Rheumatoid Arthritis Medication: Complete Treatment Guide

What Medications Are Used for Rheumatoid Arthritis?

Rheumatoid arthritis is treated with several types of medications: disease-modifying antirheumatic drugs (DMARDs) like methotrexate that slow disease progression, biologics that target specific immune pathways, NSAIDs for pain and inflammation, and corticosteroids for rapid symptom relief. Most patients need long-term DMARD therapy to control the disease.

The treatment of rheumatoid arthritis has advanced dramatically in recent decades. While there is no cure for RA, modern medications can effectively control the disease, prevent joint damage, and allow many patients to live normal, active lives. The key to successful treatment is starting early—ideally within three months of symptom onset—because joint damage can begin within the first year of disease.

Treatment typically follows a step-up approach. Most patients start with conventional DMARDs, particularly methotrexate. If these don't provide adequate control, biologic DMARDs or targeted synthetic DMARDs (like JAK inhibitors) are added. Throughout treatment, NSAIDs and corticosteroids may be used for symptom relief, though they don't slow disease progression.

The goal of modern RA treatment is remission—a state where the disease is essentially inactive—or at minimum, low disease activity. Achieving this goal requires regular monitoring and often adjustment of medications over time. Your rheumatologist will work with you to find the optimal treatment combination for your specific situation.

Types of RA Medications

Understanding the different categories of RA medications helps you participate actively in treatment decisions. Each type has a distinct role:

• NSAIDs (Non-steroidal anti-inflammatory drugs): Relieve pain and reduce inflammation but don't slow disease
• Analgesics (Pain relievers): Control pain without affecting inflammation
• Corticosteroids: Powerful anti-inflammatory drugs for rapid relief, typically used short-term
• Conventional DMARDs: Slow disease progression; methotrexate is the cornerstone
• Biologic DMARDs: Target specific immune system components; highly effective for many patients
• Targeted synthetic DMARDs: Newer oral medications (JAK inhibitors) that block specific inflammatory pathways

Multiple Medications Are Often Needed

Many factors contribute to rheumatoid arthritis, and medications can be combined in different ways for optimal effect. Which medications you need depends on your individual situation—disease severity, other health conditions, and response to treatment.

A typical treatment plan might include a long-acting antirheumatic medication (DMARD) combined with anti-inflammatory pain relief. During the initial period, you may also receive low-dose corticosteroid tablets while waiting for the DMARD to take effect. Sometimes corticosteroid injections directly into inflamed joints provide rapid relief.

If methotrexate alone doesn't fully control your RA, it may be combined with one or more other DMARDs such as sulfasalazine, hydroxychloroquine, or biologic medications. Studies show that combining these medications often provides better results than any single drug alone, without necessarily increasing side effects.

What Are NSAIDs and How Do They Work for RA?

NSAIDs (non-steroidal anti-inflammatory drugs) work by blocking cyclooxygenase (COX) enzymes that produce prostaglandins, reducing pain, inflammation, and joint stiffness in RA. They provide symptom relief within days but don't slow disease progression. Common NSAIDs include ibuprofen, naproxen, and diclofenac.

Non-steroidal anti-inflammatory drugs, commonly known as NSAIDs, are among the oldest and most widely used medications for arthritis. They work by inhibiting an enzyme called cyclooxygenase (COX) in the body. When COX is blocked, the body produces fewer prostaglandins—chemicals that cause pain, inflammation, and fever. This mechanism makes NSAIDs effective for relieving joint pain, reducing inflammation, and easing the stiffness that's characteristic of RA.

Pain relief from NSAIDs typically occurs quickly, often within hours of taking the medication. However, the full anti-inflammatory effect may take one to three weeks to develop. It's important to understand that while NSAIDs provide symptom relief, they don't stop the underlying disease process or prevent joint damage. For this reason, NSAIDs are used alongside DMARDs, not as a substitute for them.

Many different NSAIDs are available, and while their effectiveness is generally similar, side effect profiles can vary. If one NSAID doesn't work well for you or causes problems, switching to another may be beneficial. They also differ in how long they remain active in the body, affecting how often you need to take them. Long-acting formulations can be particularly helpful for morning stiffness when taken at bedtime.

Available Forms and Dosing

NSAIDs come in various forms including tablets, enteric-coated tablets (which protect the stomach), capsules, and suppositories. Some are available as long-acting formulations that provide all-day relief with once-daily dosing. The choice of formulation depends on your specific needs, stomach tolerance, and preference.

Important Considerations When Using NSAIDs

There are many different active ingredients in the NSAID family. While they work similarly, side effects can vary between them, so trying a different NSAID might be worthwhile if you experience problems with one. Never take multiple different NSAIDs simultaneously unless specifically directed by your doctor—this increases total dose and significantly raises the risk of side effects and serious complications.

Some NSAIDs are available without prescription. However, for long-term pain management, they should primarily be used for short periods. If you have asthma, you should consult your doctor before using NSAIDs, as they can trigger severe reactions including hives, runny nose, and breathing difficulties in sensitive individuals. Never use NSAIDs if you've previously had an allergic reaction to aspirin or another NSAID.

NSAIDs may be inappropriate if you have heart, kidney, or liver disease—in these cases, only use them under medical supervision. Be very cautious with NSAIDs if you have or have had recurring stomach ulcers. NSAIDs also reduce the ability of blood platelets to clump together, increasing bleeding risk. Generally, they shouldn't be used with blood-thinning medications like warfarin.

Side Effects of NSAIDs

NSAIDs can cause stomach problems including nausea, abdominal pain, and diarrhea. They can increase the risk of stomach ulcers, which can be reduced by also taking acid-reducing medications like omeprazole or esomeprazole. NSAIDs may increase the risk of cardiovascular events including heart attack and stroke.

Other potential side effects include headache, skin rash, and dizziness. While some side effects are common to all NSAIDs, the degree of risk varies between specific drugs. Some have lower stomach ulcer risk but higher cardiovascular risk, while others show the opposite pattern. Your doctor will consider your medical history when choosing which NSAID is most appropriate for you. Side effect risk generally increases with age.

How Are Pain Medications Used in RA Treatment?

Pain medications for RA include paracetamol (acetaminophen) for mild pain and opioids for severe pain. Paracetamol works centrally in the brain, blocking pain signals without reducing inflammation. It's safe for most people but doesn't address the underlying inflammation. Opioids are reserved for severe pain not controlled by other treatments.

Joint pain is one of the most disabling symptoms of rheumatoid arthritis. Pain can be categorized as acute (sudden onset) or chronic (long-lasting), and these are treated differently. Acute, short-term pain is generally easier to control than chronic pain. Pain medications work by preventing pain signals from reaching the brain—either locally at the nerve endings or centrally in the brain's pain center.

Paracetamol (known as acetaminophen in North America) is a common pain reliever available without prescription. It works primarily in the central nervous system to reduce pain perception. Unlike NSAIDs, paracetamol has minimal anti-inflammatory effects, so it's typically used in addition to other RA medications rather than as a primary treatment.

For pain that isn't adequately controlled with paracetamol or NSAIDs, doctors may prescribe centrally-acting medications such as opioids. Opioids include codeine, tramadol, and stronger medications like morphine and oxycodone. Some combination products contain both paracetamol and codeine for enhanced pain relief. Opioids are generally reserved for situations where other pain management approaches are insufficient.

Available Forms

Pain medications come in various forms including regular tablets, effervescent tablets, orally dissolving tablets, liquid formulations, and suppositories. The choice depends on personal preference, absorption needs, and ability to swallow tablets.

Important Considerations

There is a risk of developing dependence on opioids. When used appropriately for genuine pain conditions and for limited periods, they provide effective relief with relatively low addiction risk. However, opioids can affect your alertness and reaction time, which is important to consider when driving or operating machinery.

You should avoid alcohol while taking paracetamol, as there's a risk of liver damage, particularly with excessive doses or chronic alcohol use. Similarly, don't drink alcohol while taking opioids without first consulting your doctor. Alcohol, sleep medications, or other drugs affecting the central nervous system can intensify the drowsiness caused by opioids. Combining opioids with alcohol can also increase the risk of respiratory problems. The same applies if you take too high a dose.

Pregnancy and Breastfeeding

Paracetamol can be used during pregnancy and while breastfeeding. Discuss opioid use with your doctor if you're pregnant or breastfeeding. While opioids can be used during pregnancy, they should be avoided if possible. Long-term use, especially near delivery, can cause respiratory depression and withdrawal symptoms in the newborn.

Side Effects

Side effects are uncommon when paracetamol is used correctly at recommended doses. Nausea and vomiting are common when starting opioid treatment. A very common side effect of opioids is constipation—your doctor will typically prescribe laxatives when starting a strong opioid to prevent this.

Other opioid side effects may include drowsiness, confusion, dizziness, and dry mouth. Dry mouth increases the risk of dental cavities, so careful dental hygiene with fluoride toothpaste and flossing is especially important during treatment.

How Are Corticosteroids Used for Rheumatoid Arthritis?

Corticosteroids like prednisone are powerful anti-inflammatory drugs that provide rapid relief of RA symptoms. They mimic the body's natural cortisol and suppress inflammation effectively. Most patients receive low-dose corticosteroids during the first two years of RA, which reduces long-term joint damage. Corticosteroid injections into inflamed joints offer targeted relief.

Corticosteroid medications are synthetic versions of cortisol, a hormone naturally produced by your adrenal glands. They work by reducing the chemicals that cause inflammation, thereby rapidly suppressing the inflammatory process. The symptoms of RA—fatigue, pain, stiffness, and weakness—are largely driven by inflammation, and corticosteroids address these very effectively.

Most patients receive low-dose corticosteroids during the initial phase of their disease. Research has shown that corticosteroid treatment during the first two years after diagnosis significantly reduces long-term joint damage. If joint inflammation resolves quickly, it may be possible to taper and discontinue corticosteroids earlier. However, some patients need longer-term corticosteroid therapy—your doctor will make this determination based on your individual situation.

Corticosteroid injections directly into an inflamed joint provide a gentle, targeted treatment with typically rapid effects. These are used when one or more joints remain significantly inflamed despite other medications. Only a small amount of the corticosteroid enters the bloodstream, so the risk of systemic side effects is lower than with oral corticosteroids.

In very severe situations where organs other than joints are affected by inflammation, high-dose corticosteroids can be life-saving. The body's natural cortisol production peaks in the morning, so the full corticosteroid dose is usually taken in the morning to minimize disruption to natural hormone rhythms. If you need high doses, you may need to split the dose, taking a smaller portion in the evening.

Available Forms

Corticosteroids come as tablets and injectable solutions. The injectable form can be given intramuscularly or directly into joints.

Important Considerations

If you've been on corticosteroids for an extended period, your body's own cortisol production may be suppressed to the point where it can't produce the extra cortisol needed during stress like fever, serious infection, or injury. In such situations, you may need additional corticosteroid supplementation.

After long-term use at higher doses, natural cortisol production decreases. Suddenly stopping corticosteroids can cause cortisol deficiency, which can be very serious. Therefore, you should never stop corticosteroids abruptly after long-term use—instead, gradually taper the dose under medical supervision.

Corticosteroids can mask signs of infection, so don't delay seeking medical attention if you develop signs of infection like fever. Combining corticosteroids with NSAIDs increases the risk of stomach bleeding.

Pregnancy and Breastfeeding

Corticosteroids can be used during pregnancy—discuss with your doctor first. Avoid high doses if possible, as they may increase the risk of premature birth or affect fetal growth. If you need corticosteroids while breastfeeding, follow your doctor's recommendations—when used appropriately, there's no evidence of harm to the infant.

Side Effects

Long-term corticosteroid use can cause side effects, which are also influenced by dose. Corticosteroids can cause various problems, but they're simultaneously fast-acting and effective for many symptoms. Short-term, low-dose use provides more benefits than risks because inflammation is suppressed so effectively. Potential side effects include:

• Fluid retention causing swollen hands and feet
• High blood pressure
• Elevated blood sugar and diabetes risk
• Skin thinning and easy bruising
• Delayed wound healing
• Weight gain
• Fat redistribution (rounded face and trunk)
• Sleep difficulties and mood changes (with high doses)

One of the most serious side effects is osteoporosis, which increases fracture risk. This can be partially prevented by taking calcium and vitamin D supplements.

What Are DMARDs and Why Are They Important?

DMARDs (disease-modifying antirheumatic drugs) are the cornerstone of RA treatment because they actually slow disease progression and prevent joint damage. Unlike NSAIDs and corticosteroids that only treat symptoms, DMARDs modify the underlying disease process. Methotrexate is the first-line DMARD and is effective for most patients.

The group of long-acting antirheumatic drugs, known as DMARDs (disease-modifying antirheumatic drugs), includes several different types of medications. Interestingly, many of these drugs were originally developed to treat other conditions but were found to be effective for RA. DMARDs reduce joint inflammation in various ways, thereby decreasing pain, stiffness, and swelling while protecting joints from damage.

Sometimes one DMARD isn't sufficient to control inflammation, and combinations of several different antirheumatic medications may be used. Examples of conventional DMARDs include methotrexate, sulfasalazine, hydroxychloroquine, leflunomide, and ciclosporin. Newer targeted synthetic DMARDs include JAK inhibitors.

Methotrexate

Methotrexate is the primary medication used for rheumatoid arthritis. This is because it has both good antirheumatic efficacy and relatively few side effects. Since the medication is used for many years, minimizing side effects is crucial. Methotrexate can be used alone or combined with other DMARDs like sulfasalazine, hydroxychloroquine, or biologic medications.

The medication suppresses the immune system, which reduces inflammation. Effects typically appear within two to three months. When taking methotrexate, you also take folic acid (a B vitamin) to reduce side effects.

Methotrexate is available as tablets and injectable solution. The medication is taken in low doses once weekly—not daily. This is an important distinction to remember.

You may be more susceptible to infections while using methotrexate. If you develop an infection, you may need to pause the medication—discuss this with your doctor.

Methotrexate Side Effects

You may feel nauseous the day after taking the medication. This can be reduced by lowering the dose or taking tablets in the evening. Switching to injectable methotrexate can also help reduce nausea. Increasing your folic acid dose can counteract and relieve nausea—don't take folic acid on the same day as methotrexate, as this may reduce its effectiveness.

Some people may develop mouth sores, headache, dizziness, hair loss, skin rash, or loss of appetite. Liver effects are another side effect often related to dose, which may require a treatment break. Liver problems usually aren't noticeable and are detected through regular blood tests taken during treatment.

A rare but serious side effect is dry cough and breathing difficulties due to lung inflammation. If you experience these symptoms, contact your doctor immediately.

Sulfasalazine

For rheumatoid arthritis, sulfasalazine is used to slow disease progression. From when you start taking it, it may take up to three months before you notice improvement in your joints. Sulfasalazine is also used for inflammatory bowel diseases like ulcerative colitis and Crohn's disease.

You should not use sulfasalazine if you're allergic to sulfa or aspirin. White blood cell counts may occasionally decrease, increasing infection risk, though this is uncommon. The risk is highest during the first few months. Contact your doctor if you develop high fever or other signs of infection during the initial months of sulfasalazine treatment. You can use the medication during pregnancy but should also take folic acid.

Hydroxychloroquine

Medications containing hydroxychloroquine counteract inflammation. They're not always sufficiently effective against RA when used alone and are primarily used in combination with methotrexate and sulfasalazine. It may take one to three months before achieving full effect.

You should not use these medications if you have epilepsy, porphyria, or certain vision or hearing impairments. Side effects are usually mild but may include nausea, loss of appetite, and stomach discomfort—these typically improve with continued use. Some may experience blurred vision and difficulty adjusting focus from far to near vision. These eye symptoms often appear early in treatment and are harmless, usually resolving if you stop the medication or reduce the dose. With long-term high-dose treatment, there's a small risk of retinal damage, so periodic eye examinations may be needed.

Leflunomide

Leflunomide counteracts inflammation with effectiveness comparable to methotrexate. It can raise blood pressure, so regular monitoring is needed if you have high blood pressure or heart disease.

You should not use leflunomide during pregnancy—it can harm the fetus. Use reliable contraception for up to two years after treatment ends (this period can be shortened to 11 days with specific medication). Avoid leflunomide while breastfeeding.

Ciclosporin

For rheumatic disease, ciclosporin slows disease progression by suppressing the immune system, reducing inflammation. Effects typically appear within 2-3 months. It can be used alone or in combination with other medications.

You may be more susceptible to infections when treated with immunosuppressive medications. Contact your doctor if you develop symptoms like fever, sore throat, cold symptoms, or flu-like symptoms. Ciclosporin can interact with many other medications, so have a thorough review of your medications before starting treatment. Avoid grapefruit and grapefruit juice, as they inhibit ciclosporin breakdown in the body.

JAK Inhibitors

JAK inhibitors are a newer group of medications classified as targeted synthetic DMARDs. They work by reducing the activity of enzymes called Janus kinases, which are involved in inflammation. Examples include baricitinib (Olumiant), tofacitinib (Xeljanz), upadacitinib (Rinvoq), and filgotinib (Jyseleca). These are taken as tablets.

You should not take JAK inhibitors during pregnancy. Stop treatment at least 4 weeks (varies by specific drug) before a planned pregnancy. Experience is limited regarding effects on breastfed infants, so avoid these medications while nursing.

The risk of blood clots, cardiovascular disease, and cancer may increase with JAK inhibitor treatment. Your doctor will assess these risks before starting treatment. The immune-suppressing effect increases infection risk, including respiratory infections and shingles. You'll need to pause the medication during active infections. If you carry latent tuberculosis or viral hepatitis, these diseases can become active with these medications—your doctor will screen for these before starting treatment.

What Are Biologic Medications for Rheumatoid Arthritis?

Biologic medications have revolutionized RA treatment. They target specific parts of the immune system—particularly cytokines like TNF-alpha and interleukins—that drive inflammation. Biologics can provide dramatic improvement for patients who haven't responded to traditional DMARDs. They're given by injection or infusion and are typically used with methotrexate.

Biologic medications have transformed the treatment of rheumatoid arthritis. Many patients who have tried multiple different antirheumatic medications without success can be helped by biologics. Most biologic medications affect the function of cytokines, a large group of substances that regulate inflammation in the body.

By targeting these pathways, biologics suppress inflammation and slow disease progression. Pain, stiffness, and the general feeling of illness decrease or disappear. The medications can also slow the breakdown of joint cartilage and bone. The inflammation in RA affects not just joints but the entire body, potentially causing fatigue, depression, weight loss, muscle weakness, and osteoporosis. When cytokines are blocked, these problems also improve.

TNF Inhibitors

Several medications block the cytokine TNF-alpha, including infliximab, etanercept, adalimumab, certolizumab pegol, and golimumab. Infliximab is given as an intravenous infusion, typically every eight weeks (more frequently initially). The others are self-administered as subcutaneous injections at intervals ranging from weekly to monthly, depending on the specific medication.

Biosimilars

Biosimilars are essentially copies of some TNF inhibitors. They have the same effectiveness as the original products but cost less. Your doctor may suggest switching to a biosimilar to reduce healthcare costs. The requirement for biosimilar approval is that it must have the same effect as the original—you don't need to worry about switching medications.

Other Biologic Medications

Additional biologics include tocilizumab, rituximab, and abatacept. Tocilizumab blocks cytokine effects, while the other two affect white blood cells. Rituximab removes a type of white blood cell called B lymphocytes. Abatacept blocks another type called T lymphocytes. Both B and T lymphocytes stimulate inflammation in the body—by stopping or blocking these lymphocytes, rheumatoid arthritis can be controlled.

Effectiveness May Decrease Over Time

The effectiveness of biologic medications may diminish over time. This can happen because the body's immune system has reacted to the medication. Another explanation is that other cytokines in the body take over and drive the inflammation. In such cases, switching to a different biologic may restore disease control.

Important Considerations

Cytokines are part of the body's defense against infections, among other things. Therefore, infection risk increases when using biologic medications. It's important to know that the body's defense against tuberculosis and viral hepatitis is weakened when cytokines are blocked. You may have been infected long ago and have a dormant infection that flares up when starting a biologic medication. The risk of infection if you come into contact with someone with tuberculosis also increases. Your doctor will therefore investigate whether you may have been infected before starting treatment.

Side Effects of Biologics

You may experience mild flu-like symptoms such as chills and joint or muscle aches. This can occur at the start of treatment and usually resolves on its own. Over-the-counter paracetamol can help relieve these symptoms.

Besides tuberculosis risk, there's risk of other infections, primarily respiratory infections. Common colds are most common. You may also get urinary tract infections, joint infections, or pneumonia. If you already have an infection in a wound, it can worsen. If you develop an infection, pause treatment until it has healed—otherwise, there's a risk of becoming more ill.

Skin around the injection site may become red, but this is usually harmless. Occasionally the redness becomes extensive and bothersome enough to discontinue treatment. Severe allergic reactions are quite uncommon. If it's important to continue treatment despite an allergic reaction, you can receive corticosteroids and antihistamine medications beforehand.

Can RA Medications Affect My Ability to Drive?

Some RA medications can affect your ability to drive safely. You may become drowsy, dizzy, or have blurred vision. Opioid pain medications are most likely to cause impairment. Different people react differently—you're responsible for assessing whether you can safely drive or perform work requiring alertness.

Your ability to drive can be affected by certain medications. For example, you may become drowsy, dizzy, or have blurred vision. Different people react differently to medications. You are personally responsible for assessing whether you can drive a car or other motor vehicle, or perform work that requires alertness and quick reactions.

Opioid pain medications are particularly likely to cause drowsiness and impaired reaction time. Even some NSAIDs can cause dizziness in some people. If you're starting a new medication, it's wise to see how it affects you before driving or operating machinery.

Why Don't I Always Feel Better on RA Medications?

Finding the right RA treatment often requires patience and trial-and-error. Treatment is based more on accumulated clinical experience than complete understanding of what causes RA. Doctors may need to try different medications to find what works best for you. Unfortunately, effective medications sometimes must be stopped due to side effects.

The treatment of rheumatoid arthritis is based more on doctors' accumulated experience of which medications slow the disease than on complete knowledge of what actually causes RA and how it develops in the body. Therefore, doctors must try different antirheumatic medications to find what works best for each individual patient.

This requires patience, but eventually you and your doctor usually find the most effective treatment. Unfortunately, sometimes you may develop side effects that require stopping a medication that was working well. This can be frustrating, but there are now many treatment options available, and most patients can eventually achieve good disease control.

It's also worth noting that RA is a variable disease—you may have periods of flare and periods of relative calm even with consistent treatment. Regular communication with your rheumatologist helps optimize your treatment over time.