About Rheumatoid Arthritis (RA)
What is rheumatoid arthritis?
Rheumatoid arthritis (RA) is a systemic autoimmune disease where a person’s immune system attacks the lining of the joints causing inflammation and pain. If untreated, it can lead to chronic damage and disability. It is not yet known what causes RA, but scientists think that multiple factors work together to put people at risk, including:
A person with new RA usually has one or more of these symptoms:
Who can develop rheumatoid arthritis?
Rheumatoid arthritis is diagnosed in approximately 1 in 100 people in Canada. The disease affects women twice as often as men. Usually, people are diagnosed between the ages of 20 and 50, though rheumatoid arthritis can start at any age, adulthood onwards.
Canadian studies have shown that RA is more common in Indigenous Peoples than in non-Indigenous Peoples.1 Indigenous Peoples are three times more likely to develop RA and are often younger at the time of diagnosis which means that they live with the disease for longer.2
Getting a diagnosis of rheumatoid arthritis
A person experiencing symptoms of rheumatoid arthritis should first be seen by their family doctor. After history and physical exam, if RA is suspected, they should be referred to an arthritis specialist, called a “rheumatologist”.
At the first visit with the rheumatologist, they will go thorough a full medical history where they will ask detailed questions about symptoms. A full physical examination including a full joint examination, which even includes feet, may follow. Each physician needs to hear from the person experiencing the symptoms directly to ensure they are getting the full picture. Diagnosing RA is nearly an “art form” as there are no definitive blood tests that confirm disease presence, unlike in other conditions.
It is very important for the person experiencing the symptoms to carefully describe them.
Again, rheumatoid arthritis has several "hallmark" symptoms when the disease first presents itself. These include:
Treatment for rheumatoid arthritis
Once a rheumatologist has diagnosed RA, there are effective treatments available to help a person manage the symptoms and minimize joint damage. While there is no known cure for RA, a rheumatologist and other arthritis health care providers can help build an all-encompassing treatment plan that usually includes learning about the disease, medications, physiotherapy/physical therapy and occupational therapy, lifestyle changes, self-care strategies and Indigenous healing practices.
Because people with active, moderate to severe RA are at high risk for joint damage caused by the disease, it is very important for them to integrate their treatment regimen into their life. Health promoting habits and wellness practices can preserve physical function and help to achieve the highest quality of life possible. Further, arthritis treatment for ethnically diverse groups requires approaches that are culturally sensitive and relevant and incorporate traditional healing practices or alternative therapies. Research shows that culturally appropriate models may be more effective in resolving care gaps and optimizing health outcomes for Indigenous Peoples living with arthritis and other comorbidities.3
1. Medication treatments
There are six major medication groups used to manage symptoms and treat RA. These are:
Step 1:
A person newly or recently diagnosed with moderate to severe rheumatoid arthritis is typically started on methotrexate, and possibly one or two other DMARDs such as sulfasalazine and hydroxychloroquine in combination (triple therapy). While waiting for the drugs to take effect, an NSAID or cox 2 inhibitor or in some cases prednisone, can be used to reduce inflammation quickly.
Step 2:
If a person does not respond, or does not respond well enough to the above combination therapy (which is to say their inflammation is not well controlled), they will be switched to another csDMARD or combination or to a bsDMARD or tsDMARD (only one is used at any given time). They are usually used in combination with methotrexate.
This medication approach is very similar to that used to treat cancer. In cancer, aggressive medication therapy is used to stop or reduce the size of tumours or lesions. In RA, early and aggressive medication therapy is used to stop or markedly reduce inflammation – inflammation is the equivalent of a tumour.
2. Non-medication treatments
In addition to medications, a well-rounded treatment plan for RA includes several important components. Taking control of your disease means ensuring that the body is as healthy and strong as possible. This means eating nutritious foods, getting enough of the right vitamins and minerals, maintaining a healthy body weight, quitting smoking, doing the right kinds of exercise, and making home and work environments as supportive and accessible as possible.
Nutrition
Maintaining a well-balanced diet can help fight arthritis and encourage overall health. It is important to note that food choices are highly personal. What works for some may not work for others. Many other factors – such as culture, biology, and access to resources – can impact food choices.
Exercise
Physical activity is any movement that requires your muscles to work and expend energy. Exercise is planned, structured and purposeful physical activity. The goal of exercise is to maintain and improve the components of physical fitness – endurance, strength, flexibility, and body composition. Not all physical activity is exercise, and exercise is likely to be a higher intensity (level of exertion) than leisure physical activity.
Indigenous healing practices5
According to the First Nations Health Authority, traditional healing “refers to the health practices, approaches, knowledge and beliefs that incorporate First Nations healing and wellness using ceremonies, plant, animal or mineral-based medicines, energetic therapies such as ceremonial dancing, and physical/hands-on techniques.”
For people living with RA who come from cultures that use traditional healing practices or alternative therapies, it is important to discuss these options when co-creating a patient-centered treatment plan with health care providers.4
Occupational therapy
An occupational therapist helps to solve the problems that interfere with a person’s ability to do the things that are important to them – everyday things like self-care (getting dressed, eating, moving), being productive (going to work or school, participating in the community), and participating in leisure activities (sports, social activities).
Physiotherapist/physical therapist
A physiotherapist/physical therapist trained in RA is the ideal person to recommend a safe and effective exercise program for people living with the disease. If you do not have access to a physiotherapist/physical therapist, a physical education teacher or coach can also provide general exercise guidance.
Medical cannabis6
For people living with arthritis, medical cannabis may help to alleviate certain arthritis symptoms, including pain relief, improvement in mood and/or sleep promotion. While medical cannabis has been a legal treatment option for arthritis since 2021, it has not been subject to the standard review required for drug approval by Health Canada. In the absence of studies examining the effects of medical cannabis in patients with rheumatic diseases, patients can review the position of the Canadian Rheumatology Association here.
Sleep and fatigue
People with RA typically have several permanently inflamed joints. The inflammation inside the body can lead to general physical weakness, drowsiness and exhaustion. This feeling of extreme tiredness is also called "fatigue." Some people find this to be the worst symptom of the disease.
Sometimes fatigue persists as a major problem despite a person adjusting their daily schedule, doing physical exercise and getting support from others. Professional help may be an option, for instance in the form of psychological treatment or occupational therapy. Some specialized programs have been developed specifically for people with RA who have fatigue.
Smoking cessation
There is increasing evidence that environmental air pollution is associated with people developing RA. At the 2021 Annual European Congress of Rheumatology, a large population-based study of French women reported that passive exposure to smoking during childhood or adulthood increases the risk of developing RA.7 Another study concluded that environmental air pollution may lead to poor response to biologic treatment.8 The Government of Canada provides a list of resources by province or territory here.
Stress reduction
Those living with RA may experience higher levels of stress than those living without chronic conditions due to reduced life quality, disability, and inability to work as much or at all, or take part in their usual activities. Symptoms of stress include feelings of irritability, changes in sleep patterns, fluctuations in weight, negative thoughts, and loss of interest. Some strategies for managing stress and RA include:
For people living with arthritis, active disease activity makes it challenging to prepare and eat the wide variety of foods necessary to maintain adequate vitamin and mineral levels in the body. A doctor or registered dietitian can answer your questions about starting a vitamin plan.
Dental maintenance and hygiene
Reports show that a based on clinical evidence, oral infection can either cause or aggravate many diseases, such as rheumatoid arthritis, heart disease, and skin, ocular and renal disease.12 A dentist or dental hygienist can answer your questions or concerns about your oral health.
Resources to help you on your rheumatoid arthritis journey
References
| ACE is committed to using inclusive language that is free from words, phrases and tone that reflect discriminatory or stereotyped views of underrepresented people or groups. In our attempt to avoid bias or using language that appropriates other cultures as it relates to Indigenous Peoples health and wellness, ACE consults with Indigenous advisors to ensure its website and other written materials use terms and expressions that align with Indigenous identities and are culturally appropriate. |
Rheumatoid arthritis (RA) is a systemic autoimmune disease where a person’s immune system attacks the lining of the joints causing inflammation and pain. If untreated, it can lead to chronic damage and disability. It is not yet known what causes RA, but scientists think that multiple factors work together to put people at risk, including:
- gender
- age
- genetics (family history of RA or other autoimmune disease)
- environmental exposures
- stress
- poor dentition (dental maintenance and hygiene)
- smoking
- obesity
A person with new RA usually has one or more of these symptoms:
- Pain, swelling, redness and warmth in the small joints of the hands and feet; often the same on both sides
- Morning stiffness, gradually improving over hours each day
- Reduced function and loss of motion in affected joints
- Severe fatigue
Who can develop rheumatoid arthritis?
Rheumatoid arthritis is diagnosed in approximately 1 in 100 people in Canada. The disease affects women twice as often as men. Usually, people are diagnosed between the ages of 20 and 50, though rheumatoid arthritis can start at any age, adulthood onwards.
Canadian studies have shown that RA is more common in Indigenous Peoples than in non-Indigenous Peoples.1 Indigenous Peoples are three times more likely to develop RA and are often younger at the time of diagnosis which means that they live with the disease for longer.2
Getting a diagnosis of rheumatoid arthritis
A person experiencing symptoms of rheumatoid arthritis should first be seen by their family doctor. After history and physical exam, if RA is suspected, they should be referred to an arthritis specialist, called a “rheumatologist”.
At the first visit with the rheumatologist, they will go thorough a full medical history where they will ask detailed questions about symptoms. A full physical examination including a full joint examination, which even includes feet, may follow. Each physician needs to hear from the person experiencing the symptoms directly to ensure they are getting the full picture. Diagnosing RA is nearly an “art form” as there are no definitive blood tests that confirm disease presence, unlike in other conditions.
It is very important for the person experiencing the symptoms to carefully describe them.
Again, rheumatoid arthritis has several "hallmark" symptoms when the disease first presents itself. These include:
- Morning stiffness, lasting longer than 45 minutes
- Pain and/or inflammation in the same joints on both sides of your body
- Pain in three or more joints at the same time
- Loss of motion in affected joints
- Severe fatigue
- Referral for joint ultrasound to look for evidence of joint swelling that they can’t find on routine examination.
- Blood work looking for inflammation. At the same time, they might ask for blood tests to look at how well your liver, bone marrow and kidneys work before starting treatment. They will also look for “antibodies” which sometimes can predict if the disease could be more aggressive.
- Baseline x-rays of the hands, feet and chest to look for early joint damage or destruction.
- Joint fluid tests, or “arthrocentesis”, in which a small amount of joint fluid is extracted using a needle and then analyzed in the laboratory.
Treatment for rheumatoid arthritis
Once a rheumatologist has diagnosed RA, there are effective treatments available to help a person manage the symptoms and minimize joint damage. While there is no known cure for RA, a rheumatologist and other arthritis health care providers can help build an all-encompassing treatment plan that usually includes learning about the disease, medications, physiotherapy/physical therapy and occupational therapy, lifestyle changes, self-care strategies and Indigenous healing practices.
Because people with active, moderate to severe RA are at high risk for joint damage caused by the disease, it is very important for them to integrate their treatment regimen into their life. Health promoting habits and wellness practices can preserve physical function and help to achieve the highest quality of life possible. Further, arthritis treatment for ethnically diverse groups requires approaches that are culturally sensitive and relevant and incorporate traditional healing practices or alternative therapies. Research shows that culturally appropriate models may be more effective in resolving care gaps and optimizing health outcomes for Indigenous Peoples living with arthritis and other comorbidities.3
1. Medication treatments
There are six major medication groups used to manage symptoms and treat RA. These are:
- Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (for example Advil® or Motrin IB®), naproxen (or Naprosyn®), diclofenac (or Voltaren® and Arthrotec®)
- COX-2 inhibitors, such as celecoxib (Celebrex®)
- Corticosteroids including prednisone and intra-articular cortisone injections
- Conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) including methotrexate, sulfasalazine, hydroxychloroquine, leflunomide and azathioprine
- Biologic disease-modifying anti-rheumatic drugs (boDMARds and bsDMARDs) including abatacept (Orencia®), adalimumab (Abrilada®, Amgevita®, Hadlima®, Hulio®, Humira®, Hyrimoz®, Idacio®, Simlandi®, Yuflyma®), anakinra (Kineret®), certolizumab pegol (Cimzia®), etanercept (Brenzys®, Enbrel®, Erelzi®), golimumab (Simponi®), infliximab (Avsola®, Inflectra®, Remicade®, Remsima®SC, Renflexis®), rituximab (Riabni®, Rituxan®, Riximyo®, Ruxience®, Truxima®), sarilumab (Kevzara®), tocilizumab (Actemra®)
- Targeted-Synthetic disease-modifying antii-rheumatic drugs (tsDMARDs) including baricitinib (Olumiant®), tofacitinib (Xeljanz®), and upadacitinib (Rinvoq®)
Step 1:
A person newly or recently diagnosed with moderate to severe rheumatoid arthritis is typically started on methotrexate, and possibly one or two other DMARDs such as sulfasalazine and hydroxychloroquine in combination (triple therapy). While waiting for the drugs to take effect, an NSAID or cox 2 inhibitor or in some cases prednisone, can be used to reduce inflammation quickly.
Step 2:
If a person does not respond, or does not respond well enough to the above combination therapy (which is to say their inflammation is not well controlled), they will be switched to another csDMARD or combination or to a bsDMARD or tsDMARD (only one is used at any given time). They are usually used in combination with methotrexate.
This medication approach is very similar to that used to treat cancer. In cancer, aggressive medication therapy is used to stop or reduce the size of tumours or lesions. In RA, early and aggressive medication therapy is used to stop or markedly reduce inflammation – inflammation is the equivalent of a tumour.
2. Non-medication treatments
In addition to medications, a well-rounded treatment plan for RA includes several important components. Taking control of your disease means ensuring that the body is as healthy and strong as possible. This means eating nutritious foods, getting enough of the right vitamins and minerals, maintaining a healthy body weight, quitting smoking, doing the right kinds of exercise, and making home and work environments as supportive and accessible as possible.
Nutrition
Maintaining a well-balanced diet can help fight arthritis and encourage overall health. It is important to note that food choices are highly personal. What works for some may not work for others. Many other factors – such as culture, biology, and access to resources – can impact food choices.
Exercise
Physical activity is any movement that requires your muscles to work and expend energy. Exercise is planned, structured and purposeful physical activity. The goal of exercise is to maintain and improve the components of physical fitness – endurance, strength, flexibility, and body composition. Not all physical activity is exercise, and exercise is likely to be a higher intensity (level of exertion) than leisure physical activity.
Indigenous healing practices5
According to the First Nations Health Authority, traditional healing “refers to the health practices, approaches, knowledge and beliefs that incorporate First Nations healing and wellness using ceremonies, plant, animal or mineral-based medicines, energetic therapies such as ceremonial dancing, and physical/hands-on techniques.”
For people living with RA who come from cultures that use traditional healing practices or alternative therapies, it is important to discuss these options when co-creating a patient-centered treatment plan with health care providers.4
Occupational therapy
An occupational therapist helps to solve the problems that interfere with a person’s ability to do the things that are important to them – everyday things like self-care (getting dressed, eating, moving), being productive (going to work or school, participating in the community), and participating in leisure activities (sports, social activities).
Physiotherapist/physical therapist
A physiotherapist/physical therapist trained in RA is the ideal person to recommend a safe and effective exercise program for people living with the disease. If you do not have access to a physiotherapist/physical therapist, a physical education teacher or coach can also provide general exercise guidance.
Medical cannabis6
For people living with arthritis, medical cannabis may help to alleviate certain arthritis symptoms, including pain relief, improvement in mood and/or sleep promotion. While medical cannabis has been a legal treatment option for arthritis since 2021, it has not been subject to the standard review required for drug approval by Health Canada. In the absence of studies examining the effects of medical cannabis in patients with rheumatic diseases, patients can review the position of the Canadian Rheumatology Association here.
Sleep and fatigue
People with RA typically have several permanently inflamed joints. The inflammation inside the body can lead to general physical weakness, drowsiness and exhaustion. This feeling of extreme tiredness is also called "fatigue." Some people find this to be the worst symptom of the disease.
Sometimes fatigue persists as a major problem despite a person adjusting their daily schedule, doing physical exercise and getting support from others. Professional help may be an option, for instance in the form of psychological treatment or occupational therapy. Some specialized programs have been developed specifically for people with RA who have fatigue.
Smoking cessation
There is increasing evidence that environmental air pollution is associated with people developing RA. At the 2021 Annual European Congress of Rheumatology, a large population-based study of French women reported that passive exposure to smoking during childhood or adulthood increases the risk of developing RA.7 Another study concluded that environmental air pollution may lead to poor response to biologic treatment.8 The Government of Canada provides a list of resources by province or territory here.
Stress reduction
Those living with RA may experience higher levels of stress than those living without chronic conditions due to reduced life quality, disability, and inability to work as much or at all, or take part in their usual activities. Symptoms of stress include feelings of irritability, changes in sleep patterns, fluctuations in weight, negative thoughts, and loss of interest. Some strategies for managing stress and RA include:
- Regular rest and exercise.
- Ask family and friends to help out with your chores or to reduce your workload.
- Planning your day according to how you are feeling.
- Mindfulness techniques – being fully present in one’s body and actions to not be overly reactive to one’s surrounding.
- Find a way to express how you feel – talk to others, write in a journal, cry, go for a run, or laugh.
- Practicing breathing techniques to relax.
- Consider getting support from a counsellor, social worker, allied health professional, or mental health professional.
For people living with arthritis, active disease activity makes it challenging to prepare and eat the wide variety of foods necessary to maintain adequate vitamin and mineral levels in the body. A doctor or registered dietitian can answer your questions about starting a vitamin plan.
Dental maintenance and hygiene
Reports show that a based on clinical evidence, oral infection can either cause or aggravate many diseases, such as rheumatoid arthritis, heart disease, and skin, ocular and renal disease.12 A dentist or dental hygienist can answer your questions or concerns about your oral health.
Resources to help you on your rheumatoid arthritis journey
- ACE Public Policy Priorities: Models of Care
- ACE: JointHealth™ Education online learning program - ACE has developed the JointHealth™ Education Rheumatoid Arthritis course to help people living with RA learn more about their disease.
- ACE: Mental health and arthritis: a complex relationship
- The Canadian 24-Hour Movement Guidelines for Adults
- Canadian Mental Health Association
- Canadian Sleep & Circadian Network – Resources on sleep and health
- The Science of Mindfulness
References
| 1 | Barnabe et al (2017). Inflammatory Arthritis Prevalence and Health Services Use in the First Nationals and Non-First Nationals Populations of Alberta, Canada https://onlinelibrary.wiley.com/doi/epdf/10.1002/acr.22959 |
| 2 | Hitchon et al (2020). Prevalence and Incidence of Rheumatoid Arthritis in Canadian First Nations and Non–First Nations People. A Population-Based Study. https://journals.lww.com/jclinrheum/Fulltext/2020/08000/Prevalence_and_Incidence_of_Rheumatoid_Arthritis.2.aspx |
| 3 | Umaefulam et al (2022). Arthritis liaison: a First Nations community-based patient care facilitator https://www.canada.ca/en/public-health/services/reports-publications/health-promotion-chronic-disease-prevention-canada-research-policy-practice/vol-41-no-6-2021/arthritis-liaison-first-nations-community-care-facilitator.html |
| 4 | Oulanova & Moodley (2010). Navigating Two Worlds: Experiences of Counsellors Who Integrate Aboriginal Traditional Healing Practices. https://files.eric.ed.gov/fulltext/EJ912087.pdf |
| 5 | Traditional Wellness and healing. https://www.fnha.ca/what-we-do/health-system/traditional-wellness-and-healing |
| 6 | Position statement: Medical cannabis use in rheumatic disease. https://rheum.ca/resources/publications/canadian-rheumatology-association-cra-position-statement-on-medical-cannabis-use-in-rheumatic-disease/ |
| 7 | Nguyen , et al. Association between passive smoking in childhood and adulthood, and rheumatoid arthritis: results from the French E3N-EPIC cohort study. Presented at EULAR 2021; abstract OP0012. |
| 8 | Adami, et al. Air pollution is a predictor of poor response to biological therapies in chronic inflammatory arthritides. Presented at EULAR 2021; poster POS0644. |
| 9 | McKenna, Treatment of moderate rheumatoid arthritis. https://doi.org/10.1093/rheumatology/keab582 |
| 10 | Lacaille et al. (2004). Identification of modifiable work‐related factors that influence the risk of work disability in rheumatoid arthritis. https://doi.org/10.1002/art.20690 |
| 11 | Wolfe, & Hawley (1998). The longterm outcomes of rheumatoid arthritis: Work disability: a prospective 18 year study of 823 patients. |
| 12 | Shafer William G., Hine Maynard K., Levy Barnet M. Spread of oral infection. A textbook of oral pathology. (4th ed) 1993:511–27. Chapter 9. |
Arthritis Consumer Experts
ACE thanks Arthritis Research Canada (ARC) for its scientific review of ACE and JointHealth™ information and education programs.