Understanding Rheumatoid Arthritis Progression and Its Management

Understanding Disease Progression in Rheumatoid Arthritis

Understanding Disease Progression in Rheumatoid Arthritis
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Published on February 10, 2025
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Rheumatoid arthritis (RA) is a chronic autoimmune disease (one in which the immune system attacks healthy cells) that primarily affects your joints. It is a progressive condition that gets worse over time and can lead to joint damage and eventually disability, resulting in significant limitations in daily activities. Getting diagnosed and starting treatment early can help minimize symptoms, slow the progression of the disease, and improve long-term quality of life.

8 Things About Rheumatoid Arthritis That Are Difficult to Explain or Understand

Rheumatoid Arthritis doesn't have to be a mystery! Understanding the basics can help with treatment and symptoms both physical and mental.
8 Things About Rheumatoid Arthritis That Are Difficult to Explain or Understand

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Early RA

In the early stages of RA, the immune system begins to mistakenly attack the synovium, the tissue lining your joints. This leads to mild inflammation, which may cause joint pain, stiffness, and swelling, particularly in the morning. These initial symptoms usually affect smaller joints such as those in the fingers and feet, but they sometimes also impact the knees.

Early stage RA is sometimes known as the triggering stage because it’s when the interplay of genetics and environmental factors spark the production of the immune system’s attack on the joints.

There are many potential triggers for RA, such as:

  • Exposure to certain toxins and pollutants, such as cigarette smoke, asbestos, pesticides, and silica dust
  • Infections including Epstein-Barr virus, E. coli, and hepatitis C
  • Childhood trauma
  • Obesity
  • Gum disease
  • Inflammatory diet
  • Changes in gut and microbiome health

Diagnosing RA in the early stages is challenging and usually involves a review of your symptoms, medical history, and family history. Your healthcare provider may also conduct blood tests to see if you have certain biomarkers (biological signs) for RA or inflammation, including rheumatoid factor, anti-citrullinated protein antibodies, C-reactive protein, and erythrocyte sedimentation rate (though positive results don’t necessarily mean you have RA or will develop it). They may order imaging tests such as X-rays, ultrasound, and MRI, both to look for joint damage and to rule out other potential diagnoses.

Early intervention to manage your inflammation is crucial for preventing long-term joint damage and the development of more severe symptoms. Treatments may include:


  • Nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Low-dose corticosteroids

  • Disease-modifying antirheumatic drugs (DMARDs), including methotrexate (Trexall), hydroxychloroquine (Plaquenil), leflunomide (Arava), and sulfasalazine (Azulfidine)
  • Lifestyle modifications, such as quitting smoking, losing weight, and following a healthy diet such as the Mediterranean diet

Moderate RA

In moderate stages of rheumatoid arthritis, inflammation becomes more pronounced. You may experience:

  • Worsening joint pain, swelling, and stiffness
  • More joints impacted by inflammation

  • Rheumatoid nodules, which are lumps that typically develop on the elbows, fingers, back, heels, and the back of your head
  • Cartilage damage
  • Some loss of mobility or range of motion in the joints

  • Inflammation affecting other organ systems, including the lungs, eyes, skin, and heart

This stage of progression is also sometimes known as the maturation stage — it’s when the disease progresses enough that the body produces antibodies (proteins that normally attack germ cells) like rheumatoid factor and anti-citrullinated protein antibodies (anti-CCP) to attack healthy cells.

If you have moderate stage RA, you are more likely to have blood tests that are positive for rheumatoid factor or anti-CCP. Imaging tests may also show early signs of joint damage, such as narrowing joint spaces. Tests include X-rays, ultrasound, and the most sensitive test, MRI, which can pick up damage undetected in other tests.

Joint damage from RA is irreversible, so treatment is critical. You may still receive NSAIDs, low-dose prednisone, or steroid injections for inflammation, but you will likely need conventional or biologic DMARDs to control it.

Biologic DMARDs are genetically engineered from living cells and target specific immune system processes that cause RA-related inflammation. Also known as biologic response modifiers, biologics work differently in the body, so you may need to try a few to find one that works well for you.

Common biologics for RA include:

  • abatacept (Orencia)
  • adalimumab (Humira)
  • anakinra (Kineret)
  • certolizumab (Cimzia)
  • etanercept (Enbrel)
  • golimumab (Simponi)
  • infliximab (Remicade)
  • rituximab (Rituxan)
  • tocilizumab (Actemra)

Alternatively, you may be prescribed a Janus kinase (JAK) inhibitor, which blocks JAK enzymes that play a role in inflammatory and immune responses. These medications include:

  • tofacitinib (Xeljanz)
  • baracitinib (Olumiant)
  • upadacitinib (Rinvoq)
Your healthcare provider may also recommend physical or occupational therapy to help you reduce pain and inflammation, develop a safe workout routine, increase your range of motion or mobility, and learn how to better live with RA. This includes teaching you what braces, orthotics, or other assistive devices are best for your situation.

Severe RA

In severe rheumatoid arthritis, joint inflammation and damage is severe, affecting both cartilage and bone, potentially causing significant functional impairment.

Symptoms may include:

  • Severe pain and swelling
  • Noticeable joint deformities, such as misaligned or twisted fingers or toes and thickened knuckles
  • Further loss of mobility and flexibility
  • Decreased muscle strength

  • Rheumatoid nodules

  • Carpal tunnel syndrome

  • Occipital headache, causing pain in the back of the head, and pain in the upper neck
You may also experience significant symptoms if inflammation affects other organs, such as chest pain, persistent cough, dry eyes, and life-threatening organ failure (if your blood vessels become inflamed).

Severe RA can cause severe challenges in daily life, such as:

  • Difficulty walking
  • Trouble grasping or gripping objects, tying shoes, opening jars, and similar tasks

  • Fatigue
  • Emotional challenges, including anxiety and depression due to reduced independence
If you have severe RA, treatment is aggressive. You may need a combination of conventional and biologic DMARDs or be prescribed a Janus kinase (JAK) inhibitor. If you have severe joint damage, you may need joint surgery, but this is a last resort. Hip and knee replacements are the two most common types of joint surgeries in people with RA.

Advanced RA

Sometimes known as end-stage RA, advanced RA is marked by the complete loss of joint function and, in some cases, the fusion of joints (called ankylosis). Extreme and chronic pain and swelling, joint deformities, and significant limitations in range of motion or mobility are all common in advanced RA, even though inflammation stops (because there is no synovial tissue left to attack).

If necessary and possible, you may undergo joint replacement surgery. Your surgeon may also fuse and realign joints and repair damaged tendons, depending on your needs.

During advanced RA, however, pain management is the priority. In addition to continuing drug therapy, you may consider trying:

  • Acupuncture

  • Hot and cold therapy
  • Massage therapy

  • Relaxation techniques, such as deep breathing, visualization, and mindfulness meditation
  • Physical therapy exercises

People with advanced RA, or even milder cases of it, are often well versed in the use of assistive (“self-help”) devices, which can help you better navigate day-to-day life when you have disabilities. An occupational therapist can help you determine which tools are best for you. These can include:

  • Appliances and kitchen tools that make food preparation easier, such as electric can openers, specialized utensils that are easier to hold, lightweight cookware, and food processors
  • Handrails and grab bars in the bathroom, a stool for the shower or bathtub, and electric toothbrushes and water flossers
  • Wheelchairs, braces, and other tools to help with mobility
  • Button hooks, zipper pulls, long-handled shoehorns, and other tools to help you get dressed
  • Foam kneeling pads and lightweight hoses for gardening

These and other devices can help you remain as independent as possible, but it’s also crucial to have a strong support system of family, friends, and healthcare providers. Support groups, counselors, and mental health professionals can further help you manage the psychological impacts of RA.

The Takeaway

  • Rheumatoid arthritis can progress through early, moderate, severe, and advanced stages, each with unique challenges and management strategies.
  • Early diagnosis and intervention can significantly reduce the disease's impact, and advanced treatments and supportive care can help maintain quality of life in later stages.
  • By recognizing the signs of RA and understanding its progression, you can take proactive steps to manage your condition effectively.
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Beth Biggee, MD

Medical Reviewer
Member of American College of Lifestyle Medicine, Castle Connolly Top Doctor

Beth Biggee, MD, is medical director and an integrative rheumatologist at Rheumission, a virtual integrative rheumatology practice for people residing in California and Pennsylvania. This first-of-its-kind company offers whole person autoimmune care by a team of integrative rheumatologists, lifestyle medicine practitioners, autoimmune dietitians, psychologists, and care coordinators.

Dr. Biggee also works as a healthcare wellness consultant for Synergy Wellness Center in Hudson, Massachusetts. Teamed with Synergy, she provides in-person lifestyle medicine and holistic consults, and contributes to employee workplace wellness programs. She has over 20 years of experience in rheumatology and holds board certifications in rheumatology and integrative and lifestyle medicine. Dr. Biggee brings a human-centered approach to wellness rather than focusing solely on diseases.

Dr. Biggee graduated cum laude with a bachelor's degree from Canisius College, and graduated magna cum laude and as valedictorian from SUNY Health Science Center at Syracuse Medical School. She completed her internship and residency in internal medicine at Yale New Haven Hospital, completed her fellowship in rheumatology at Tufts–New England Medical Center, and completed training in integrative rheumatology at the University of Arizona Andrew Weil Center for Integrative Medicine. Following her training, she attained board certification in rheumatology and internal medicine through the American Board of Internal Medicine, attained board certification in integrative medicine through the American Board of Physician Specialties, and attained accreditation as a certified lifestyle medicine physician through the American College of Lifestyle Medicine. She is certified in Helms auricular acupuncture and is currently completing coursework for the Aloha Ayurveda integrative medicine course for physicians.

In prior roles, Dr. Biggee taught as an assistant clinical professor of medicine at Mary Imogene Bassett Hospital (an affiliate of Columbia University). She was also clinical associate of medicine at Tufts University School of Medicine and instructed "introduction to clinical medicine" for medical students at Tufts. She was preceptor for the Lawrence General Hospital Family Medicine Residency.

Dr. Biggee has published in Annals of Rheumatic Diseases, Arthritis in Rheumatism, Current Opinions in Rheumatology, Journal for Musculoskeletal Medicine, Medicine and Health Rhode Island, and Field Guide to Internal Medicine.

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Joseph Bennington-Castro

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Joseph Bennington-Castro is a science writer based in Hawaii. He has written well over a thousand articles for the general public on a wide range topics, including health, astronomy, archaeology, renewable energy, biomaterials, conservation, history, animal behavior, artificial intelligence, and many others.

In addition to writing for Everyday Health, Bennington-Castro has also written for publications such as Scientific American, National Geographic online, USA Today, Materials Research Society, Wired UK, Men's Journal, Live Science, Space.com, NBC News Mach, NOAA Fisheries, io9.com, and Discover.

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Resources
  1. Chauhan K et al. Rheumatoid Arthritis. StatPearls. May 25, 2023.
  2. Guo Q et al. Rheumatoid arthritis: pathological mechanisms and modern pharmacologic therapies. Bone Research. April 27, 2018.
  3. Rath L. 11 Risk Factors for Rheumatoid Arthritis and What You Can Do about Them. Arthritis Foundation. December 14, 2022.
  4. Cush JJ. Rheumatoid Arthritis: Early Diagnosis and Treatment. Rheumatic Disease Clinics of North America. May 2022.
  5. What Are the 4 Stages of Rheumatoid Arthritis? . UCF Health.
  6. Understanding RA Stages and Progression. RheumatoidArthritis.net. April 2021.
  7. Freeman J. RA Progression: What Are the Signs of Rheumatoid Arthritis Progression? Rheumatoid Arthritis Support Network. October 27, 2018.
  8. Donvito T. The 4 Stages of Rheumatoid Arthritis Progression. Creaky Joints. November 14, 2018.
  9. Dunkin MA. Treatments for Rheumatoid Arthritis . Arthritis Foundation. June 12, 2022.
  10. Rheumatoid Arthritis Guideline. American College of Rheumatology.
  11. Michaud K. Patient education: Rheumatoid arthritis treatment (Beyond the Basics). UpToDate. October 31, 2024.
  12. Rheumatoid Arthritis Complications. NHS. March 8, 2023.
  13. Rheumatoid Arthritis. Johns Hopkins Medicine.
  14. Rheumatoid Arthritis Treatment. Rush.
  15. Ezerioha M. RA Treatment: What is the Safest Treatment for Rheumatoid Arthritis? Rheumatoid Arthritis Support Network. November 2, 2018.
  16. Li H et al. Clinical Efficacy of Acupuncture for the Treatment of Rheumatoid Arthritis: Meta-Analysis of Randomized Clinical Trials. Evidence-Based Complementary and Alternative Medicine. April 30, 2022.
  17. Self-Help Arthritis Devices. Arthritis Foundation.