare, RA pain would be part of the evaluation that a rheumatologist would do to determine if a patient is having a flare. In addition to joint pain, an RA flare can cause fatigue, irritability, aggressiveness, and depression.
Both RA pain and an RA flare can vary in intensity, duration, and frequency, but an RA flare can be alleviated if treated promptly and properly. Often a short course of steroids can be enough to stop the flare, and then you go back to a cycle of maintenance.
It’s not uncommon for an RA patient who is on medication and in low disease activity or remission to have one or two RA flares per year, however, if you find yourself getting flares that don’t resolve or come back often, this may mean that your medications are no longer working as well as they should, and it is time to discuss a medication change with your doctor.
It’s important to recognize and avoid RA flare triggers, which include:
• Overexertion
• Stress
• Hormonal changes (such as the menstrual cycle or entering menopause)
• Infections
• Poor sleep
Alert your rheumatologist if you start to experience more frequent or more intense flares.
How Rheumatoid Arthritis Medications Treat Pain
A goal of RA treatment is for you to achieve a state of complete remission from RA, which means no stiffness, swelling, or systemic inflammation and little to no pain. Even if remission isn’t possible for you, you can still work with your doctor to achieve low disease activity and fewer bouts of pain.
RA medications fall into two general categories:
• Drugs that work to reduce inflammation overall
• Drugs that tamp down your overactive immune system to help prevent joint damage and lower your risk of joint disability
These medications work together to suppress the immune system, ease inflammation, stop the progression of RA, and alleviate pain. You can’t treat RA pain effectively without first controlling the underlying inflammation and stopping the progression of the disease.
Here is a quick overview of the RA medications that your rheumatologist might prescribe to help treat your RA and minimize pain:
Non-steroidal anti-inflammatory (NSAIDs) like ibuprofen (Motrin, Advil) and naproxen sodium (Aleve) help to quickly relieve pain and inflammation. They are often used in combination with other medications. They are typically used early on in disease to manage mild symptoms or for breakthrough pain symptoms during a patient’s disease, they do not help prevent the progression of joint disease or damage.
Glucocorticoids, also called corticosteroids or steroids, help to quickly reduce inflammation. They can help you control pain and swelling until disease-modifying medications “kick in.” They can also be used if you have a flare and need quick pain relief. However, glucocorticoids are not recommended for long-term use because they can have a wide range of side effects. The goal is taper the dose as quickly as possible to prevent long-term side effects. The most prescribed glucocorticoids are prednisone and methylprednisolone (Medrol).
DMARDs, which stands for disease-modifying antirheumatic drugs, are the most widely used drugs used to slow down the progression of RA. The most used DMARD for RA is methotrexate, which has two benefits: It can block the RA inflammation and block the body from becoming immune to a biologic drug by preventing the production of anti-drug antibodies.
Other DMARDs used for RA include hydroxychloroquine (Plaquenil), leflunomide (Arava), and leflunomide (Arava).
TNFi biologics target tumor necrosis factor proteins (TNF) that send signals to your body, leading to inflammation. By stopping TNF, these medications can reduce inflammation and pain. They may be added to a DMARD or used alone without a DMARD. TNFi biologics include adalimumab (Humira), certolizumab pegol (Cimzia), etanercept (Enbrel), golimumab (Simponi, Simponi Aria), and infliximab (Remicade).
Non-TNFi biologics interact with different parts of your immune system and block chemicals called cytokines that cause inflammation. Non-TNFi biologics may be added to a DMARD or used alone without a DMARD. For RA, these medications include abatacept (Orencia), anakinra (Kineret), rituximab (Rituxan), sarilumab (Kevzara), and tocilizumab (Actemra).
Janus kinase (JAK) inhibitors decrease your immune system’s ability to make certain enzymes that can lead to RA symptoms, including pain. JAK inhibitors may be added to a DMARD or used alone without a DMARD. Common JAK inhibitors include baricitinib (Olumiant), tofacitinib (Xeljanz), and upadacitinib (Rinvoq).
When It’s Time for an RA Treatment Change
Even if your rheumatoid arthritis has been under good control for years, your medication can stop working after years of being on it. Luckily, there are many treatment options now and each works differently (this is known as mechanism of action). If one type of medication is no longer providing adequate relief, a medication with a different mechanism of action may be a better fit for you.
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