Rheumatoid arthritis (RA) is an inflammatory disease that occurs when the body essentially turns on itself.
“RA is an autoimmune process where the immune system is attacking normal tissue,” explains rheumatologist Linda Mileti, MD, who has been treating people with RA at Cleveland Clinic since 2013. “In the case of rheumatoid arthritis, it’s attacking the joints.”
Symptoms progress along a continuum, and early treatment offers the best chance for long-term relief and to prevent RA disease progression.
What Is Rheumatoid Arthritis?
RA is a systemic, immune-regulated condition that causes pain, stiffness, and swelling in the lining of your joints, called the synovium. It occurs most often in the hands, wrists, knees, ankles, and feet but also can affect other joints. Inflammation damages the cartilage in your joints, and in later stages the bone erodes, leading to fusion of affected joints.
RA can also affect other parts of the body, such as the skin, eyes, mouth, heart, and lungs. Many people with RA feel fatigued and sometimes have a fever. Symptoms usually develop between ages 30 and 60, but they can start at any age. Many people experience flares, or periods when symptoms get worse temporarily. Some people have periods of remission without any symptoms.
The cause of RA is not fully understood, but researchers suspect a combination of genetics, hormones, and environmental factors contribute to the disease’s development.
Why Understanding the Stages Is Important
Early recognition, diagnosis, and tailored treatment are important to prevent RA disease progression. “There is this concept of a window of opportunity where if you treat someone early and more aggressively, you can really get the disease quiet,” Dr. Mileti explains.
The risks from RA are not just to the joints. “Systemic inflammation from RA can really impact vascular health,” she warns. So, people with untreated RA, especially those who smoke, are at increased risk for cardiovascular events like heart attacks, strokes, and blood clots.
What Are the 4 Stages of Rheumatoid Arthritis
Unlike cancer, there aren’t medically defined numbered stages for RA. Nonetheless, the disease can be categorized into four stages:
Early-Stage Rheumatoid Arthritis
Early signs of RA include joint pain, stiffness, and swelling. “It typically starts in multiple joints of the hands and feet in a symmetrical pattern, but sometimes patients present with only a few involved joints,” Dr. Mileti says. This early stage is the best time to start treatment to avoid the permanent joint damage that can come in later stages. In this early stage, x-rays will not show damage to bones.
Moderate Rheumatoid Arthritis
Inflammation that starts to destroy cartilage in the joints is evidence of moderate disease progression. Stiffness may increase or last longer in the morning, and range of motion in the affected joints may decrease at this stage. “People with RA in the hands may describe that they can’t make a fist in the morning after they wake up,” Dr. Mileti says. “As the disease progresses, the time may increase from a few minutes to an hour or more.”
Severe Rheumatoid Arthritis
People with severe RA have visible joint damage and deformities that can affect quality of life. The inflammation is destroying bone, and the stiffness and pain are greater than in earlier stages.
End-Stage Rheumatoid Arthritis
The end stage of RA involves loss of joint function, complications, and challenging long-term management. “We used to call this stage burnt-out RA,” Dr. Mileti explains. “The active inflammation is no longer there much, but all the damage is left over.” People at this stage of RA often experience severe pain, swelling, stiffness, and loss of mobility. With earlier treatment, many individuals can avoid this stage.
How Rheumatoid Arthritis Progresses
Rheumatoid arthritis symptoms sometimes progress slowly over years or decades and sometimes progress rapidly.
Factors that influence progression include genetics, lifestyle, and treatment adherence. If you have a family member with RA, you may find your progression is similar to theirs.
Smoking and excess weight also affect the progression of RA. “Smoking has a negative impact on RA disease activity, and I find it hard to get the RA under control when someone is smoking,” Dr. Mileti says. In addition, excess weight contributes to a pro-inflammatory state, which can accelerate RA progression while putting extra strain on joints.
Increasing pain and stiffness and lengthier periods of joint stiffness in the morning are indications that your RA may be getting worse. Noticeable changes in the appearance of your joints also are an indication of progression.
Rheumatoid Arthritis Diagnosis and Monitoring
RA is diagnosed using a physical exam, blood tests, and imaging. The history and physical exam are most important for making the diagnosis, according to Dr. Mileti. She will ask her patients which joints are involved, whether there is swelling, and how long their morning joint stiffness lasts. On the physical exam, she looks for joint warmth, redness, swelling, decreased range of motion, and tenderness.
Blood tests for rheumatoid factor and anti-citrullinated peptide antibodies (anti-CCPs or ACPA) can help with the diagnosis, but not everyone with RA will be positive on these tests. Having positive results for both tests is a pretty good indicator of RA. Additional blood tests will rule out other conditions with similar presentation. For example, some people with hepatitis B or C have an inflammatory arthritis that mimics RA.
Diagnostic imaging will almost always entail x-rays of the affected joints and may also include magnetic resonance imaging (MRI) or ultrasound. The x-rays can help identify the stage of progression, and the ultrasound is helpful in seeing the synovial inflammation in the joints, especially in earlier RA. MRIs are helpful in seeing soft tissue and may help a provider make an RA diagnosis and rule out other causes of joint pain.
Rheumatoid Arthritis Treatment Options at Each Stage
Medications for RA include a class called traditional disease-modifying antirheumatic drugs (DMARDs). The first line of DMARD treatment is often an oral medication called methotrexate, which works to mildly suppress the immune system and is considered backbone therapy for RA, according to Dr. Mileti. About 30% of people respond to methotrexate alone. For the remainder, other medications can be added. It may take three to six months to determine if symptoms are fully responding to a new medication. If Dr. Mileti sees no response at three months, she is likely to add or change medications.
The oral antimalarial medication hydroxychloroquine can sometimes control symptoms for those with very early symptoms. Corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs) may also manage symptoms.
A range of other medications, including biologic drugs and targeted synthetic DMARDs, may help manage moderate-to-severe RA. They may be taken orally or administered by injection or infusion. They are taken individually or in combination. The goal of treatment is to reduce symptoms while minimizing joint damage. Results are much better when treatment is started early rather than waiting until the symptoms are more severe and joint damage has already occurred.
Joint replacement surgery may become necessary at more advanced stages when joints are severely damaged. Other surgical procedures can correct joint deformities from RA.
Tips for Managing Rheumatoid Arthritis
Consider these recommendations to help manage and reduce the risk of joint damage in rheumatoid arthritis:
- See your clinician when you start having symptoms and if symptoms worsen. It is easier to treat earlier stages of the disease and prevent progression and loss of function.
- Quit smoking. It can be hard to get RA symptoms under control if you’re smoking or vaping.
- Manage your weight. Carrying excess weight increases inflammation, which can exacerbate RA symptoms.
- Stay active. Physical activity helps manage disease progression and symptoms.
