Treatment of Rheumatoid Arthritis

Non-Pharmacologic Therapies

Non-pharmacologic therapies include treatments other than medications and are the foundation of treatment for all people with rheumatoid arthritis.

Rest – When joints are inflamed, the risk of injury of the joint itself and the adjacent soft tissue structures (such as tendons and ligaments) is high. This is why inflamed joints should be rested. However, physical fitness should be maintained as much as possible. At the same time, maintaining a good range of motion in your joints and good fitness overall are important in coping with the systemic features of the disease.
Exercise – Pain, and stiffness often prompt people with rheumatoid arthritis to become inactive. However, inactivity can lead to a loss of joint motion, contractions, and a loss of muscle strength. These, in turn, decrease joint stability and further increase fatigue. Regular exercise, especially in a controlled fashion with the help of physical therapists and occupational therapists, can help prevent and reverse these effects. Types of exercises that have been shown to be beneficial include range-of-motion exercises to preserve and restore joint motion, exercises to increase strength and exercises to increase endurance (walking, swimming, and cycling).
Physical and Occupational Therapy – Physical and occupational therapy can relieve pain, reduce inflammation, and help preserve joint structure and function for patients with rheumatoid arthritis.

Specific types of therapy are used to address the specific effects of rheumatoid arthritis:

The application of heat or cold can relieve pain or stiffness.
Use of ultrasound to help reduce inflammation of the sheaths surrounding tendons (tenosynovitis)
Passive and active exercises to improve and maintain the range of motion of the joints
Rest and splinting to reduce joint pain and improve joint function
Finger-splinting and other assistive devices to prevent deformities and improve hand function.
Relaxation techniques to relieve secondary muscle spasm

Occupational therapists also focus on helping people with rheumatoid arthritis to be able to continue to actively participate in work and recreational activity with special attention to maintaining good function of the hands and arms.

Nutrition and dietary therapy – Weight loss may be recommended for overweight and obese people to reduce stress on inflamed joints. People with rheumatoid arthritis have a higher risk of developing coronary artery disease. High blood cholesterol is one risk factor for coronary disease that can respond to changes in diet. A nutritionist can recommend specific foods to eat or avoid in order to achieve a desirable cholesterol level. Changes in diet have been investigated as treatments for rheumatoid arthritis, but there is no diet that is proven to cure rheumatoid arthritis. No herbal or nutritional supplements, such as cartilage or collagen, can cure rheumatoid arthritis. These treatments can be dangerous and are not usually recommended.
Smoking and alcohol – Smoking is a risk factor for rheumatoid arthritis and it has been shown that quitting smoking can improve the condition. People who smoke need to quit completely. Assistance in quitting should be obtained if needed. Moderate alcohol consumption is not harmful to rheumatoid arthritis, although it may increase the risk of liver damage from some drugs such as methotrexate. People should discuss the safety of alcohol use with a doctor because recommendations depend on the medications a person is taking and on their other medical conditions.
Measures to reduce bone loss – Inflammatory conditions such as rheumatoid arthritis can cause bone loss, which can lead to osteoporosis. The use of prednisone further increases the risk of bone loss, especially in postmenopausal women. It is important to do a risk assessment and address risk factors that can be changed in order to help prevent bone loss.

Patients may do the following to help minimize the bone loss associated with steroid therapy:

Use the lowest possible dose of glucocorticoids for the shortest possible time, when possible, to minimize bone loss.
Consume an adequate amount of calcium and vitamin D, either in the diet or by taking supplements.
Use medications that can reduce bone loss, including that which is caused by glucocorticoids.
Control the disease itself with appropriate medications prescribed by your doctor.

Medications

There are many medications available to decrease joint pain, swelling and inflammation and hopefully, prevent or minimize the progression of the disease. The type of drugs that your doctor recommends will depend on how severe your arthritis is and how well you respond to the medications. These medications include:

Analgesics – Prescription-strength drugs that relieve pain but not inflammation.
Non-steroidal anti-inflammatory drugs (NSAIDs – such as aspirin, ibuprofen or naproxen)Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include aspirin, ibuprofen (Motrin, Advil), and naproxen (Naprosyn, Aleve).
COX-2 inhibitors (celecoxib)
Antidepressants- A Drugs that block pain messages from your brain and boost the effects of endorphins (your body’s natural painkillers).
Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
Muscle Relaxants– These medications provide relief from spinal muscle spasms.
Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
Calcium & vitamin D3 – to improve bones health and healing fracture.
Corticosteroid to healing the nerve inflammation and clotted blood in the joints.
A dietary supplement to remove the general weakness & improved the health.
Disease-modifying anti-rheumatic drugs (DMARDs) – such as hydroxychloroquine, methotrexate, sulfasalazine, and leflunomide, An improvement in symptoms may require four to six weeks of treatment with methotrexate. Improvement may require one to two months of treatment with sulfasalazine and two to three months of treatment with hydroxychloroquine.
Biologic agents (such as infliximab, etanercept, adalimumab, certolizumab and golimumab, tocilizumab, rituximab,abatacept, anakinra, tofacitinib) Biologics tend to work rapidly, within two weeks for some medications and within four to six weeks for others. Biologics may be used alone or in combination with other DMARDs. Usually, they are reserved for patients who do not adequately respond to DMARDs, or if adverse prognostic factors are present. Combinations of DMARDs may be more effective than single drugs. For example, hydroxychloroquine, sulfasalazine, and methotrexate together are more effective than methotrexate alone or the other two together.

Combining a DMARD – with another drug, such as methotrexate plus a TNF-α antagonist or an IL-1 receptor antagonist or a rapidly tapered corticosteroid, may be more effective than using DMARDs alone.

Methotrexate – is a folate antagonist with immunosuppressive effects at the high dose. It is anti-inflammatory at doses used in RA. It is very effective and has a relatively rapid onset (a clinical benefit often within 3 to 4 wk). Methotrexate should be used with caution, if at all, in patients with hepatic dysfunction or renal failure. Alcohol should be avoided. Supplemental folate, 1 mg PO once/day, reduces the likelihood of adverse effects. CBC, AST, ALT, and albumin and creatinine level should be determined about every 8 wks. When used early in the course of RA, efficacy may equal the biologic agents. Rarely, a liver biopsy is needed if liver function test findings are persistently twice the upper limit of normal or more and the patient needs to continue to use methotrexate. Severe relapses of arthritis can occur after withdrawal of methotrexate. Paradoxically, rheumatoid nodules may enlarge with methotrexate therapy.

Hydroxychloroquine – can also control symptoms of mild RA. Funduscopic examination should be done and visual fields should be assessed before and every 12 mo during treatment. The drug should be stopped if no improvement occurs after 9 mo.

Leflunomide – interferes with an enzyme involved with pyrimidine metabolism. It is about as effective as methotrexate but is less likely to suppress bone marrow, cause abnormal liver function, or cause pneumonitis. Alopecia and diarrhea are fairly common at the onset of therapy but may resolve with the continuation of therapy.
Sulfasalazine – Sulfasalazine (Azulfidine, generic) works best when the disease is confined to the joints. Symptom relief occurs within 1 – 3 months. Side effects are common, particularly stomach and intestinal distress, which usually occur early in the course of treatment. (However, serious gastrointestinal side effects, such as stomach ulcers, occur less frequently with sulfasalazine than with NSAIDs.) A coated-tablet form may help reduce side effects. Other side effects include skin rash and headache. Sulfasalazine increases sensitivity to sunlight. Be sure to wear sunscreen (SPF 15 or higher) while taking this drug. People with intestinal or urinary obstructions or who have allergies to sulfa drugs or salicylates should not take sulfasalazine.
Minocycline – Minocycline is a tetracycline antibiotic that is generally reserved for patients with mild RA. It can take 2 – 3 months before symptoms begin to improve and up to a year for full benefit. Side effects include upset stomach, dizziness, and skin rash. Long-term use of minocycline can cause changes in skin color, but this side effect usually disappears once the medication is stopped. Minocycline can cause yeast infections in women. It should not be used by women who are pregnant or planning on becoming pregnant. Minocycline increases sensitivity to sunlight and patients should be sure to wear sunscreen. In rare cases, minocycline can affect the kidneys and liver.
Tofacitinib- Tofacitinib is the newest DMARD. Approved in 2012, tofacitinib is the first in a new class of drugs. It works by blocking “Janus kinase” molecules involved in joint inflammation. There is hope that DMARD might be an alternative to biologic DMARDs and a new option for patients with moderate-to-severe RA who have not been helped by methotrexate. Tofacitinib, which is taken as a twice-daily pill, can be used alone or in combination with methotrexate. Tofacitinib may increase the risk of serious infections. Because it is new a drug, long-term side effects are still unknown.
Gold- Gold used to be a time-honored DMARD for rheumatoid arthritis but its use has decreased with the development of newer DMARDs and biologic drugs. Gold is usually administered in an injected form because the oral form, auranofin (Ridaura, generic), is much less effective. There are two injectable forms of gold: Gold sodium thiomalate (Myochrysine, generic) and aurothioglucose (Solganal, generic). It can take 3 – 6 months before injections have an effect on RA symptoms. Gold injections can cause a number of side effects including mouth sores and skin rash and in rare cases more serious problems such as kidney damage.
Azathioprine – Azathioprine suppresses immune system activity. It takes 6 – 8 weeks for early symptom improvement and up to 12 weeks for full benefit. Azathioprine can cause serious problems with the gastrointestinal tract including nausea and vomiting, often accompanied by stomach pain and diarrhea. Azathioprine can also cause problems with liver function and pancreas gland inflammation and can reduce white blood cell count.
Cyclosporine – Like azathioprine, cyclosporine (Sandimmune, Neoral, generic) is an immunosuppressant. It is used for people with RA who have not responded to other drugs. It can take a week before symptoms improve and up to 3 months for full benefit. The most serious and common side effects of cyclosporine are high blood pressure and kidney function problems. While kidney function usually improves once the drug is stopped, mild-to-moderate high blood pressure may continue. Swelling of the gums is also common. Patients should practice good dental hygiene, including regular brushing and flossing.
Corticosteroids – Systemic corticosteroids decrease inflammation and other symptoms more rapidly and to a greater degree than other drugs. They also seem to slow bone erosion. However, they may not prevent joint destruction, and their clinical benefit often diminishes with time. Furthermore, rebound often follows the withdrawal of corticosteroids in active disease. Because of their long-term adverse effects, some doctors recommend that corticosteroids are given to maintain function only until another DMARD has taken effect Corticosteroids may be used for severe joint or systemic manifestations of RA (eg, vasculitis, pleurisy, pericarditis). Relative contraindications include peptic ulcer disease, hypertension, untreated infections, diabetes mellitus, and glaucoma. The risk of latent TB should be considered before corticosteroid therapy is begun.
Intra-articular injections – of depot corticosteroids may temporarily help control pain and swelling in particularly painful joints. Triamcinolone hexacetonide may suppress inflammation for the longest time. Triamcinolone acetonide and methylprednisolone acetate are also effective. No single joint should be injected with a corticosteroid more than 3 to 4 times a year, as too-frequent injections may accelerate joint destruction (although there are no specific data from humans to support this effect). Because injectable corticosteroid esters are crystalline, local inflammation transiently increases within a few hours in < 2% of patients receiving injections. Although infection occurs in only < 1:40,000 patients, it must be considered if pain occurs > 24 h after injection.
Immunomodulatory, cytotoxic, and immunosuppressive drugs – Treatment with azathioprine or cyclosporine (an immunomodulatory drug) provides efficacy similar to DMARDs. However, these drugs are more toxic. Thus, they are used only for patients in whom treatment with DMARDs has failed or to decrease the need for corticosteroids. They are used infrequently unless there are extra-articular complications. For maintenance therapy with azathioprine, the lowest effective dose should be used. Low-dose cyclosporine may be effective alone or when combined with methotrexate. It may be less toxic than azathioprine. Cyclophosphamide is no longer recommended due to its toxicity
Rituximab – is an anti-CD 20 antibody that depletes B cells. It can be used in refractory patients. The response is often delayed but may last 6 mo. The course can be repeated after 6 mo. Mild adverse effects are common, and analgesia, corticosteroids, diphenhydramine, or a combination may need to be given concomitantly. Rituximab is usually restricted to patients who have not improved after using a TNF-α inhibitor and methotrexate. Rituximab therapy has been associated with progressive multifocal leukoencephalopathy, mucocutaneous reactions, delayed leukopenia, and hepatitis B reactivation.
Abatacept – a soluble fusion cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) Ig, is indicated for patients with RA with an inadequate response to other DMARDs.
Anakinra – is a recombinant IL-1 receptor antagonist. IL-1 is heavily involved in the pathogenesis of RA. Infection and leukopenia can be problems.
TNF-α antagonists – (eg, adalimumab, etanercept, golimumab, certolizumab pegol, and infliximab) reduce the progression of erosions and reduce the number of new erosions. Although not all patients respond, many have a prompt, dramatic feeling of well being, sometimes with the first injection. Inflammation is often dramatically reduced. These drugs are often added to methotrexate therapy to increase the effect and possibly prevent the development of drug-neutralizing antibodies.
Tocilizumab – blocks the effect of IL-6 and has clinical efficacy in patients who have responded incompletely to other biologic agents.
Tofacitinib – is a Janus kinase (JAK) inhibitor that is given orally with or without concomitant methotrexate to patients who do not respond to methotrexate alone or other biologic agents. Although there are some differences among agents, the most serious problem is an infection, particularly with reactivated TB. Patients should be screened for TB with PPD or an interferon-gamma release assay. TNF-α antagonists should probably be stopped before major surgery. Etanercept, infliximab, and adalimumab can and probably should be used with methotrexate. High-dose infliximab should not be used in patients with severe heart failure.

However, the risk of side effects from treatment must be weighed against the benefits on an individual basis.

Common treatments for RA and their targets and toxicities

Abbreviations: CBC: complete blood count, Cr: creatinine, LFTs: liver function tests, PML: progressive multifocal leukoencephalopathy, TB: tuberculosis, TLR: toll-like receptor, TNF: tumor necrosis factor.

Conventional DMARDs	Target	Testing Prior to Starting Medication	Toxicities	Monitoring
Methotrexate	Enhances adenosine release; inhibits polyamines; folic acid antagonist	Cr, CBC, LFTs, Hepatitis B and C screening	Nausea, Diarrhea, Liver Toxicity, Pneumonitis, Cytopenias, Infections, Lymphoma	LFTs, Cr, CBC every 4–8 weeks
Leflunomide	Pyrimidine synthesis	Cr, CBC, LFTs, Hepatitis B and C screening	Nausea, Diarrhea, Liver Toxicity. Pneumonitis(rare), Infections	LFTs, Cr, CBC every 4–8 weeks
Hydroxychloroquine	TLR signaling; Stabilization of lysosomal membranes	Retinal screen	Retinal Toxicity, Nausea	Yearly ophthalmolog ic exam
Sulfasalazine	Enhances adenosine pathways and inhibits arachidonic acid	CBC	Nausea, Diarrhea, Allergic Reactions, Neutropenia (rare)	CBC every 4–8 weeks during first year of treatment
Biologic DMARDs
Anti-TNF drugs	TNF-α	TB screen, Hepatitis B and C screen, fungal screens (depending on geography)	Infusion and injection site reactions, Rash, Infections, Lymphoma	None
Rituximab	CD-20	Hepatitis B screen, TB screen	Infusion reaction (can be severe), PML (rare)	None
Abatacept	CTLA-4 CD 80/86 interaction	TB screen, Hepatitis B and C screen, fungal screens (depending on geography)	Possible infusion reaction, Infections	None
Anakinra	IL-1 receptor antagonist	TB screen, CBC	Injection site reactions, Neutropenia, Infections	Monthly CBC
Tocilizumab	IL-6 receptor antagonist	Lipid profile, CBC, TB screen, hepatitis B and C screen, fungal screens (depending on geography)	Neutropenia, Thrombocytopenia, Elevated total cholesterol and triglycerides, Bowel perforations (rare), Infections	Monthly CBC, Cr, cholesterol profile.

DMARDs approved for the treatment of rheumatoid arthritis (cDMARD white, bDMARD olive)

Active substance	Dosage	The strength of recommendation (S1 guideline [Rx])	When?	Frequent adverse effects (>1/100; recorded using the treatment monitoring form of the DGRh [http://dgrh.de/therapieueberwachen.html] unless otherwise specified)
Abatacept	10 mg/kg BW/ 4 weeks after induction phase	↑ ↑	As 1^st or 2^ndbDMARD following inadequate response to 2 cDMARDs	Hyperlipidemia, headache, dizziness, drowsiness, bronchitis, coughing, upper airway infections (including tracheitis, nasopharyngitis), rhinitis, abdominal pain, nausea, diarrhea, dyspepsia, skin rash, herpes simplex, urinary tract infection, tiredness, weight loss, hypertension, flushing
Adalimumab	40 mg/2 weeks	↑ ↑	As 1^st or 2^ndbDMARD following inadequate response to 2 cDMARDs	Decreased hemoglobin concentration, hypertension, headache, dizziness, drowsiness, upper airway infections, rhinitis, sinusitis, bronchitis, increased coughing, pneumonia, nausea, diarrhea, sore throat, elevated transaminases, reactions at injection site, skin rash, pruritus, herpes simplex, urinary tract infection, weight loss, influenza syndrome
Anakinra	100 mg/day	↑	As alternative to 1^st or 2^ndbDMARD	Reactions at injection site, headache
Antimalarial drugs	4 mg chloroquine/kg or >6.5 mg hydroxychloroquine/kg BW/day	↑	As alternative to 2^ndcDMARD or in combination with cDMARDs	Nausea, lack of appetite, diarrhea
Azathioprine	2–3 mg/kg BW/day	–	As alternative to 2^ndcDMARD	Nausea, vomiting, diarrhea, leukopenia, anemia, infection, drug fever
Certolizumab	200 mg/ 2 weeks after induction phase	↑ ↑	As 1^st or 2^ndbDMARD following inadequate response to 2 cDMARDs	Urinary tract infection, herpes simplex, upper airway infections, headache, dizziness, skin rash, pruritus, exhaustion, pyrexia, pain and reddening at site of administration (product information 04/2009)
Cyclosporine	2.5–3.5 mg/kg BW/day	↑	As alternative to 2^ndcDMARD or in combination with cDMARDs	Lack of appetite, nausea and occasional vomiting, diarrhea, muscle twitching and cramp may indicate magnesium deficiency, slight trembling of hands, slight increase in body hair, swelling and inflammation of gums, hypertension, tiredness
Etanercept	50 mg/week	↑ ↑	As 1^st or 2^ndbDMARD following inadequate response to 2 cDMARDs	Irritation at injection site, infections
Golimumab	50 mg/month	↑ ↑	As 1^st or 2^ndbDMARD following inadequate response to 2 cDMARDs	Upper airway infections (nasopharyngitis, pharyngitis, laryngitis, rhinitis), bacterial infections (e.g., inflammation of subcutaneous tissue), viral infections (e.g., influenza and herpes), bronchitis, sinusitis, superficial fungal infections, anemia, allergic reactions (bronchospasm, hypersensitivity, urticaria), autoantibody positive, depression, sleeplessness, dizziness, paresthesias, headache, hypertension, obstipation, dyspepsia, gastrointestinal and abdominal pain, nausea, elevated ALT/GPT levels, elevated AST/GOT levels, alopecia, dermatitis, itching, skin rash, fever, asthenia, reaction at injection site (e.g., erythema, urticaria, induration, pain, bruising, itching, irritation und paresthesias), delayed wound healing, thoracic symptoms (product information 11/2012)
Infliximab	3–5 mg/kg BW every 8 weeks after induction phase	↑ ↑	As 1^st or 2^ndbDMARD following inadequate response to 2 cDMARDs	Headache, dizziness, drowsiness, infections of upper and lower respiratory tract (e.g., sinusitis, pneumonia), nausea, diarrhea, elevated transaminases, urticaria, skin rash, pruritus, reactions to infusion
Leflunomide	10–20 mg/day	↑ ↑	As alternative to 1^st or 2^ndcDMARD or in combination with cDMARDs	Diarrhea, nausea, vomiting, abdominal pain, mouth ulcers, elevated liver parameters, leukocytopenia, headache, dizziness, asthenia, hypertension, eczema, hair loss, skin rash, itching, weight loss, mutagenicity, teratogenicity (both in animal experiments)
Methotrexate	10–25 mg/week	↑ ↑	As 1st cDMARD or in combination with cDMARDs and especially bDMARDs	Stomatitis, hair loss, nausea, vomiting, elevated transaminases
Parenteral gold	50 mg/ 2 weeks after the initial phase	↑	As an alternative to 2^ndcDMARD	Dermatitis, stomatitis, pruritus, eosinophilia, proteinuria, deposits on cornea/lens if gold dose >1500 mg (harmless), metallic taste
Rituximab	Two doses of 1000 mg at a 2-week interval every 6–12 months	↑ ↑	As 2^ndbDMARD following inadequate response to 2 cDMARDs	Airway infections, reactions to infusion, influenza-like symptoms, infections, transitory hyperuricemia (15%)
Sulfasalazine	2 g/day after initial phase	↑	As alternative to 1st or 2^ndcDMARD or in combination treatment with cDMARDs	Exanthema, pruritus, nausea, abdominal pain, lack of appetite, hyperchromasia, oligospermia, reversible loss of fertility in men, headache, feeling of weakness, tiredness
Tocilizumab	8 mg/kg BW every 28 days	↑ ↑	As 1st or 2^ndbDMARD following inadequate response to 2 cDMARDs	Skin and subcutaneous infections, pneumonia, oral herpes simplex, herpes zoster, mouth ulcers, gastritis, exanthema, pruritus, headache, dizziness, elevated transaminases, hypertension, leukopenia, neutropenia, conjunctivitis

Essential Fatty Acids

Omega-3 or omega-6 fatty acids – have shown their potential as immunosuppressants and anti-inflammatory agents (Rx). Borage seed oil provides a high amount of omega-6 fatty acid or gamma-linolenic acid (GLA) [Rx]. A double-blind trial was conducted on 37 patients with active RA, and they were assigned to consume borage seed oil containing 1.4 g of GLA per day while the placebo group was given cottonseed oil. After 24 weeks of consumption, the group which received GLA had significantly reduced tender and swollen joint scores, whereas the placebo group did not show any change [Rx].
Gamma-linolenic acid and omega-3 fatty acid – alpha-linolenic and stearidonic acid from black currant seed oil (BCSO) have also been investigated for their therapeutic activity. About 10.5 g of BCSO were given to RA patients in double-blind fashion and soybean oil as a placebo for 24 weeks continuously. BCSO treated group, when compared with placebo group came up with significant positive effects in pain relieving and joint tenderness [Rx].
Fish oils – provide a high amount of omega-3 fatty acids, and their efficacy to treat RA has been checked in several controlled trials. RA patients were provided with fish oil with 3.6 g of omega-3 fatty acids per day in double-blind fashion, and placebo group was treated with a mixture of fatty acids for 12 weeks, which was very much similar in the amount found in the average diet. The group which received fish oil had reduced morning stiffness, a significant increase in grip strength compared to the placebo group [Rx]. Eicosapentaenoic and docosahexaenoic acids are ethyl ester derivatives of omega-3 fatty acids, and their capability to reduce the severity of RA has been assessed. When RA patients consumed these derivatives in an amount of 130 mg/kg body weight/day for 26–30 weeks, a significant decrease in pain, morning stiffness, and tender joints was observed in comparison with the placebo group that received only corn oil [RX].
Synbiotics – are composed of probiotics and prebiotics (the non-digestible food products beneficial for the growth of helpful bacteria in the large intestine and provides health-promoting effects) [Rx]. Several reports have confirmed the reduction of oxidative stress in the human body by consumption of synbiotics [Rx]. As per FDA, probiotics are “live microorganisms which, when administered in adequate amounts, confer a health benefit on the host” [Rx]. Bifidobacterium and Lactobacillus are the key strains widely used as probiotics in commercial, pharmaceutical, and nutraceutical products [Rx]. Many reports have frequently stated that the population of gut microbes gets altered in a person affected with RA [Rx ], and several animal studies have already proved that any alteration in gut microbiota corresponds to the initiation of RA [Rx].

Tea

Epigallocatechin-3-gallate (EGCG) has proved its therapeutic potential and has been of particular interest among natural products for its use as a nutraceutical [Rx]. It is a main phytochemical present in green tea that is obtained from dried leaves of Camellia sinensis and C. assamica of Theacease family [Rx]. The protective effects exerted by green tea have been well proved in neurodegenerative disease, inflammatory disease, cardiovascular disease, and several types of cancer [Rx].

Herbs

Plants with effective health-promoting effects are known as herbs, and these have a long history of being used as medicine to cure several diseases. Synthetic drugs used in arthropathies have been associated with numerous side effects on health, which in return has led the focus toward medicines of botanical origin [Rx].

Sallaki (Boswellia serrata) – is widely recommended as an anti-inflammatory herb as prescribed in Ayurveda [Rx]. The phytochemical which acts as a key player is boswellic acid from pentacyclic triterpene family [Rx]. Boswellic acid inhibits the expression of lipoxygenase-5 and eventually lowering down leukotriene synthesis and leukotrienes are well known for their role in inflammation [Rx]. These have also proved their potency to block NF-κβ activation and brought down the levels of pro-inflammatory cytokines like TNF-α, IL-1, IL-2, IL-4, IL-6, and IFN-γ and also prevented classical complement pathway by restricting the cleavage of C3 to C3b [Rx].
Ashwagandha (Withania somnifera) – is one of the plants being described in Ayurveda as a potent anti-inflammatory plant [Rx]. It is rich in Withaferin A, a steroidal phytochemical which can prevent proceeding of the NF-κβ signaling pathway [Rx]. In vitro studies with ashwagandha extract suppressed the release of pro-inflammatory cytokines as TNF-α, IL-12, and IL-1β from synoviocytes of RA patients but it failed to stop synthesis and subsequent release of IL-6 [Rx]. Rats with induced arthritis, when treated with powder of Ashwagandha roots, showed less destruction of bone collagen [Rx]. Moreover, in a double-blind placebo-controlled study aqueous extract significantly reduced stiffness, disability to move knee and joints, and pain score [Rx].
Ginger – has been known for its therapeutic properties due to the presence of pungent phenolics such as shogaols and gingerols [Rx]. Turmeric, rich in phenolic curcuminoids, has also proved its beneficial effects against several malignancies [Rx]. In a study, a perfect mixture of blended ginger and turmeric were given to the adjuvant-induced arthritic rats. This mixture showed protective effects against extra-articular complications of RA [Rx]. In another study conducted by the same group, they found that ginger and turmeric administered at a dose of 200 mg/kg body weight could independently lower down the signs and symptoms of RA in the adjuvant-induced arthritic male Wistar albino rats. The results were significant with a p-value <0.05 as compared to the control group receiving only indomethacin [Rx].
Curcumin – has also presented itself as a potent anti-inflammatory spice by blocking the expression of IL-1 and IL-6 in an in vitro study with RA patient-derived fibroblast-like synoviocytes [Rx]. Methotrexate is a widely prescribed antirheumatic drug for the treatment of RA but it increases oxidative stress, decreases NO levels, and leads to vascular endothelial dysfunction [Rx]. Curcumin and folic acid co-administration were found to lower down methotrexate-induced vascular endothelial dysfunctions in male Wistar rats [Rx].
The bark of Cinnamomum zeylanicum (Cinnamon bark) – is widely used in South-East Asian dishes. Rathi et al. treated RA animal models involving male Swiss albino mice and Wistar rats with a polyphenolic fraction of cinnamon barks and found inhibitory effects on the secretion of cytokines IL-2, IL-4, and IFN-γ and reduction in levels of TNF-α [Rx].
Kaempferol – an important phytochemical found in grapefruits, can bring down the level of inflammatory cytokine IL-1β, inhibiting the cell signaling pathways like phosphorylation of ERK1/2, p38, and JNK and activation of NF-κβ [Rx]. Several enzymes inducing oxidative stress such as MMPs, COX-2, and PGE-2 in RA-derived synoviocytes were lowered down on the administration of kaempferol [Rx]. These molecules are reported in the destruction of bone and articular cartilage leading to the pathogenesis of RA [Rx]. A mixture of polyphenols composed of epigallocatechin, gallate, catechin, tannic acid, and quercetin when injected at the intra-articular region of a rat model of RA, prevented cartilage destruction while reducing inflammation [Rx].
p-Coumaric acid – is largely present in grapes, oranges, apples, tomatoes, spinach, and potatoes. In an in vivo study using a rat model of adjuvant-induced arthritis, p-coumaric acid intake significantly reduced the expression of TNF-α [Rx]. Genistein, an important isoflavone present in soybeans maintained a perfect balance between T helper cell, Th1, and Th2, and inhibited IFN-γ and IL-4 production which ultimately brings down the inflammation [Rx]. Freshly prepared orange juice has a high content of beta-cryptoxanthin and its intake reduces the risk of RA in humans [Rx]. Pineapple stem is a rich source of a proteolytic enzyme called as bromelain. In a study, bromelain was consumed orally by RA patients in dosages of 20 or 40 mg for 3–4 times daily up to 13 months. About 72% of the total patients involved in the study came up with promising results, and there were no side effects detected. In spite of promising results obtained, the significance of the study cannot be explained due to the lack of control groups (Rx].
Anthocyanins – have proved themselves as potent antioxidants and are more abundant in black rice, eggplant, and black soybean. These have properties to reduce oxidative stress by increasing superoxide dismutase (SOD) and decreasing serum malondialdehyde (MDA). It has been reported in mouse models of RA that the uptake of anthocyanins can bring down TNF-α levels [Rx], thereby reducing disease activity. Resveratrol from black grapes has been found to exert a protective effect in rat model of RA [Rx]. It was reported that resveratrol can lower down specific RA biomarkers such as serum RF, COMP, and MMP-3; immunological biomarkers as IgG and antinuclear antibody; immunomodulatory cytokines (TNF-α) and oxidative stress [Rx]. Mangiferin, a polyphenolic compound found in mangoes, used in an in vivo study on RA-induced DBA-1/J male mice reported downregulation of IL-1β, IL-6, and TNF-α, inhibited NF-κβ signaling, and activated extracellular signal-regulated kinase 1/2 (ERK1/2) [Rx]. In another study with mangiferin, it was observed that mangiferin prevented joint destruction in RA by inducing proapoptotic effects on human synovium-derived synoviocytes [Rx].
Kaempferol – an important phytochemical found in grapefruits, can bring down the level of inflammatory cytokine IL-1β, inhibiting the cell signaling pathways like phosphorylation of ERK1/2, p38, and JNK and activation of NF-κβ [Rx]. Several enzymes inducing oxidative stress such as MMPs, COX-2, and PGE-2 in RA-derived synoviocytes were lowered down on the administration of kaempferol [Rx]. These molecules are reported in the destruction of bone and articular cartilage leading to the pathogenesis of RA[Rx]. A mixture of polyphenols composed of epigallocatechin, gallate, catechin, tannic acid, and quercetin when injected at the intra-articular region of a rat model of RA, prevented cartilage destruction while reducing inflammation [Rx].
p-Coumaric acid – is largely present in grapes, oranges, apples, tomatoes, spinach, and potatoes. In an in vivo study using a rat model of adjuvant-induced arthritis, p-coumaric acid intake significantly reduced the expression of TNF-α [Rx]. Genistein, an important isoflavone present in soybeans maintained a perfect balance between T helper cell, Th1, and Th2, and inhibited IFN-γ and IL-4 production which ultimately brings down the inflammation [Rx]. Freshly prepared orange juice has a high content of beta-cryptoxanthin and its intake reduces the risk of RA in humans [Rx]. Pineapple stem is a rich source of a proteolytic enzyme called as bromelain. In a study, bromelain was consumed orally by RA patients in dosages of 20 or 40 mg for 3–4 times daily up to 13 months. About 72% of the total patients involved in the study came up with promising results, and there were no side effects detected. In spite of promising results obtained, the significance of the study cannot be explained due to lack of control groups [Rx].

Other strategies to manage rheumatoid arthritis

Other important strategies that can help you manage rheumatoid arthritis include

Self-management courses – can help people with rheumatoid arthritis and other chronic (ongoing) conditions to build skills and confidence in becoming more actively involved in your healthcare and in managing rheumatoid arthritis day to day.
Aids and equipment – supports such as walking aids and specialized cooking utensils reduce joint strain and can help you to manage pain and fatigue. An occupational therapist can give you advice on aids. You can also phone the Independent Living Centre for advice.
Relaxation techniques – muscle relaxation, distraction, guided imagery, and other techniques can help you manage pain and difficult emotions such as anxiety. If exercise is causing sharp pain, stop immediately. If lesser aches and pains continue for more than 2 hours afterward, try a lighter exercise program for a while. Using large joints instead of small ones for ordinary tasks can help relieve pressure, for instance, closing a door with the hip or pushing buttons with the palm of the hand.
Exercise – It is important for patients with RA to maintain a balance between rest (which will reduce inflammation) and moderate exercise (which will relieve stiffness and weakness). Studies have suggested that even as little as 3 hours of physical therapy over 6 weeks can help people with RA and that these benefits are sustained. The goal of the exercise is to Maintain a wide range of motion. Increase strength, endurance, and mobility Improve general health, Promote well-being

In general, doctors recommend the following approaches

Start with the easiest exercises, stretching and tensing of the joints without movement.
Next, attempt mild strength training.
The next step is to try aerobic exercises. These include walking, dancing, or swimming, particularly in heated pools. Avoid heavy impact exercises, such as running, downhill skiing, and jumping.
Tai chi, which uses graceful slow sweeping movements, is an excellent method for combining stretching and range-of-motion exercises with relaxation techniques. It may be of particular value for elderly patients with RA.

A common-sense approach to exercise is the best guide

Rest – can help you to manage fatigue and is particularly important when your joints are swollen.
Nutrition – while there is no specific ‘diet’ for people with rheumatoid arthritis, it is important to have a healthy, balanced diet to maintain general health and, prevent weight gain and other medical problems, such as diabetes and heart disease.
Support – a peer support group can provide understanding, advice, support, and information from others in a similar situation. Contact MOVE muscle, bone & joint health for more information.
Complementary therapies – such as massage or acupuncture may be helpful. Consult your doctor or rheumatologist before commencing any treatment. Fish oil supplements may also be helpful as they contain a certain type of fat called omega-3. Current research suggests omega-3 fats can help reduce inflammation in rheumatoid arthritis.
Omega-3 fatty acids
There are lots of natural anti-inflammatories, but the best studied by far are omega-3 fatty acids. These heart-healthy, brain-boosting fats are especially prevalent in seafood, especially fatty fish such as salmon, sardines, and tuna. Studies have found that adding omega-3s to the diet can reduce joint pain and morning stiffness in people with RA, says Chaim Putterman, M.D., chief of rheumatology at Montefiore Medical Center and Albert Einstein College of Medicine in New York City. Not a fan of fish? Fish oil capsules can give you the same benefits. But beware: High concentrations of omega-3s can thin the blood, so consult your doctor for the right dose.
Gamma linolenic acid
Gamma linolenic acid (GLA) is another fatty acid with anti-inflammatory properties, says Robert Zurier, M.D., who has studied the effects of GLA in rheumatoid arthritis patients at the University of Massachusetts Medical School. GLA is found mostly in botanical oils—evening primrose, black currant seed and especially borage oil, its richest source. The patients in Dr. Zurier’s studies took three 1,000-milliliter capsules of borage oil every day for six months and reported less joint pain and stiffness than patients who took placebo capsules, and they also reduced their dose of nonsteroidal anti-inflammatory drugs.
Joint surgery – may be necessary in some cases if the joint is very painful or there is a risk of losing overall function. Any medication or treatment for arthritis must be discussed with and monitored by your doctor or rheumatologist. They will take into account the condition being treated, any other health issues and identifiable risk factors.
Diet – Many patients with RA try dietary approaches, such as fasting, vegan diets, or eliminating specific foods that seem to worsen RA symptoms. There is little scientific evidence to support these approaches but some patients report anecdotally that they are helpful.In recent years, a number of studies have suggested that the omega-3 fatty acids contained in fish oil may have anti-inflammatory properties useful for RA joint pain relief. The best source of fish oil is through increased consumption of fatty fish such as salmon, mackerel, and herring. Fish oil supplements are another option, but they may interact with certain medications. If you are thinking of trying fish oil supplements, talk to your doctor first.
Pain with Stress Management – Patients can learn strategies to cope with the stress and frustration of living with chronic pain. Relaxation and stress management techniques such as guided imagery, breathing exercises, hypnosis, or biofeedback can be helpful. Although there is no definitive evidence to support their efficacy, some patients report relief with modalities such as acupuncture, massage, and mineral baths.
Assistive Devices – There are many different types of assisted devices that can help make life easier in the home. Kitchen gadgets, such as jar openers, can assist with gripping and grabbing. Door-knob extenders and key turners are helpful for patients who have trouble turning their wrists. Bathrooms can be fitted with shower benches, grip bars, and raised toilet seats. An occupational therapist can advise you on choosing the right kinds of assistive devices.
Miscellaneous Supportive Treatments – Various ointments, including Ben Gay and capsaicin (a cream that uses the active ingredient in chili peppers), may help soothe painful joints. Orthotic devices are specialized braces and splints that support and help align joints. Many such devices made from a variety of light materials are available and can be very helpful when worn properly.

Disease-modifying antirheumatic drugs and monitoring in rheumatoid arthritis

Drug	Adverse drug reaction	Monitoring	Action
For all DMARDs	Myelosuppression Hepatotoxicity	Routine unless otherwise specified: FBE, EUC, LFTs at baseline, 2–4 weekly for 3–6 months and every 6–12 weeks thereafter. This regimen is influenced by comorbidities and changes to therapy.	Abnormalities in blood monitoring may lead to dose adjustments, treatment interruption or cessation.
Malignancy	Age-related cancer screening programs and self-reported symptoms
Infection	Self-reported fever (>38 °C), localising symptoms or unexplained illness. Fever may not always be present due to DMARD-induced alterations in cytokine profile. Maintain a high index of suspicion, particularly for reactivation of latent tuberculosis or hepatitis B infection.
Methotrexate	Alopecia	Self-reported hair loss	Usually reversible after stopping drug
Mouth ulcers	Self-reported mouth ulcers Inspection of oral mucosa	Folic acid supplementation (not on day of methotrexate)
Pneumonitis	Symptoms of cough or dyspnoea Routine respiratory examination	CXR, PFTs and urgent specialist review
Abnormal LFTs Cirrhosis	LFTs as per routine for all DMARDs	Continue folic acid supplementation. If AST or ALT <2 x ULN, repeat LFTs in a month. If normalising, continue. If persistent elevation, reduce dose. If AST or ALT >2 x ULN, interrupt treatment and discuss with rheumatologist.
Sulfasalazine	Haemolytic anaemia	Symptoms of anaemia	Stop treatment and seek specialist advice.
Abnormal LFTs	LFTs as per routine for all DMARDs	If AST or ALT <2 x ULN, repeat LFTs in a month. If normalising, continue. If persistent elevation, reduce dose. If AST or ALT >2 x ULN, interrupt treatment and discuss with rheumatologist.
Corticosteroids	Adrenal suppression (more likely with courses >3 weeks and prednisolone doses ≥7.5 mg)	No specific monitoring required	Do not stop abruptly. Consider increasing the dose during intercurrent acute illness.
Diabetes	Blood glucose and HbA1c monitoring	If continued use is necessary, consider escalation of hypoglycaemic treatment.
Hypertension	Blood pressure checks each visit	If continued use is necessary, consider antihypertensive drugs.
Osteoporosis (when used at doses of prednisolone ≥7.5 mg for ≥3 months)	Bone mineral density assessment at baseline, repeat at 3 months Self-reported skeletal pain suggesting fracture	If continued use is necessary, strongly consider starting a bisphosphonate.
Psychosis Mania Delirium Depression Insomnia	Vigilance for new or worsened mental health or sleep disturbance	Cease, or use the lowest possible dose. Seek specialist advice. Discuss with rheumatologist.
Hydroxychloroquine	Photosensitivity	Self-reported sensitivity	Sun protection strategies
Haemolytic anaemia	Symptoms of anaemia	Stop treatment and seek specialist advice.
Blue–grey skin discolouration	Self-reported skin discolouration and examination of sun-exposed sites	Stop treatment immediately and seek specialist advice. Sun protection strategies
Corneal deposits Retinal toxicity	Baseline ophthalmological assessment, then repeat at 5 years with annual review thereafter if therapy ongoing.²⁰ Annual review is recommended from initiation of therapy in high-risk patients (age >70 years, macular disease, renal disease, liver disease, higher than recommended dose).²⁰ Self-reported visual disturbance	Stop drug and seek specialist advice.
Leflunomide	Alopecia	Self-reported hair loss	Usually reversible. Reduce dose or stop drug.
Hypertension	Blood pressure assessment on each visit	Reduce dose and/or add antihypertensive.
Pneumonitis	Symptoms of cough or dyspnoea Routine respiratory examination	CXR, PFTs and seek specialist review.
Peripheral neuropathy	Self-reported paraesthesia or weakness	Stop drug, consider NCS and EMG if not resolving, seek specialist advice.
Hepatotoxicity	LFTs every 2–4 weeks for 3 months, then every 3 months ongoing	If AST or ALT <2 x ULN, continue and repeat LFTs in a month. If AST or ALT 2–3 x ULN, reduce dose and repeat LFTs in 2–4 weeks. Continue if normalising. If persistent elevation, discuss with rheumatologist. If AST or ALT >3 x ULN, stop drug and repeat LFTs in 2–4 weeks. If elevated, discontinue, consider washout and discuss with rheumatologist. Note: For any severe reactions to leflunomide consider cholestyramine washout (8 g 3 times a day for 11 days)
Tofacitinib	Abnormal LFTs	LFT frequency determined by other DMARDs used	If AST or ALT 1–2 x ULN, seek specialist advice. If AST or ALT >2 x ULN, seek urgent advice.
Myelosuppression	FBE after 3–4 weeks, then every 3 months	Seek specialist advice, stop drug if severe.
Dyslipidaemia	Lipid profile 8 weeks after starting and then guided by results	Modify lifestyle and diet, consider lipid-lowering therapy.
Reactivated tuberculosis	Ideally detected pre-treatment, but may present during treatment as pulmonary or disseminated disease	Stop treatment immediately and seek specialist advice.
Herpes zoster	Patient-reported rash or pain	Start antiviral treatment within 72 hours of rash onset. If recurrent, discuss with rheumatologist.
Abatacept	COPD exacerbation	Symptoms of COPD exacerbation	Treat exacerbation and discuss with rheumatologist.
Hypertension	Blood pressure	Modify lifestyle, consider antihypertensive.
Injection site reactions	Visualisation of injection site	Rotation of injection sites, antihistamines, topical cold packs, topical corticosteroids
Anaphylaxis	–	See Australian Prescriberwallchart²¹
Rituximab	Infusion reactions	–	Stop or slow the rate of infusion, treat symptoms.
Anaphylaxis	–	See Australian Prescriberwallchart²¹
Myelosuppression	FBE before each treatment	If severe, delay treatment.
Anakinra	Myelosuppression (especially neutropaenia)	FBE frequency determined by other DMARDs used. Neutropaenia may be delayed and prolonged.	Discontinue and discuss with rheumatologist.
Injection site reactions	Visualisation of injection sites	Rotation of injection sites, antihistamines, topical cold packs, topical corticosteroids
Infection	As per routine monitoring for all DMARDs	Arrange follow-up visit, consider antimicrobial, remain vigilant for deterioration and the need for hospitalisation, stop if serious infection.
Anaphylaxis	–	See Australian Prescriberwallchart²¹
TNF inhibitors	Injection site reactions	Visualisation of injection sites	Rotation of injection sites, antihistamines, topical cold packs, topical corticosteroids
Drug-induced lupus	Self-reported rash, fever or arthralgia	Assess urine for evidence of glomerulonephritis. Assess serum lupus antibody profile and complement levels. Seek urgent advice from rheumatologist.
Demyelinating syndrome	Self-reported neurological symptoms	Consider MRI, seek specialist advice.
Malignancy	Participation in age-appropriate screening programs	Stop treatment immediately and seek specialist advice.
Infection	As per routine monitoring for all DMARDs	Arrange follow-up visit, consider antimicrobial, remain vigilant for deterioration and the need for hospitalisation, stop if serious infection.
Reactivated tuberculosis	Ideally detected pre-treatment, but may present during as pulmonary or disseminated disease without fever	Stop treatment immediately and seek specialist advice.
Herpes zoster	Self-reported rash or pain	Start antiviral treatment within 72 hours of rash onset. If recurrent, discuss with rheumatologist.
Tocilizumab	Hypertension	Blood pressure checks each visit	Modify lifestyle modification, consider antihypertensive.
Myelosuppression	FBE at baseline, then every 4–8 weeks	Interrupt treatment and discuss with rheumatologist.
Dyslipidaemia	Lipid profile at baseline. Repeat after 4–8 weeks of treatment, then as per relevant guidelines	Modify lifestyle modification, consider lipid-lowering therapy.
Gastrointestinal perforation	Self-reported abdominal pain	Stop therapy and discuss with rheumatologist.
Infection	As per routine monitoring for all DMARDs Note: CRP is an unreliable marker for infection during tocilizumab therapy due to IL-6 blockade	Minor infection – interrupt treatment until recovered. Serious infection – stop treatment.
Abnormal LFTs	LFTs at baseline and every 4–8 weeks for 6 months, then every 3 months	If AST or ALT >1–3 x ULN, reduce dose, or stop until normal. If AST or ALT >3 x ULN, stop until >1–3 x ULN then reduce dose. If AST or ALT >5 x ULN, discontinue treatment.

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ALT alanine aminotransferase

AST aspartate aminotransferase

COPD chronic obstructive pulmonary disease

CRP C-reactive protein

CXR chest x-ray

DMARDs disease-modifying antirheumatic drugs

EMG electromyography

EUC electrolytes, urea, creatinine

FBE full blood examination

HbA1c glycated haemoglobin

IL-6 Interleukin-6

LFTs liver function tests

MRI magnetic resonance imaging

NCS nerve conduction study

PFTs pulmonary function tests

TNF tumour necrosis factor

ULN upper limit of normal

Herbal Remedies

1. Massage

This is the first out of the most efficient home remedies for rheumatoid arthritis in the body that I want to reveal in this entire writing.

When being applied properly, massage can help to relieve the pain caused rheumatoid arthritis as it can relax your stiff muscles. Massage will help to boost your blood circulation, which is essential for alleviating the discomfort due to the symptoms of rheumatoid arthritis.

2. Evening Primrose Oil

Evening primrose oil is one kind of plant oil which can help to relieve morning stiffness and pain effectively. This plant oil has the gamma-linolenic acid properties – an essential fatty acid which can help to relieve the intensity of numerous symptoms caused by rheumatoid arthritis.

Take 540 mg to 2.8 g of evening primrose oil in divided doses every day. Remember to consult an expert to get proper dosage because this oil may interfere with some medications.

3. Epsom Salt

Epsom salt is also a great and highly effective natural remedy which can help to soothe the pain and swelling due to rheumatoid arthritis. Epsom salt is an abundant source of magnesium, so it can help to regulate the pH levels in your body effectively as well. In turn, it can help to reduce rheumatoid arthritis, stiffness, and pain in the joints. In addition, it can help to mineralize bone well.

Add 2 cups of Epsom salt to a bathtub full of warm water.
Soak in the bathtub within about half an hour.
Apply this method up to 3 times weekly.

In fact, this is also one of the best home remedies for rheumatoid arthritis in the body that people should make use for good!

4. Ginger

In naturopathy and Ayurvedic as well, ginger has been used for people at all ages to deal with inflammatory conditions, including rheumatoid arthritis. Ginger contains a compound named gingerol – a powerful agent with natural anti-inflammatory properties, helping to relieve swelling and pain due to rheumatoid arthritis effectively.

You can add ginger to daily food dishes or drink two or three cups of ginger tea every day.
Alternatively, you can chew some fresh ginger slices every day.
Use ginger oil to rub onto your affected area. Then expose that area to sunlight for five to ten minutes to generate heat and warmth. Apply this tip on a regular basis.

In brief, making use of ginger is one of the most effective home remedies for rheumatoid arthritis pain that people should never look down and should apply for good!

5. Garlic

Thanks to its powerful anti-inflammatory properties, garlic is also advisable for dealing with rheumatoid arthritis. Garlic can help to inhibit the pro-inflammatory substances (also called “cytokines”) production, helping to relieve swelling and pain efficiently and fast.

You can take garlic capsules. For correct dosage, remember to consult experts.
You can also eat one or two raw garlic cloves every day

6. Apple Cider Vinegar

Apple cider vinegar is considered very useful in helping people relieve several symptoms caused by rheumatoid arthritis. Being rich in minerals, such as phosphorus, potassium, magnesium, and calcium, apple cider vinegar can help to relieve the rheumatoid arthritis pain effectively.

You should use some apple cider vinegar to directly apply to the affected area of your body. Then, use warm castor oil to massage your painful area. Finally, use a cotton cloth to wrap that area and use plastic to cover it. Apply this method every day before bedtime for good results as desired.
Mix one teaspoon of honey with one tablespoon of raw, unfiltered apple cider vinegar and add them to 1/2 cup of warm water. Consume this solution once every day.

7. Turmeric

Turmeric can help to reduce the risk of joint rheumatoid arthritis by blocking certain cytokines and enzymes causing rheumatoid arthritis.

You can add turmeric powder into your daily meals to benefit from this natural ingredient.
Alternatively, you can take turmeric in form of capsules by 500 – 1,000 mg three times daily. Remember to consult experts initially.
Bring 1 quart of water to a boil. Add 1 tablespoon of turmeric powder and boil it for another 10 minutes. Allow it to cool and drink it once or twice daily.

Note: Do not consume high doses of turmeric because it can act as a blood thinner as well as leading to a stomach upset.

This is actually one of the best home remedies for rheumatoid arthritis pain that I would like to reveal in this entire article and want my readers to make use for good!

8. Fish Oil

Fish oil contains omega-3 fatty acids – DHA and EPA – that have a powerful anti-inflammatory ability and can help to relieve pain as well. In addition, fish oil can help to prevent the risks of heart disease, which rheumatoid arthritis sufferers are usually at high risks.

Add cold water fish like salmon and tuna to your daily diet
Take up to 2.6 grams of fish oil (containing 30% DHA/EPA at least) 2 times every day.

Note: Before taking fish oil supplements, remember to consult your doctor because the supplements could interfere with some types of medications you are taking.

9. Hot And Cold Compresses

Alternating hot and cold compresses are also a great way to reduce the symptoms caused by rheumatoid arthritis. While a cold compress can dull the pain and relieve rheumatoid arthritis and joint swelling, a hot compress can help to relieve pain by relaxing sore joints and muscles.

For the cold compress, use a thin towel to wrap some ice cubes.
For the hot compress, use a towel to wrap a hot water bag.
Put the hot compress right onto the affected area and let it stay within just three minutes.
Remove the hot compress and place the cold compress immediately in its place within just one minute.
Repeat these steps for fifteen to twenty minutes 2 – 3 times every day until your pain is relieved.

10. Parsley
In a research conducted by JNR (Journal of Natural Remedies) on rats, it was found that extract made of fresh leaves of parsley had reduced inflammation in their paws. Therefore, using it as a home remedy to relieve you from your arthritis pain can have a positive impact.

11. Carrots
Carrots have an abundance amount of Vitamin C and beta-carotene. Beta-carotene and Vitamin C both have antioxidant properties that kill free radicals which are responsible for arthritis inflammation.

12. Rosemary
Rosemary has a polyphenol called rosmarinic acid which is a potent antioxidant and inflammation reliever.

13. Kale
Kale is a vegetable that is a rich source of anti-oxidants, Vitamin C, Vitamin K, and beta-carotene that can reverse arthritis inflammation.

14. Coriander
According to a medical research conducted by All India Institute of Medical Sciences, the coriander powder has the potential to reduce swelling and inflammation. It can also be digested as green leaves.

15. Olive Oil
Olive oil, especially raw ice-pressed, has many health benefits starting from reducing your blood cholesterol to diabetes and inflammation. It can be used as cooking oil that could not only make your dish tastier but also loads with various health benefits. The anti-inflammatory properties of olive oil relieve you from arthritis joints pain.

16. Green tea
Green tea is a wonder drink that is loaded with antioxidants that have anti-inflammatory properties. Along with relieving you from severe arthritis pain, green tea has many health benefits from lowering your LDL cholesterol to minimizing the risk of bladder cancer.

17. Pineapple
The stems of pineapples are rich in a protein called bromelain. It acts as a digestive enzyme that relieves from arthritis inflammation.

18. Blueberries
Blueberries are rich in various minerals and they are considered to be the potential sources of antioxidants. However, always go for organically grown berries because they have higher amounts of polyphenols than the non-organically grown. These polyphenols and antioxidants prevent cell damage and reduce inflammation.

Homeopathic Treatment for Rheumatoid Arthritis

The treatment for Rheumatoid Arthritis may vary from cases to the case – some requiring short-term whereas others requiring long-term treatment. The duration of treatment depends on various factors such as the severity, duration, and extent of the illness, the nature of treatment taken for the same and general health of the patient.

Common Homeopathy medicines for Rheumatoid Arthritis are

Arnica – Useful for chronic arthritis with a feeling of bruising and soreness. The painful parts feel worse from being moved or touched.
Bryonia – Helpful for stiffness and inflammation with tearing or throbbing pain, made worse by motion. The condition may have developed gradually and is worse in cold dry weather. Discomfort is aggravated by being touched or bumped, or from any movement. Relief can be had from pressure and from rest. The person may want to stay completely still and not be interfered with.
Calcarea carbonica- Helpful for deeply aching arthritis involving node formation around the joints. Inflammation and soreness are worse from cold and dampness, and problems may be focused on the knees and hands. Common symptoms are the weakness in the muscles, easy fatigue from exertion, and a feeling of chilliness or sluggishness. The person who benefits from Calcarea is often solid and responsible, but tends to become extremely anxious and overwhelmed when ill or overworked.
Aurum metallicum- This remedy is often prescribed for wandering pains in the muscles and joints that are better from motion and warmth, and worse at night. The person may experience deep pain in the limbs when trying to sleep.
Causticum – Useful when deformities develop in the joints, in a person with tendon problems, muscle weakness, and contractures. The hands and fingers may be most affected. Stiffness and pain are worse from being cold, and relief may come with warmth. The person often feels best in rainy weather and worse when the days are clear and dry.
Calcarea fluorica – Helpful when arthritic pains improve with heat and motion. Joints become enlarged and hard, and nodes or deformities develop. Arthritis after a chronic injury to joints also responds to Calcarea fluorica.
Dulcamara – Indicated if arthritis flares up during cold damp weather. The person gets chilled and wet. They are often stout, with a tendency toward back pain, chronic stiffness in the muscles, and allergies.
Kali bichromicum – This is useful when arthritic pains alternate with asthma or stomach symptoms. Pains may suddenly come and go, or shift around. Discomfort and inflammation are aggravated by heat and worse when the weather is warm.
Kali carbonicum – Arthritis with great stiffness and stitching pains, worse in the early morning hours and worse from cold and dampness, may respond to Kali carbonicum. The joints may be becoming thickened or deformed.
Kalmia latiflora – Useful for intense arthritic pain that flares up suddenly. The problems start in higher joints and extend to lower ones. Pain and inflammation may begin in the elbows, spreading down to the wrists and hands. Discomfort is worse from motion and often worse at night.
Ledum palustre – Arthritis that starts in lower joints and extends to higher ones are a candidate for this remedy. Pain and inflammation often begin in the toes and spread upward to the ankles and knees. The joints may also make cracking sounds. Ledum is strongly indicated when swelling is significant and relieved by cold applications.
Pulsatilla – Applicable when rheumatoid arthritis pain is changeable in quality, or when the flare-ups move from place to place. The symptoms (and the person) feel worse from warmth, and better from fresh air and cold applications. Can benefit people who are emotional and affectionate, sometimes having teary moods.
Rhododendron – Strongly indicated if swelling and soreness flare up before a storm, continuing until the weather clears. Cold and dampness aggravate the symptoms. Discomfort is often worse toward early morning, or after staying still too long.
Rhus Toxicodendron – Useful for rheumatoid arthritis, with pain and stiffness that is worse in the morning and worse on the first motion, but better from continued movement. Hot baths or showers, and warm applications improve the stiffness and relieve the pain. The condition is worse in cold, wet weather. The person may feel extremely restless, unable to find a comfortable position, and need to keep moving constantly. The continued motion also helps to relieve anxiety.
Ruta graveolens – Arthritis with a feeling of great stiffness and lameness, worse from cold and damp and worse from exertion, may be helped by Ruta graveolens. Tendons and capsules of the joints can be deeply affected or damaged. Arthritis may have developed after overuse, from repeated wear and tear.

Treatment of Rheumatoid Arthritis

Non-Pharmacologic Therapies