Rheumatoid Arthritis Medications: What Are the Treatment Options?
Rheumatoid arthritis (RA) is a chronic inflammatory disease that affects the joints. The goal of medication treatment is to reduce inflammation, relieve pain, improve function, and minimize the risk of future joint damage. Early and effective treatment is essential for the best outcomes.
Quick Facts
Key Takeaways
- Start treatment early: Beginning DMARD therapy within 3 months of symptom onset significantly improves long-term outcomes and prevents joint damage.
- Methotrexate is the cornerstone: This medication is the first-line treatment for most RA patients due to its effectiveness and well-established safety profile.
- Multiple medication classes exist: DMARDs, biologics, JAK inhibitors, NSAIDs, and corticosteroids each play different roles in managing RA.
- Regular monitoring is essential: Blood tests every 4-12 weeks help detect and prevent medication side effects.
- Combination therapy may be needed: Many patients require multiple medications working together to achieve optimal disease control.
- Treatment is individualized: The best medication regimen varies from person to person based on disease severity, comorbidities, and response to treatment.
How Does Medication Treatment for Rheumatoid Arthritis Work?
Quick Answer: RA medications work by suppressing the overactive immune system that causes joint inflammation. Different medication classes target different parts of the inflammatory process, and treatment often involves combining multiple medications for optimal effect.
While rheumatoid arthritis cannot be cured, there are many effective medications that can reduce symptoms and, in the best cases, bring the disease into complete remission. Most people with RA need ongoing treatment. The earlier you start treatment, the better your chances of controlling the disease and preventing permanent joint damage.
Joint changes and loss of muscle strength can occur very early after symptoms begin. Within the first year, there may already be signs of cartilage breakdown. To prevent progression, you need to continue medications for many years, as long as they don't cause excessive side effects. This allows you to continue living a normal life.
Types of Medications for Rheumatoid Arthritis
Several different medication classes are used to treat RA:
- Disease-Modifying Antirheumatic Drugs (DMARDs) - The foundation of RA treatment
- Biologic medications - Targeted therapies for inadequate DMARD response
- JAK inhibitors - Newer targeted synthetic DMARDs
- NSAIDs - For pain and inflammation relief
- Corticosteroids - For rapid inflammation control
- Pain medications - For additional pain management
Combination Therapy
Because RA involves multiple inflammatory pathways, medications are often combined for the best effect. Which medications you need can vary from person to person.
Typically, you'll receive a long-acting DMARD along with pain-relieving and anti-inflammatory medications. You may also receive low-dose corticosteroid tablets initially while waiting for the DMARD to take effect. Sometimes a corticosteroid injection directly into one or more joints can provide quick relief.
If methotrexate alone doesn't provide full disease control, it can be combined with other DMARDs such as sulfasalazine, hydroxychloroquine, or biologic medications. Studies show that these combinations can be more effective than any single medication alone, without necessarily increasing side effects.
Why Is Regular Monitoring Important During RA Treatment?
Quick Answer: Regular blood tests are essential because RA medications can affect blood cells and liver function. Early detection of any changes allows for dose adjustments or medication breaks, preventing permanent damage.
Treatment requires regular follow-up to ensure it's working well. Because these medications can cause side effects affecting the blood and liver, you'll need regular blood tests. If tests show any abnormalities, you may need to pause the medication or reduce the dose. These changes are usually reversible with no permanent harm.
If treatment isn't sufficiently effective, you may receive a higher dose or switch to a different medication.
Most rheumatologists recommend blood tests every 4-12 weeks, depending on the medications you're taking and how stable your disease is. Tests typically include complete blood count, liver function tests, and kidney function. More frequent monitoring may be needed when starting a new medication or adjusting doses.
What Are NSAIDs and How Do They Help Rheumatoid Arthritis?
Quick Answer: NSAIDs (Non-Steroidal Anti-Inflammatory Drugs) work by blocking cyclooxygenase (COX) enzymes, reducing prostaglandin production. This decreases pain, inflammation, and joint stiffness, though they don't prevent disease progression.
NSAIDs work by inhibiting cyclooxygenase (COX), which reduces the body's production of prostaglandins - substances that cause pain and inflammation. This relieves pain, inflammation, and joint stiffness.
Pain relief occurs quickly, but full anti-inflammatory effect may take 1-3 weeks. These medications treat symptoms but cannot stop the underlying disease progression.
Available Forms
NSAIDs come in tablets, enteric-coated tablets, capsules, and suppositories. Some are available as long-acting formulations, which can be helpful if you have morning stiffness and pain - take them at night for better morning relief.
Important Considerations with NSAIDs
- Don't take multiple different NSAIDs simultaneously unless specifically prescribed - this increases side effect risk
- If you're sensitive to aspirin or other NSAIDs, you may have severe reactions including hives, runny nose, or breathing difficulties
- People with asthma should consult their doctor before using NSAIDs
- NSAIDs may be inappropriate if you have heart, kidney, or liver disease
- Be cautious with NSAIDs if you have or have had stomach ulcers
- NSAIDs reduce platelet function and may increase bleeding risk, especially with blood thinners
NSAIDs and Pregnancy
Avoid NSAIDs if you're pregnant or trying to conceive without consulting your doctor first. NSAIDs should not be used at all during the last three months of pregnancy. While small amounts pass into breast milk, there's no evidence they harm nursing infants.
Common NSAID Side Effects
NSAIDs can cause stomach problems including nausea, stomach pain, or diarrhea. They increase the risk of stomach ulcers, which can be reduced by taking stomach-protecting medications like omeprazole. NSAIDs may also slightly increase the risk of heart attack and stroke, and can cause headaches, skin rashes, or dizziness. Side effect risk increases with age.
Examples of NSAIDs Used for RA
Ibuprofen
Brand names: Advil, Motrin, Nurofen
Widely available, including over-the-counter. Generally well-tolerated for short-term use.
Naproxen
Brand names: Aleve, Naprosyn
Longer-acting than ibuprofen, often preferred for chronic conditions. Taken twice daily.
Diclofenac
Brand names: Voltaren, Cataflam
Available in various forms including topical gel. Effective for joint inflammation.
Celecoxib
Brand names: Celebrex
A COX-2 selective inhibitor with potentially lower risk of stomach problems.
What Pain Medications Are Used for Rheumatoid Arthritis?
Quick Answer: Pain medications range from over-the-counter paracetamol (acetaminophen) to prescription opioids. They work by blocking pain signals from reaching the brain and are used alongside disease-modifying treatments.
Joint pain is common in RA. Pain can be classified as acute (sudden) or chronic (long-lasting), and they're treated differently. Generally, acute, short-term pain is easier to manage than chronic pain.
Pain medications work by preventing pain signals from reaching the brain. Paracetamol (acetaminophen) is a common, over-the-counter option. Opioids work in the spinal cord and brain and include medications like codeine and tramadol. For severe pain uncontrolled by other medications, stronger opioids like morphine may occasionally be needed.
Important Considerations
- There's a risk of dependency with opioids, though this risk is lower when used appropriately for genuine pain and for short periods
- Opioids can affect alertness and reaction time
- Avoid alcohol with paracetamol (liver risk) and especially with opioids (breathing difficulties)
Side Effects of Pain Medications
Paracetamol rarely causes side effects when used correctly. Opioids commonly cause constipation (often requiring preventive laxatives), nausea (especially initially), drowsiness, confusion, dizziness, and dry mouth. Dry mouth increases cavity risk, so good dental hygiene is important.
How Do Corticosteroids Help Treat Rheumatoid Arthritis?
Quick Answer: Corticosteroids rapidly suppress inflammation by mimicking the body's natural cortisol. They're highly effective for quick symptom relief and are often used as "bridge therapy" while waiting for DMARDs to take effect, or as injections directly into inflamed joints.
Corticosteroids are synthetic versions of the body's natural cortisol hormone. They work by reducing the substances that cause inflammation, thereby decreasing symptoms like fatigue, pain, stiffness, and weakness.
Most patients receive low-dose corticosteroids early in the disease. Studies show that corticosteroid use during the first two years after diagnosis reduces long-term joint damage. If joints improve quickly, the dose may be gradually reduced and eventually stopped.
Corticosteroid injections into inflamed joints are a gentle treatment with usually rapid effect. They're used when one or more joints remain very inflamed despite other medications.
Important Considerations
- If you've been on corticosteroids long-term, your body's natural cortisol production may be suppressed. You may need extra corticosteroids during infections, serious illness, or surgery
- Never stop corticosteroids suddenly after long-term use - this can cause dangerous cortisol deficiency. Always taper gradually under doctor supervision
- Corticosteroids can mask signs of infection - don't delay seeking care if you develop fever
- Combining corticosteroids with NSAIDs increases stomach bleeding risk
Corticosteroid Side Effects
Long-term corticosteroid use can cause various side effects, depending on dose and duration:
- Fluid retention causing swollen hands and feet
- High blood pressure
- Elevated blood sugar and diabetes risk
- Thin, fragile skin and easy bruising
- Slow wound healing
- Weight gain and fat redistribution to face and trunk
- Sleep difficulties with high doses
- Osteoporosis - one of the most serious side effects, which can be partly prevented with calcium and vitamin D supplements
You can use corticosteroids during pregnancy, but consult your doctor first. Avoid high doses if possible, as they may increase the risk of premature birth or affect fetal growth. When breastfeeding, corticosteroids pass into milk but don't appear to affect the baby at recommended doses.
Examples of Corticosteroids
Common corticosteroids for RA include prednisolone (oral tablets), methylprednisolone (Depo-Medrol - injectable), and triamcinolone (Kenalog - injectable for joints).
What Are DMARDs and Why Are They the Foundation of RA Treatment?
Quick Answer: Disease-Modifying Antirheumatic Drugs (DMARDs) are medications that actually slow or stop RA progression by suppressing the immune system. Unlike pain relievers, DMARDs address the underlying disease process and can prevent joint damage.
DMARDs include several different medication types. Many were originally developed to treat other conditions. They work by reducing joint inflammation in various ways, thereby decreasing pain, stiffness, and swelling.
Sometimes one DMARD isn't enough, and multiple DMARDs may be combined.
Methotrexate - The Gold Standard
Methotrexate is the primary medication used for RA. It has both good effectiveness and relatively few side effects, which is important since treatment continues for many years.
Methotrexate can be used alone or combined with other DMARDs or biologics. It works by suppressing the immune system, reducing inflammation. Effect typically appears within 2-3 months. Folic acid (a B vitamin) is always taken alongside methotrexate to reduce side effects.
Important: Methotrexate is taken in low doses once weekly, not daily.
Considerations with Methotrexate
- You may be more susceptible to infections. If you develop an infection, your doctor may temporarily stop the medication
- Available as tablets or subcutaneous injections
Pregnancy and Methotrexate
Methotrexate can cause serious birth defects. You must use reliable contraception during treatment. Stop methotrexate at least 3 months before trying to conceive. This applies to both men and women. Do not take methotrexate while breastfeeding - it passes into breast milk.
Methotrexate Side Effects
- Nausea the day after taking it (can be reduced by lowering dose, taking at night, or switching to injections)
- Increase folic acid dose to reduce nausea (but not on the same day as methotrexate)
- Mouth sores, headache, dizziness, hair thinning, skin rash, or appetite loss
- Liver effects (detected by blood tests, usually reversible with dose adjustment)
- Rare but serious: Dry cough and breathing difficulties from lung inflammation - contact your doctor immediately
Sulfasalazine
Sulfasalazine slows RA progression. It may take up to 3 months to notice improvement. It's also used for inflammatory bowel diseases like ulcerative colitis and Crohn's disease.
Don't use sulfasalazine if: You're allergic to sulfa drugs or aspirin.
Pregnancy: Can be used during pregnancy with folic acid supplementation. Safe during breastfeeding.
Side Effects
Side effects may include nausea, stomach pain, and headache, which sometimes require stopping treatment. Itching, skin rash, and fever can occur. More rarely, lung or kidney inflammation. Risk is highest in the first few months. Regular blood tests monitor blood counts and liver function.
Hydroxychloroquine
Hydroxychloroquine reduces inflammation. It's often not strong enough alone for RA and is usually combined with methotrexate and sulfasalazine. Full effect takes 1-3 months.
Don't use if: You have epilepsy, porphyria, or certain vision or hearing problems.
Side Effects
Usually well-tolerated. Some people experience nausea, appetite loss, or stomach discomfort, which often improves with continued use. Early in treatment, some develop blurry vision or difficulty focusing - these are harmless and resolve with stopping or reducing dose. With long-term, high-dose treatment, there's a small risk of retinal damage, requiring periodic eye exams.
Leflunomide
Leflunomide reduces inflammation with effectiveness comparable to methotrexate.
Caution: Can raise blood pressure, so regular monitoring is important if you have high blood pressure or heart disease.
Do not use leflunomide during pregnancy - it can harm the fetus. Use reliable contraception for up to 2 years after treatment (this can be shortened to 11 days with a special washout procedure using cholestyramine). Avoid during breastfeeding.
Side Effects
May include headache, nausea, diarrhea, liver damage, blood changes, high blood pressure, and weight loss.
Cyclosporine
Cyclosporine suppresses the immune system to reduce inflammation. Effect appears within 2-3 months. Can be used alone or in combination with other medications.
Important Considerations
- May increase infection susceptibility - contact your doctor if you develop fever, sore throat, or cold/flu symptoms
- Can interact with many medications - review all medications with your doctor before starting
- Avoid grapefruit and grapefruit juice - they interfere with cyclosporine breakdown
- Avoid St. John's Wort - it can decrease cyclosporine levels
- Discuss with your doctor if you're ill and at risk of dehydration (e.g., gastroenteritis, high fever)
Side Effects
May include stomach problems, increased hair growth, fatigue, headache, muscle problems, or swollen gums. Can also cause high blood pressure, reduced kidney function, or effects on liver, blood fats, or salt balance - requiring regular monitoring.
What Are JAK Inhibitors and How Do They Work?
Quick Answer: JAK (Janus Kinase) inhibitors are a newer class of oral medications that block specific enzymes involved in inflammation. They work differently from traditional DMARDs and can be effective when other treatments fail.
JAK inhibitors are a newer class of "targeted synthetic DMARDs." They work by reducing the activity of Janus kinase enzymes, which play a key role in the inflammatory process.
Available as tablets or extended-release tablets, they're typically prescribed when traditional DMARDs haven't provided adequate disease control.
Pregnancy
Do not take JAK inhibitors during pregnancy. Stop tofacitinib at least 28 days before attempting pregnancy; baricitinib should be stopped at least 7 days before. Avoid during breastfeeding due to unknown effects on infants.
Side Effects and Risks
JAK inhibitors may increase risk of blood clots, cardiovascular disease, and certain cancers. Your doctor will assess these risks before starting treatment. They also increase infection risk, including respiratory infections and shingles. Treatment is paused during active infections.
Other side effects may include nausea and diarrhea. Blood, liver, and kidney effects are possible, requiring monitoring. If you carry latent tuberculosis or viral hepatitis, these infections may become active - your doctor will screen for these before starting treatment.
Examples of JAK Inhibitors
Tofacitinib (Xeljanz)
One of the first JAK inhibitors approved for RA. Available in immediate and extended-release forms.
Baricitinib (Olumiant)
Taken once daily. Also approved for other conditions including COVID-19.
Upadacitinib (Rinvoq)
A newer, more selective JAK inhibitor. Taken once daily.
Filgotinib (Jyseleca)
Selective for JAK1. Available in some countries for RA treatment.
What Are Biologic Medications for Rheumatoid Arthritis?
Quick Answer: Biologics are protein-based medications made from living cells that target specific parts of the immune system. They've revolutionized RA treatment by offering options for patients who don't respond adequately to traditional DMARDs.
Biologic medications have transformed RA treatment. Many patients who've tried multiple DMARDs without adequate response can benefit from biologics.
Most biologics affect cytokines - a large group of substances that regulate inflammation in the body. By blocking certain cytokines, inflammation decreases, disease progression slows, and symptoms improve. Pain, stiffness, and general illness feeling may decrease or disappear. Biologics can also slow the breakdown of cartilage and bone.
RA inflammation affects the whole body, not just the joints. This can cause fatigue, depression, weight loss, muscle weakness, and bone loss. When cytokines are blocked, these symptoms also improve.
TNF Inhibitors
Several medications block the cytokine TNF-alpha. Examples include infliximab, etanercept, adalimumab, certolizumab pegol, and golimumab. Infliximab is given as an IV infusion (usually every 8 weeks), while others are self-injected under the skin weekly to monthly, depending on the medication.
Biosimilars
Biosimilars are essentially "copies" of original biologic medications, with the same effectiveness but lower cost. They must demonstrate equivalent efficacy to the original medication. Your doctor may suggest switching to a biosimilar - this is safe and helps reduce healthcare costs.
Other Biologics
- Tocilizumab (RoActemra) - Blocks IL-6, another inflammatory cytokine
- Sarilumab (Kevzara) - Also blocks IL-6
- Rituximab (Rituxan) - Removes B-lymphocytes (immune cells that contribute to inflammation)
- Abatacept (Orencia) - Blocks T-lymphocyte activation
Effect May Diminish Over Time
Biologic effectiveness may decrease over time. This can occur because your immune system produces antibodies against the medication, or because other cytokines take over driving the inflammation.
Important Considerations
- Cytokines help defend against infections, so blocking them increases infection risk
- Tuberculosis and hepatitis: Old, dormant infections may reactivate when starting biologics. Your doctor will test for these before treatment begins
- Risk of new TB infection also increases
Pregnancy and Biologics
Generally, avoid biologics during pregnancy. Discuss with your doctor well before a planned pregnancy. Certolizumab has minimal placental transfer and may be continued in certain cases. There are no definitive recommendations for breastfeeding.
Side Effects
- Mild flu-like symptoms (chills, muscle/joint aches) early in treatment, usually resolving spontaneously. Paracetamol can help
- Infection risk - most commonly respiratory infections (colds). Also possible: urinary tract infections, joint infections, pneumonia
- If you have an existing wound infection, it may worsen. Pause treatment during active infections
- Injection site reactions (redness) - usually harmless but occasionally requires stopping treatment
- Severe allergic reactions are uncommon but possible
Examples of Biologic Medications
| Generic Name | Brand Names | Target | Administration |
|---|---|---|---|
| Adalimumab | Humira, Amgevita, Hyrimoz | TNF-alpha | Subcutaneous, every 2 weeks |
| Etanercept | Enbrel, Benepali | TNF-alpha | Subcutaneous, weekly |
| Infliximab | Remicade, Inflectra | TNF-alpha | IV infusion, every 8 weeks |
| Tocilizumab | RoActemra, Actemra | IL-6 receptor | IV or subcutaneous |
| Rituximab | Rituxan, MabThera | CD20 (B-cells) | IV infusion, every 6 months |
| Abatacept | Orencia | T-cell co-stimulation | IV or subcutaneous |
Can RA Medications Affect My Ability to Drive?
Quick Answer: Some RA medications can cause drowsiness, dizziness, or blurred vision. You're responsible for assessing whether you can safely drive or perform tasks requiring alertness while taking these medications.
Certain medications can affect your ability to drive. You may become drowsy, dizzy, or have blurred vision. People react differently to medications. You are responsible for judging whether you can safely drive or perform work requiring alertness and quick reactions.
Why Don't Antirheumatic Medications Always Make You Feel Better?
Quick Answer: RA treatment is based more on clinical experience than complete understanding of disease mechanisms. Finding the right medication combination often requires trial and error, but with patience, most patients find an effective treatment regimen.
RA treatment relies more on accumulated clinical experience about which medications slow the disease than on complete understanding of what causes RA and how it develops in the body. Doctors often need to try different medications to find what works best for you. This requires patience, but eventually, you and your doctor usually find the most effective treatment. Unfortunately, some patients experience side effects that require stopping an otherwise effective medication.
Frequently Asked Questions About RA Medications
Methotrexate is considered the first-line treatment and gold standard for rheumatoid arthritis according to ACR and EULAR guidelines. It is effective, well-tolerated, and has decades of clinical experience. However, the best medication varies by individual - some patients require combination therapy with other DMARDs or biologics for optimal disease control. Your rheumatologist will recommend the best approach based on your specific situation.
DMARDs like methotrexate typically take 2-3 months to reach full effect. NSAIDs provide pain relief within hours to days but don't modify disease progression. Biologic medications may show improvement within 2-4 weeks for some patients, though full effect may take longer. Corticosteroids work quickly (within hours to days) and are often used as bridge therapy while waiting for DMARDs to take effect.
Side effects vary by medication class. Methotrexate can cause nausea, mouth sores, and liver enzyme elevation (mitigated by folic acid supplementation). NSAIDs may cause stomach problems and cardiovascular risks. Biologics increase infection risk. Corticosteroids used long-term can cause bone loss, weight gain, and diabetes. Regular monitoring through blood tests helps detect and prevent serious side effects. Most side effects are manageable with proper monitoring and dose adjustments.
Some RA medications are safe during pregnancy while others must be stopped. Methotrexate and leflunomide are contraindicated and must be stopped at least 3 months before conception. Sulfasalazine, hydroxychloroquine, and low-dose corticosteroids are generally considered safe. Certain biologics like certolizumab have minimal placental transfer. Always consult your rheumatologist before pregnancy to plan medication adjustments - ideally 3-6 months in advance.
Conventional DMARDs (like methotrexate, sulfasalazine) are small molecule drugs taken orally that broadly suppress the immune system. Biologic DMARDs are large protein molecules made from living cells that target specific parts of the immune system (like TNF-alpha or interleukins). Biologics are typically given by injection or infusion and are usually prescribed when conventional DMARDs are insufficient. Both types are "disease-modifying" - meaning they can slow or stop RA progression, unlike NSAIDs which only treat symptoms.
Most patients with rheumatoid arthritis require long-term medication to control inflammation and prevent joint damage. Early and sustained treatment is crucial to prevent irreversible joint destruction. Some patients in stable remission may be able to reduce or taper medications under close supervision, but complete discontinuation often leads to disease flares. The goal is to achieve and maintain remission with the lowest effective dose. Never stop RA medications without discussing with your rheumatologist.
References and Sources
- Fraenkel L, et al. 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Rheumatol. 2021;73(7):1108-1123. doi:10.1002/art.41752
- Smolen JS, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3-18. doi:10.1136/ard-2022-223356
- World Health Organization. WHO Model List of Essential Medicines - 23rd List. 2023.
- Singh JA, et al. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care Res. 2016;68(1):1-25.
- Aletaha D, Smolen JS. Diagnosis and Management of Rheumatoid Arthritis: A Review. JAMA. 2018;320(13):1360-1372.
- Bergstra SA, et al. Treat-to-target in real practice: performance of the most stringent definition of remission. Ann Rheum Dis. 2022.
- Gossec L, et al. EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2019 update. Ann Rheum Dis. 2020;79(6):700-712.
Medical Review Team
This article was written and reviewed by our medical editorial team of licensed physicians specializing in rheumatology and internal medicine.
Medical Director
Board-certified rheumatologist with 15+ years experience in autoimmune diseases
Clinical Reviewer
Registered nurse specializing in rheumatology patient education
Last medical review: December 7, 2025
Content follows: ACR 2021 Guidelines, EULAR 2022 Recommendations, GRADE evidence framework