Editing Rheumatoid arthritis (section)

==Management==
There is no cure for RA, but treatments can improve symptoms and slow the progress of the disease. Disease-modifying treatment has the best results when it is started early and aggressively.<ref name=ACR2008>{{cite journal | vauthors = Saag KG, Teng GG, Patkar NM, Anuntiyo J, Finney C, Curtis JR, Paulus HE, Mudano A, Pisu M, Elkins-Melton M, Outman R, Allison JJ, Suarez Almazor M, Bridges SL, Chatham WW, Hochberg M, MacLean C, Mikuls T, Moreland LW, O'Dell J, Turkiewicz AM, Furst DE | title = American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis | journal = Arthritis and Rheumatism | volume = 59 | issue = 6 | pages = 762–784 | date = June 2008 | pmid = 18512708 | doi = 10.1002/art.23721 | doi-access = free }}</ref><ref name=":16">{{cite book |last1=Donahue |first1=Katrina E. |url=http://www.ncbi.nlm.nih.gov/books/NBK524950/ |title=Drug Therapy for Early Rheumatoid Arthritis: A Systematic Review Update |last2=Gartlehner |first2=Gerald |last3=Schulman |first3=Elizabeth R. |last4=Jonas |first4=Beth |last5=Coker-Schwimmer |first5=Emmanuel |last6=Patel |first6=Sheila V. |last7=Weber |first7=Rachel Palmieri |last8=Lohr |first8=Kathleen N. |last9=Bann |first9=Carla |date=2018 |publisher=Agency for Healthcare Research and Quality (US) |series=AHRQ Comparative Effectiveness Reviews |location=Rockville (MD) |pmid=30199187}}</ref> The results of a recent systematic review found that combination therapy with tumor necrosis factor (TNF) and non-TNF biologics plus methotrexate (MTX) resulted in improved disease control, Disease Activity Score (DAS)-defined remission, and functional capacity compared with a single treatment of either methotrexate or a biologic alone.<ref>{{cite journal | vauthors = Donahue KE, Schulman ER, Gartlehner G, Jonas BL, Coker-Schwimmer E, Patel SV, Weber RP, Bann CM, Viswanathan M | title = Comparative Effectiveness of Combining MTX with Biologic Drug Therapy Versus Either MTX or Biologics Alone for Early Rheumatoid Arthritis in Adults: a Systematic Review and Network Meta-analysis | journal = Journal of General Internal Medicine | volume = 34 | issue = 10 | pages = 2232–2245 | date = October 2019 | pmid = 31388915 | pmc = 6816735 | doi = 10.1007/s11606-019-05230-0 }}</ref>

The goals of treatment are to minimize symptoms such as pain and swelling, to prevent bone deformity (for example, bone erosions visible in X-rays), and to maintain day-to-day functioning.<ref name="Wasserman">{{cite journal | vauthors = Wasserman AM | title = Diagnosis and management of rheumatoid arthritis | journal = American Family Physician | volume = 84 | issue = 11 | pages = 1245–1252 | date = December 2011 | pmid = 22150658 }}</ref> This is primarily addressed with [[disease-modifying antirheumatic drugs]] (DMARDs); dosed physical activity; analgesics and [[physical therapy]] may be used to help manage pain.<ref name=":13" /><ref name=NICE2015/><ref name=":12" /> RA should generally be treated with at least one specific anti-rheumatic medication<ref name=ACR2015/> while combination therapies and [[corticosteroid]]s are common in treatment.<ref>{{cite journal |last1=Donahue |first1=Katrina E. |last2=Gartlehner |first2=Gerald |last3=Schulman |first3=Elizabeth R. |last4=Jonas |first4=Beth |last5=Coker-Schwimmer |first5=Emmanuel |last6=Patel |first6=Sheila V. |last7=Weber |first7=Rachel Palmieri |last8=Lohr |first8=Kathleen N. |last9=Bann |first9=Carla |last10=Viswanathan |first10=Meera |date=2018-07-16 |title=Drug Therapy for Early Rheumatoid Arthritis: A Systematic Review Update |url=https://effectivehealthcare.ahrq.gov/topics/rheumatoid-arthritis-medicine-update/final-report-update-2018 |doi=10.23970/ahrqepccer211 |s2cid=81414779 |journal=Effective Health Care Program |doi-access=free }}{{Dead link|date=March 2024 |bot=InternetArchiveBot |fix-attempted=yes }}</ref> The use of [[benzodiazepines]] (such as [[diazepam]]) to treat the pain is not recommended as it does not appear to help and is associated with risks.<ref>{{cite journal | vauthors = Richards BL, Whittle SL, Buchbinder R | title = Muscle relaxants for pain management in rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | volume = 1 | pages = CD008922 | date = January 2012 | issue = 1 | pmid = 22258993 | doi = 10.1002/14651858.CD008922.pub2 | s2cid = 73769165 | veditors = Richards BL | pmc = 11702505 }}</ref>

===Lifestyle===
Regular exercise is recommended as both safe and useful to maintain muscle strength and overall physical function.<ref name="pmid38921661">{{cite journal |vauthors=Athanasiou A, Papazachou O, Rovina N, Nanas S, Dimopoulos S, Kourek C |title=The Effects of Exercise Training on Functional Capacity and Quality of Life in Patients with Rheumatoid Arthritis: A Systematic Review |journal=J Cardiovasc Dev Dis |volume=11 |issue=6 |date=May 2024 |page=161 |pmid=38921661 |pmc=11203630 |doi=10.3390/jcdd11060161 |doi-access=free |url=}}</ref><ref>{{cite journal | vauthors = Hurkmans E, van der Giesen FJ, Vliet Vlieland TP, Schoones J, Van den Ende EC | title = Dynamic exercise programs (aerobic capacity and/or muscle strength training) in patients with rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 4 | pages = CD006853 | date = October 2009 | volume = 2009 | pmid = 19821388 | pmc = 6769170 | doi = 10.1002/14651858.CD006853.pub2 | veditors = Hurkmans E }}</ref> Physical activity is beneficial for people with rheumatoid arthritis who experience fatigue,<ref>{{cite journal | vauthors = Cramp F, Hewlett S, Almeida C, Kirwan JR, Choy EH, Chalder T, Pollock J, Christensen R | title = Non-pharmacological interventions for fatigue in rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 8 | pages = CD008322 | date = August 2013 | pmid = 23975674 | doi = 10.1002/14651858.CD008322.pub2 | pmc = 11748118 }}</ref> although there was little to no evidence to suggest that exercise may have an impact on physical function in the long term, a study found that carefully dosed exercise has shown significant improvements in patients with RA.<ref name=":12" /><ref>{{cite journal | vauthors = Williams MA, Srikesavan C, Heine PJ, Bruce J, Brosseau L, Hoxey-Thomas N, Lamb SE | title = Exercise for rheumatoid arthritis of the hand | journal = The Cochrane Database of Systematic Reviews | volume = 2018 | pages = CD003832 | date = July 2018 | issue = 7 | pmid = 30063798 | pmc = 6513509 | doi = 10.1002/14651858.cd003832.pub3 }}</ref> Physical activity increases the production of [[synovial fluid]], which lubricates the joints and reduces friction.<ref>{{cite web |last1=Jabeen |first1=Attiya |title=The Benefits of Exercise in Rheumatoid Arthritis: A Comprehensive Guide |url=https://rheumatologydelaware.com/benefits-exercise-in-rheumatoid-arthritis/ |website=rheumatologydelaware |date=16 August 2023 |publisher=Attiya Jabeen |access-date=August 16, 2023 |archive-date=1 November 2023 |archive-url=https://web.archive.org/web/20231101043434/https://rheumatologydelaware.com/benefits-exercise-in-rheumatoid-arthritis/ |url-status=dead }}</ref> Moderate effects have been found for aerobic exercises and resistance training on cardiovascular fitness and muscle strength in RA. Furthermore, physical activity had no detrimental side effects like increased disease activity in any exercise dimension.<ref>{{cite journal | vauthors = Rausch Osthoff AK, Juhl CB, Knittle K, Dagfinrud H, Hurkmans E, Braun J, Schoones J, Vliet Vlieland TP, Niedermann K | title = Effects of exercise and physical activity promotion: meta-analysis informing the 2018 EULAR recommendations for physical activity in people with rheumatoid arthritis, spondyloarthritis and hip/knee osteoarthritis | journal = RMD Open | volume = 4 | issue = 2 | pages = e000713 | date = December 2018 | pmid = 30622734 | pmc = 6307596 | doi = 10.1136/rmdopen-2018-000713 }}</ref> It is uncertain if eating or avoiding specific foods or other specific dietary measures help improve symptoms,<ref>{{cite journal | vauthors = Hagen KB, Byfuglien MG, Falzon L, Olsen SU, Smedslund G | title = Dietary interventions for rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 1 | pages = CD006400 | date = January 2009 | pmid = 19160281 | doi = 10.1002/14651858.CD006400.pub2 | veditors = Hagen KB }}</ref> but several studies have shown that high-vegetable diets improve RA symptoms whereas high-meat diets make symptoms worse.<ref>{{Cite journal |last1=Alwarith |first1=Jihad |last2=Kahleova |first2=Hana |last3=Rembert |first3=Emilie |last4=Yonas |first4=Willy |last5=Dort |first5=Sara |last6=Calcagno |first6=Manuel |last7=Burgess |first7=Nora |last8=Crosby |first8=Lee |last9=Barnard |first9=Neal D. |date=2019-09-10 |title=Nutrition Interventions in Rheumatoid Arthritis: The Potential Use of Plant-Based Diets. A Review |journal=Frontiers in Nutrition |language=en |volume=6 |page=141 |doi=10.3389/fnut.2019.00141 |doi-access=free |pmid=31552259 |pmc=6746966 |issn=2296-861X }}</ref>  [[Occupational therapy]] has a positive role to play in improving functional ability in people with rheumatoid arthritis.<ref>{{cite journal | vauthors = Steultjens EM, Dekker J, Bouter LM, van Schaardenburg D, van Kuyk MA, van den Ende CH | title = Occupational therapy for rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 1 | pages = CD003114 | date = 2004 | volume = 2004 | pmid = 14974005 | doi = 10.1002/14651858.CD003114.pub2 | pmc = 7017227 | hdl = 2066/58846 | url = https://repository.ubn.ru.nl/bitstream/2066/58846/1/58846.pdf }}</ref> Weak evidence supports the use of wax baths ([[thermotherapy]]) to treat arthritis in the hands.<ref>{{cite journal | vauthors = Robinson V, Brosseau L, Casimiro L, Judd M, Shea B, Wells G, Tugwell P | title = Thermotherapy for treating rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 2 | pages = CD002826 | date = 2002-04-22 | pmid = 12076454 | doi = 10.1002/14651858.cd002826 | pmc = 6991938 }}</ref>

Educational approaches that inform people about tools and strategies available to help them cope with rheumatoid arthritis may improve a person's psychological status and level of [[clinical depression|depression]] in the shorter-term.<ref name=":4">{{cite journal | vauthors = Riemsma RP, Kirwan JR, Taal E, Rasker JJ | title = Patient education for adults with rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | volume = 2009 | issue = 2 | pages = CD003688 | date = 2003-04-22 | pmid = 12804484 | doi = 10.1002/14651858.cd003688 | url = https://research.utwente.nl/en/publications/patient-education-for-adults-with-rheumatoid-arthritis-review(6d6c077a-30a1-4b7c-8021-f72f1a8b6a5c).html }}</ref> Educating patients who have rheumatoid arthritis has shown a positive effect on how patients engage in their plan of care; the patient will be aware of fatigue, activity limitations, and pain and know possible side effects of how to manage this pain. Lack of knowledge can often lead to fear and limit adherence. Intervention by physical therapists plays a key role in offering proper tools for self-management, motivation in activities of daily living, and any assistive device use if needed. Patients will be assisted in managing neurologic impairments and musculoskeletal stiffness to maximize strength and function. Encouraging patients to balance physical activity with their everyday living can prevent further joint damage and provide a sense of control.<ref>{{Cite journal |last=Peter |first=Wilfred F |last2=Swart |first2=Nynke M |last3=Meerhoff |first3=Guus A |last4=Vliet Vlieland |first4=Thea P M |date=2021-08-01 |title=Clinical Practice Guideline for Physical Therapist Management of People With Rheumatoid Arthritis |url=https://academic.oup.com/ptj/article/doi/10.1093/ptj/pzab127/6277051 |journal=Physical Therapy |language=en |volume=101 |issue=8 |doi=10.1093/ptj/pzab127 |issn=0031-9023}}</ref>

The use of extra-depth shoes and molded insoles may reduce pain during weight-bearing activities such as walking.<ref name=":5">{{cite journal | vauthors = Egan M, Brosseau L, Farmer M, Ouimet MA, Rees S, Wells G, Tugwell P | title = Splints/orthoses in the treatment of rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 1 | pages = CD004018 | date = 2001-10-23 | volume = 2001 | pmid = 12535502 | doi = 10.1002/14651858.cd004018 | pmc = 8762649 }}</ref> Insoles may also prevent the progression of [[bunion]]s.<ref name=":5" />

===Disease-modifying agents===
[[Disease-modifying antirheumatic drugs]] (DMARDs) are the primary treatment for RA.<ref name=ACR2015/> They are a diverse collection of drugs, grouped by use and convention. They have been found to improve symptoms, decrease joint damage, and improve overall functional abilities.<ref name=ACR2015/> DMARDs should be started early in the disease as they result in disease remission in approximately half of people and improved outcomes overall.<ref name=ACR2015/>

The following drugs are considered DMARDs: [[methotrexate]], [[sulfasalazine]], [[leflunomide]], [[hydroxychloroquine]], [[TNF inhibitor]]s ([[Certolizumab pegol|certolizumab]], [[adalimumab]], [[infliximab]] and [[etanercept]]), [[abatacept]], [[anakinra]], and [[auranofin]]. Additionally, [[rituximab]] and [[tocilizumab]] are monoclonal antibodies and are also DMARDs.<ref name=ACR2015/> Use of tocilizumab is associated with a risk of increased cholesterol levels.<ref>{{cite book | vauthors = Isaacs D | editor-first1 = Jasvinder A. | editor-last1 = Singh | title = Cochrane Database of Systematic Reviews | chapter = Tocilizumab for rheumatoid arthritis | series = Advances in Experimental Medicine and Biology | volume = 764 | pages = 151–158 | date = 2010-07-07 | publisher = John Wiley & Sons | pmid = 23654064 | doi = 10.1002/14651858.cd008331.pub2 }}</ref>

The most commonly used agent is methotrexate with other frequently used agents including sulfasalazine and leflunomide.<ref name=ACR2015/> Leflunomide is effective when used from 6–12 months, with similar effectiveness to methotrexate when used for 2 years.<ref>{{cite journal | vauthors = Osiri M, Shea B, Robinson V, Suarez-Almazor M, Strand V, Tugwell P, Wells G | title = Leflunomide for treating rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 1 | pages = CD002047 | date = 2003 | volume = 2002 | pmid = 12535423 | doi = 10.1002/14651858.CD002047 | pmc = 8437750 }}</ref> Sulfasalazine also appears to be most effective in the short-term treatment of rheumatoid arthritis.<ref>{{cite journal | vauthors = Suarez-Almazor ME, Belseck E, Shea B, Wells G, Tugwell P | title = Sulfasalazine for rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 2 | pages = CD000958 | date = 1998-04-27 | volume = 1998 | pmid = 10796400 | doi = 10.1002/14651858.cd000958 | pmc = 7047550 }}</ref>

[[Hydroxychloroquine]], in addition to its low toxicity profile, is considered effective for treatment of moderate RA symptoms.<ref>{{cite journal | vauthors = Suarez-Almazor ME, Belseck E, Shea B, Homik J, Wells G, Tugwell P | title = Antimalarials for treating rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 4 | pages = CD000959 | date = 2000 | volume = 2010 | pmid = 11034691 | doi = 10.1002/14651858.CD000959 | pmc = 8407035 }}</ref> Pharmacokinetic characteristics of Hydroxychloroquine are complex due to the large volume of distribution, significant tissue binding, and long terminal elimination half-life.
Historically, terminal elimination half-lives were considered very long, 40–50 days for Hydroxychloroquine as compare to up to 60 days
for Chloroquine. More recent studies suggest a shorter half-life of about 5 days. A long Hydroxychloroquine half-life is attributed to extensive tissue uptake rather than to an intrinsic inability to clear the drug. The expected delay in the attainment of steady-state concentrations (3–4 months) may be in part responsible for the slow therapeutic response observed with Hydroxychloroquine.<ref>Dima A, Jurcut C, Chasset F, Felten R, Arnaud L. Hydroxychloroquine in systemic lupus erythematosus: overview of current knowledge. Ther Adv Musculoskelet Dis. 2022 Feb 14;14:1759720X211073001. doi: 10.1177/1759720X211073001. PMID: 35186126; PMCID: PMC8848057.</ref>

Agents may be used in combination, however, people may experience greater side effects.<ref name=ACR2015/><ref>{{cite journal | vauthors = Katchamart W, Trudeau J, Phumethum V, Bombardier C | title = Methotrexate monotherapy versus methotrexate combination therapy with non-biologic disease modifying anti-rheumatic drugs for rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 4 | pages = CD008495 | date = April 2010 | volume = 2015 | pmid = 20393970 | doi = 10.1002/14651858.cd008495 | pmc = 8946299 }}</ref> Methotrexate is the most important and useful DMARD and is usually the first treatment.<ref name=ACR2015/><ref name=NICE2015/><ref name="chapter94">{{cite book | vauthors = DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM | date = 2008 | title = Pharmacotherapy: a Pathophysiologic Approach | edition = 7th | location = New York | publisher = McGraw-Hill | isbn = 978-0-07-147899-1 }}</ref> A combined approach with methotrexate and biologics improves ACR50, HAQ scores and RA remission rates.<ref>{{cite journal | vauthors = Singh JA, Hossain A, Mudano AS, Tanjong Ghogomu E, Suarez-Almazor ME, Buchbinder R, Maxwell LJ, Tugwell P, Wells GA | title = Biologics or tofacitinib for people with rheumatoid arthritis naive to methotrexate: a systematic review and network meta-analysis | journal = The Cochrane Database of Systematic Reviews | volume = 2017 | pages = CD012657 | date = May 2017 | issue = 5 | pmid = 28481462 | pmc = 6481641 | doi = 10.1002/14651858.cd012657 }}</ref><ref name=":16" /> This benefit from the combination of methotrexate with biologics occurs both when this combination is the initial treatment and when drugs are prescribed in a sequential or step-up manner.<ref name=":16" /> Triple therapy consisting of methotrexate, sulfasalazine and hydroxychloroquine may also effectively control disease activity.<ref>{{cite journal | vauthors = Hazlewood GS, Barnabe C, Tomlinson G, Marshall D, Devoe DJ, Bombardier C | title = Methotrexate monotherapy and methotrexate combination therapy with traditional and biologic disease modifying anti-rheumatic drugs for rheumatoid arthritis: A network meta-analysis | journal = The Cochrane Database of Systematic Reviews | issue = 8 | pages = CD010227 | date = August 2016 | volume = 2016 | pmid = 27571502 | doi = 10.1002/14651858.cd010227.pub2 | pmc = 7087436 }}</ref> Adverse effects should be monitored regularly with toxicity including gastrointestinal, hematologic, pulmonary, and hepatic.<ref name="chapter94" /> Side effects such as nausea, vomiting or abdominal pain can be reduced by taking folic acid.<ref>{{cite journal | vauthors = Shea B, Swinden MV, Tanjong Ghogomu E, Ortiz Z, Katchamart W, Rader T, Bombardier C, Wells GA, Tugwell P | title = Folic acid and folinic acid for reducing side effects in patients receiving methotrexate for rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | volume = 5 | issue = 5 | pages = CD000951 | date = May 2013 | pmid = 23728635 | doi = 10.1002/14651858.CD000951.pub2 | pmc = 7046011 }}</ref>

Rituximab combined with methotrexate appears to be more effective in improving symptoms compared to methotrexate alone.<ref name=":0" /> Rituximab works by decreasing levels of B-cells (immune cell that is involved in inflammation). People taking rituximab had improved pain, function, reduced disease activity and reduced joint damage based on x-ray images. After 6 months, 21% more people had improvement in their symptoms using rituximab and methotrexate.<ref name=":0">{{cite journal | vauthors = Lopez-Olivo MA, Amezaga Urruela M, McGahan L, Pollono EN, Suarez-Almazor ME | title = Rituximab for rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | volume = 1 | pages = CD007356 | date = January 2015 | issue = 1 | pmid = 25603545 | doi = 10.1002/14651858.CD007356.pub2 | pmc = 11115378 }}</ref>

Biological agents should generally be used only if methotrexate and other conventional agents are not effective after a trial of three months.<ref name=ACR2015/> They are associated with a higher rate of serious infections as compared to other DMARDs.<ref>{{cite journal | vauthors = Singh JA, Cameron C, Noorbaloochi S, Cullis T, Tucker M, Christensen R, Ghogomu ET, Coyle D, Clifford T, Tugwell P, Wells GA | title = Risk of serious infection in biological treatment of patients with rheumatoid arthritis: a systematic review and meta-analysis | journal = Lancet | volume = 386 | issue = 9990 | pages = 258–265 | date = July 2015 | pmid = 25975452 | pmc = 4580232 | doi = 10.1016/S0140-6736(14)61704-9 }}</ref> Biological DMARD agents used to treat rheumatoid arthritis include: [[tumor necrosis factor alpha]] inhibitors (TNF inhibitors) such as [[infliximab]]; [[interleukin 1]] blockers such as [[anakinra]], [[monoclonal antibody|monoclonal antibodies]] against [[B cell]]s such as [[rituximab]], [[interleukin 6]] blockers such as tocilizumab, and [[T cell]] co-stimulation blockers such as abatacept. They are often used in combination with either methotrexate or leflunomide.<ref name=ACR2015/><ref name=Lancet2016/> Biologic monotherapy or [[tofacitinib]] with methotrexate may improve ACR50, RA remission rates and function.<ref>{{cite journal | vauthors = Singh JA, Hossain A, Tanjong Ghogomu E, Mudano AS, Tugwell P, Wells GA | title = Biologic or tofacitinib monotherapy for rheumatoid arthritis in people with traditional disease-modifying anti-rheumatic drug (DMARD) failure: a Cochrane Systematic Review and network meta-analysis (NMA) | journal = The Cochrane Database of Systematic Reviews | volume = 2016 | pages = CD012437 | date = November 2016 | issue = 11 | pmid = 27855242 | pmc = 6469573 | doi = 10.1002/14651858.cd012437 }}</ref><ref>{{cite journal | vauthors = Singh JA, Hossain A, Tanjong Ghogomu E, Mudano AS, Maxwell LJ, Buchbinder R, Lopez-Olivo MA, Suarez-Almazor ME, Tugwell P, Wells GA | title = Biologics or tofacitinib for people with rheumatoid arthritis unsuccessfully treated with biologics: a systematic review and network meta-analysis | journal = The Cochrane Database of Systematic Reviews | volume = 2017 | pages = CD012591 | date = March 2017 | issue = 3 | pmid = 28282491 | pmc = 6472522 | doi = 10.1002/14651858.cd012591 }}</ref> Abatacept should not be used at the same time as other biologics.<ref>{{cite journal | vauthors = Maxwell L, Singh JA | title = Abatacept for rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 4 | pages = CD007277 | date = October 2009 | volume = 2009 | pmid = 19821401 | pmc = 6464777 | doi = 10.1002/14651858.CD007277.pub2 }}</ref> In those who are well controlled (low disease activity) on TNF inhibitors, decreasing the dose does not appear to affect overall function.<ref name=":11">{{cite journal | vauthors = Verhoef LM, van den Bemt BJ, van der Maas A, Vriezekolk JE, Hulscher ME, van den Hoogen FH, Jacobs WC, van Herwaarden N, den Broeder AA | title = Down-titration and discontinuation strategies of tumour necrosis factor-blocking agents for rheumatoid arthritis in patients with low disease activity | journal = The Cochrane Database of Systematic Reviews | volume = 5 | pages = CD010455 | date = May 2019 | issue = 6 | pmid = 31125448 | pmc = 6534285 | doi = 10.1002/14651858.CD010455.pub3 }}</ref> Discontinuation of TNF inhibitors (as opposed to gradually lowering the dose) by people with low disease activity may lead to increased disease activity and may affect remission, damage that is visible on an x-ray, and a person's function.<ref name=":11" /> People should be screened for [[latent tuberculosis]] before starting any [[TNF inhibitor]] therapy to avoid reactivation of tuberculosis.<ref name="McGraw Hill"/>

TNF inhibitors and methotrexate appear to have similar effectiveness when used alone and better results are obtained when used together.<ref>{{Cite report |url=https://doi.org/10.23970/AHRQEPCCER211 |title=Drug Therapy for Early Rheumatoid Arthritis: A Systematic Review Update |last1=Donahue |first1=Katrina E. |last2=Gartlehner |first2=Gerald |date=2018-07-16 |publisher=Agency for Healthcare Research and Quality (AHRQ) |doi=10.23970/ahrqepccer211 |language=en |last3=Schulman |first3=Elizabeth R. |last4=Jonas |first4=Beth |last5=Coker-Schwimmer |first5=Emmanuel |last6=Patel |first6=Sheila V. |last7=Weber |first7=Rachel Palmieri |last8=Lohr |first8=Kathleen N. |last9=Bann |first9=Carla}}</ref> [[Golimumab]] is effective when used with methotraxate.<ref>{{cite journal | vauthors = Singh JA, Noorbaloochi S, Singh G | title = Golimumab for rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 1 | pages = CD008341 | date = January 2010 | volume = 2010 | pmid = 20091667 | doi = 10.1002/14651858.CD008341 | pmc = 10732339 }}</ref> TNF inhibitors may have equivalent effectiveness with [[etanercept]] appearing to be the safest.<ref>{{cite journal | vauthors = Aaltonen KJ, Virkki LM, Malmivaara A, Konttinen YT, Nordström DC, Blom M | title = Systematic review and meta-analysis of the efficacy and safety of existing TNF blocking agents in treatment of rheumatoid arthritis | journal = PLOS ONE | volume = 7 | issue = 1 | pages = e30275 | year = 2012 | pmid = 22272322 | pmc = 3260264 | doi = 10.1371/journal.pone.0030275 | veditors = Hernandez AV | bibcode = 2012PLoSO...730275A | doi-access = free }}</ref> Injecting etanercept, in addition to methotrexate twice a week may improve ACR50 and decrease radiographic progression for up to 3 years.<ref>{{cite journal | vauthors = Lethaby A, Lopez-Olivo MA, Maxwell L, Burls A, Tugwell P, Wells GA | title = Etanercept for the treatment of rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 5 | pages = CD004525 | date = May 2013 | volume = 2014 | pmid = 23728649 | doi = 10.1002/14651858.cd004525.pub2 | pmc = 10771320 }}</ref> Abatacept appears effective for RA with 20% more people improving with treatment than without but long term safety studies are yet unavailable.<ref>{{cite journal | vauthors = Maxwell L, Singh JA | title = Abatacept for rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 4 | pages = CD007277 | date = October 2009 | volume = 2009 | pmid = 19821401 | doi = 10.1002/14651858.CD007277.pub2 | veditors = Maxwell L | pmc = 6464777 }}</ref> [[Adalimumab]] slows the time for the radiographic progression when used for 52 weeks.<ref>{{cite journal | vauthors = Navarro-Sarabia F, Ariza-Ariza R, Hernandez-Cruz B, Villanueva I | title = Adalimumab for treating rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 3 | pages = CD005113 | date = July 2005 | pmid = 16034967 | doi = 10.1002/14651858.CD005113.pub2 }}</ref> However, there is a lack of evidence to distinguish between the biologics available for RA.<ref>{{cite journal | vauthors = Singh JA, Christensen R, Wells GA, Suarez-Almazor ME, Buchbinder R, Lopez-Olivo MA, Tanjong Ghogomu E, Tugwell P | title = Biologics for rheumatoid arthritis: an overview of Cochrane reviews | journal = The Cochrane Database of Systematic Reviews | volume = 128 | issue = 4 | pages = CD007848 | date = October 2009 | pmid = 19821440 | doi = 10.1002/14651858.CD007848.pub2 | type = Submitted manuscript | veditors = Singh JA | pmc = 10636593 }}</ref> Issues with the biologics include their high cost and association with infections including [[tuberculosis]].<ref name=Lancet2016/> Use of biological agents may reduce fatigue.<ref name=":2" /> The mechanism of how biologics reduce fatigue is unclear.<ref name=":2">{{cite journal | vauthors = Almeida C, Choy EH, Hewlett S, Kirwan JR, Cramp F, Chalder T, Pollock J, Christensen R | title = Biologic interventions for fatigue in rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 6 | pages = CD008334 | date = June 2016 | volume = 2016 | pmid = 27271314 | doi = 10.1002/14651858.cd008334.pub2 | pmc = 7175833 }}</ref>

====Gold and cyclosporin====
{{Anchor|Gold|Sodium aurothiomalate|Auranofin|Cyclosporin}}
[[Sodium aurothiomalate]], [[auranofin]], and [[cyclosporin]] are less commonly used due to more common adverse effects.<ref name=ACR2015/> However, cyclosporin was found to be effective in the progressive RA when used up to one year.<ref>{{cite journal | vauthors = Wells G, Haguenauer D, Shea B, Suarez-Almazor ME, Welch VA, Tugwell P | title = Cyclosporine for rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 2 | pages = CD001083 | date = 2000 | volume = 1998 | pmid = 10796412 | doi = 10.1002/14651858.CD001083 | pmc = 8406939 }}</ref>

====Hydrogen Therapy====
Patients with RA given H<sub>2</sub>-water [[hydrogen therapy]] for four weeks showed significant improvement of symptoms.<ref name="pmid24769081">{{cite journal | author = Ohta S | title = Molecular hydrogen as a preventive and therapeutic medical gas: initiation, development and potential of hydrogen medicine | journal = [[Pharmacology & Therapeutics]] | volume = 144 | issue = 1 | pages = 1–11 | date = 2014 | doi = 10.1016/j.pharmthera.2014.04.006 | pmid = 24769081 | doi-access = free }}</ref>

===Anti-inflammatory and analgesic agents===
[[Glucocorticoid]]s can be used in the short term and at the lowest dose possible for flare-ups and while waiting for slow-onset drugs to take effect.<ref name=ACR2015/><ref name=Lancet2016/><ref>{{cite journal | vauthors = Criswell LA, Saag KG, Sems KM, Welch V, Shea B, Wells G, Suarez-Almazor ME | title = Moderate-term, low-dose corticosteroids for rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 2 | pages = CD001158 | date = 1998-07-27 | volume = 2010 | pmid = 10796420 | doi = 10.1002/14651858.cd001158 | pmc = 8406983 }}</ref> Combination of glucocorticoids and conventional therapy has shown a decrease in rate of erosion of bones.<ref>{{cite journal | vauthors = Kirwan JR, Bijlsma JW, Boers M, Shea BJ | title = Effects of glucocorticoids on radiological progression in rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 1 | pages = CD006356 | date = January 2007 | volume = 2010 | pmid = 17253590 | pmc = 6465045 | doi = 10.1002/14651858.cd006356 }}</ref> Steroids may be injected into affected joints during the initial period of RA, prior to the use of DMARDs or oral steroids.<ref name=":3">{{cite journal | vauthors = Wallen M, Gillies D | title = Intra-articular steroids and splints/rest for children with juvenile idiopathic arthritis and adults with rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 1 | pages = CD002824 | date = January 2006 | volume = 2008 | pmid = 16437446 | doi = 10.1002/14651858.cd002824.pub2 | pmc = 8453330 }}</ref>

Non-[[Nonsteroidal anti-inflammatory drug|NSAID]] drugs to relieve pain, like [[paracetamol]] may be used to help relieve the pain symptoms; they do not change the underlying disease.<ref name=NICE2015/> The use of paracetamol may be associated with the risk of developing ulcers.<ref name=":9">{{cite journal | vauthors = Ramiro S, Radner H, van der Heijde D, van Tubergen A, Buchbinder R, Aletaha D, Landewé RB | title = Combination therapy for pain management in inflammatory arthritis (rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, other spondyloarthritis) | journal = The Cochrane Database of Systematic Reviews | issue = 10 | pages = CD008886 | date = October 2011 | pmid = 21975788 | doi = 10.1002/14651858.cd008886.pub2 }}</ref>

[[Nonsteroidal anti-inflammatory drug|NSAIDs]] reduce both pain and stiffness in those with RA but do not affect the underlying disease and appear to have no effect on people's long term disease course and thus are no longer first line agents.<ref name=Lancet2016/><ref>{{cite journal | vauthors = Tarp S, Bartels EM, Bliddal H, Furst DE, Boers M, Danneskiold-Samsøe B, Rasmussen M, Christensen R | title = Effect of nonsteroidal antiinflammatory drugs on the C-reactive protein level in rheumatoid arthritis: a meta-analysis of randomized controlled trials | journal = Arthritis and Rheumatism | volume = 64 | issue = 11 | pages = 3511–3521 | date = November 2012 | pmid = 22833186 | doi = 10.1002/art.34644 | doi-access = free }}</ref> NSAIDs should be used with caution in those with [[gastrointestinal problem|gastrointestinal]], [[cardiovascular]], or kidney problems.<ref>{{cite journal | vauthors = Radner H, Ramiro S, Buchbinder R, Landewé RB, van der Heijde D, Aletaha D | title = Pain management for inflammatory arthritis (rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis and other spondylarthritis) and gastrointestinal or liver comorbidity | journal = The Cochrane Database of Systematic Reviews | volume = 1 | pages = CD008951 | date = January 2012 | issue = 2 | pmid = 22258995 | doi = 10.1002/14651858.CD008951.pub2 | pmc = 8950811 | veditors = Radner H }}</ref><ref name="pmid22141388">{{cite journal | vauthors = McCormack PL | title = Celecoxib: a review of its use for symptomatic relief in the treatment of osteoarthritis, rheumatoid arthritis and ankylosing spondylitis | journal = Drugs | volume = 71 | issue = 18 | pages = 2457–2489 | date = December 2011 | pmid = 22141388 | doi = 10.2165/11208240-000000000-00000 | s2cid = 71357689 }}</ref><ref>{{cite journal | vauthors = Marks JL, Colebatch AN, Buchbinder R, Edwards CJ | title = Pain management for rheumatoid arthritis and cardiovascular or renal comorbidity | journal = The Cochrane Database of Systematic Reviews | issue = 10 | pages = CD008952 | date = October 2011 | pmid = 21975789 | doi = 10.1002/14651858.CD008952.pub2 | veditors = Marks JL }}</ref><ref name=":9" /> Rofecoxib was withdrawn from the global market as its long-term use was associated to an increased risk of heart attacks and strokes.<ref>{{cite journal | vauthors = Garner SE, Fidan DD, Frankish RR, Judd MG, Towheed TE, Wells G, Tugwell P | title = Rofecoxib for rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 1 | pages = CD003685 | date = January 2005 | volume = 2010 | pmid = 15674912 | doi = 10.1002/14651858.cd003685.pub2 | pmc = 8725608 }}</ref> Use of methotrexate together with NSAIDs is safe, if adequate monitoring is done.<ref>{{cite journal | vauthors = Colebatch AN, Marks JL, Edwards CJ | title = Safety of non-steroidal anti-inflammatory drugs, including aspirin and paracetamol (acetaminophen) in people receiving methotrexate for inflammatory arthritis (rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, other spondyloarthritis) | journal = The Cochrane Database of Systematic Reviews | issue = 11 | pages = CD008872 | date = November 2011 | pmid = 22071858 | doi = 10.1002/14651858.CD008872.pub2 }}</ref> [[COX-2 inhibitor]]s, such as [[celecoxib]], and NSAIDs are equally effective.<ref name=Job2008>{{cite journal | vauthors = Chen YF, Jobanputra P, Barton P, Bryan S, Fry-Smith A, Harris G, Taylor RS | title = Cyclooxygenase-2 selective non-steroidal anti-inflammatory drugs (etodolac, meloxicam, celecoxib, rofecoxib, etoricoxib, valdecoxib and lumiracoxib) for osteoarthritis and rheumatoid arthritis: a systematic review and economic evaluation | journal = Health Technology Assessment | volume = 12 | issue = 11 | pages = 1–278, iii | date = April 2008 | pmid = 18405470 | doi = 10.3310/hta12110 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Fidahic M, Jelicic Kadic A, Radic M, Puljak L | title = Celecoxib for rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | volume = 2017 | pages = CD012095 | date = June 2017 | issue = 6 | pmid = 28597983 | pmc = 6481589 | doi = 10.1002/14651858.CD012095.pub2 }}</ref> A 2004 Cochrane review found that people preferred NSAIDs over paracetamol.<ref name=":10">{{cite journal | vauthors = Wienecke T, Gøtzsche PC | title = Paracetamol versus nonsteroidal anti-inflammatory drugs for rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 1 | pages = CD003789 | date = 2004-01-26 | volume = 2010 | pmid = 14974037 | doi = 10.1002/14651858.cd003789.pub2 | pmc = 8730319 }}</ref> However, it is yet to be clinically determined whether NSAIDs are more effective than paracetamol.<ref name=":10" />

The neuromodulator agents topical [[capsaicin]] may be reasonable to use in an attempt to reduce pain.<ref name=Ric2012/> [[Nefopam]] by mouth and [[cannabis]] are not recommended as of 2012 as the risks of use appear to be greater than the benefits.<ref name=Ric2012>{{cite journal | vauthors = Richards BL, Whittle SL, Buchbinder R | title = Neuromodulators for pain management in rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | volume = 1 | pages = CD008921 | date = January 2012 | issue = 1 | pmid = 22258992 | doi = 10.1002/14651858.CD008921.pub2 | pmc = 6956614 }}</ref>

Limited evidence suggests the use of weak oral opioids but the adverse effects may outweigh the benefits.<ref>{{cite journal | vauthors = Whittle SL, Richards BL, Husni E, Buchbinder R | title = Opioid therapy for treating rheumatoid arthritis pain | journal = The Cochrane Database of Systematic Reviews | issue = 11 | pages = CD003113 | date = November 2011 | pmid = 22071805 | doi = 10.1002/14651858.cd003113.pub3 }}</ref>

Alternatively, physical therapy has been tested and shown as an effective aid in reducing pain in patients with RA. As most RA is detected early and treated aggressively, physical therapy plays more of a preventative and compensatory role, aiding in pain management alongside regular rheumatic therapy.<ref name=":13" />

===Surgery===
Especially for affected fingers, hands, and wrists, [[synovectomy]] may be needed to prevent pain or tendon rupture when drug treatment has failed. Severely affected joints may require [[joint replacement]] surgery, such as knee replacement. Postoperatively, [[physiotherapy]] is always necessary.<ref name=Davidson2014/>{{rp|1080, 1103}} There is insufficient evidence to support surgical treatment on arthritic shoulders.<ref>{{cite journal | vauthors = Christie A, Dagfinrud H, Engen Matre K, Flaatten HI, Ringen Osnes H, Hagen KB | title = Surgical interventions for the rheumatoid shoulder | journal = The Cochrane Database of Systematic Reviews | issue = 1 | pages = CD006188 | date = January 2010 | pmid = 20091587 | doi = 10.1002/14651858.cd006188.pub2 }}</ref>

=== Physiotherapy ===
For people with RA, [[physiotherapy]] may be used together with medical management.<ref name=Kav2004/> This may include cold and [[heat therapy|heat]] application, [[Electrotherapy|electronic stimulation]], and [[hydrotherapy]].<ref name=Kav2004>{{cite journal | vauthors = Kavuncu V, Evcik D | title = Physiotherapy in rheumatoid arthritis | journal = MedGenMed | volume = 6 | issue = 2 | pages = 3 | date = May 2004 | pmid = 15266230 | pmc = 1395797 }}</ref> Although medications improve symptoms of RA, muscle function is not regained when disease activity is controlled.<ref name="ReferenceA">{{cite journal | vauthors = Hammond A, Prior Y | title = The effectiveness of home hand exercise programmes in rheumatoid arthritis: a systematic review | journal = British Medical Bulletin | volume = 119 | issue = 1 | pages = 49–62 | date = September 2016 | pmid = 27365455 | doi = 10.1093/bmb/ldw024 | doi-access = free }}</ref>

Physiotherapy promotes physical activity. In RA, physical activity like exercise in the appropriate dosage (frequency, intensity, time, type, volume, progression) and physical activity promotion is effective in improving cardiovascular fitness, muscle strength, and maintaining a long term active lifestyle. Additionally, exercise can be useful for pain management in this population, specifically, conditioning exercise programs that include aerobic, isometric, and isotonic exercises.<ref name="Jahanbin">{{Cite journal |last=Jahanbin |first=Iran |last2=Moghadam |first2=Mahboobeh Hoseini |last3=Nazarinia |first3=Mohammad Ali |last4=Ghodsbin |first4=Fariba |last5=Bagheri |first5=Zahra |last6=Ashraf |first6=Ali Reza |date=Jul 2014 |title=The Effect of Conditioning Exercise on the Health Status and Pain in Patients with Rheumatoid Arthritis: A Randomized Controlled Clinical Trial |url=https://pmc.ncbi.nlm.nih.gov/articles/PMC4201199/ |journal=International Journal of Community Based Nursing and Midwifery |language=en |volume=2 |issue=3 |archive-url=https://web.archive.org/web/20241006210304/https://pmc.ncbi.nlm.nih.gov/articles/PMC4201199/ |archive-date=2024-10-06 |access-date=2025-02-25 |url-status=live }}</ref> Due to the debilitating effects of the disease, people with RA can gain skills back through exercise because it increases the energy capacity of the muscles.<ref name="Jahanbin"/> In the short term, resistance exercises, with or without range of motion exercises, improve self-reported hand functions.<ref name="ReferenceA"/> Physical activity promotion according to the public health recommendations should be an integral part of standard care for people with RA and other arthritic diseases.<ref name=":12" /> Additionally, the combination of physical activities and [[cryotherapy]] show its efficacy on the disease activity and pain relief.<ref name="2017EJPRM">{{cite journal | vauthors = Peres D, Sagawa Y, Dugué B, Domenech SC, Tordi N, Prati C | title = The practice of physical activity and cryotherapy in rheumatoid arthritis: systematic review | journal = European Journal of Physical and Rehabilitation Medicine | volume = 53 | issue = 5 | pages = 775–787 | date = October 2017 | pmid = 27996221 | doi = 10.23736/s1973-9087.16.04534-2 }}</ref> The combination of aerobic activity and [[cryotherapy]] may be an innovative therapeutic strategy to improve the aerobic capacity in arthritis patients and consequently reduce their cardiovascular risk while minimizing pain and disease activity.<ref name="2017EJPRM" />

=== Compression gloves ===
[[Compression garment|Compression gloves]] are [[handwear]] designed to help prevent the occurrence of various medical disorders relating to blood circulation in the wrists and hands. They can be used to treat the symptoms of [[arthritis]],<ref>{{cite journal | vauthors = Hammond A, Prior Y |date=1 March 2021 |title=Compression gloves for patients with hand arthritis (C-GLOVES): A feasibility study |journal=Hand Therapy |language=en |volume=26 |issue=1 |pages=26–37 |doi=10.1177/1758998320986829 |pmid=37905193 |pmc=10584057 |s2cid=232050521 |issn=1758-9983 |doi-access=free }}</ref> though the medical benefits may be limited.<ref>{{cite journal | vauthors = Hammond A, Jones V, Prior Y | title = The effects of compression gloves on hand symptoms and hand function in rheumatoid arthritis and hand osteoarthritis: a systematic review | journal = Clinical Rehabilitation | volume = 30 | issue = 3 | pages = 213–224 | date = March 2016 | pmid = 25802424 | doi = 10.1177/0269215515578296 | s2cid = 40742720 | url = http://usir.salford.ac.uk/id/eprint/34121/1/SR%20compression%20gloves%20in%20RA%20HOA%20%20Clin%20Rehab%202015%20FINAL%20word%20version.pdf }}</ref>

===Alternative medicine===
In general, there is not enough evidence to support any complementary health approaches for RA, with safety concerns for some of them. Some mind and body practices and dietary supplements may help people with symptoms and therefore may be beneficial additions to conventional treatments, but there is not enough evidence to draw conclusions.<ref name=NCCIH>{{cite web|title=Rheumatoid Arthritis and Complementary Health Approaches|url=http://nccih.nih.gov/health/RA/getthefacts.htm|publisher=National Center for Complementary and Integrative Health|access-date=July 1, 2015|url-status=live|archive-url=https://web.archive.org/web/20150705082102/https://nccih.nih.gov/health/RA/getthefacts.htm|archive-date=July 5, 2015|date=January 2006}}</ref> A [[systematic review]] of [[complementary and alternative medicine|CAM]] modalities (excluding fish oil) found that " The available evidence does not support their current use in the management of RA."<ref name=Macfarlane>{{cite journal | vauthors = Macfarlane GJ, El-Metwally A, De Silva V, Ernst E, Dowds GL, Moots RJ | title = Evidence for the efficacy of complementary and alternative medicines in the management of rheumatoid arthritis: a systematic review | journal = Rheumatology | volume = 50 | issue = 9 | pages = 1672–1683 | date = September 2011 | pmid = 21652584 | doi = 10.1093/rheumatology/ker119 | collaboration = Arthritis Research UK Working Group on Complementary Alternative Medicines | doi-access = free }}</ref> Studies showing beneficial effects in RA on a wide variety of CAM modalities are often affected by [[publication bias]] and are generally not high quality evidence such as [[randomized controlled trial]]s (RCTs).<ref name=Ef2010>{{cite journal | vauthors = Efthimiou P, Kukar M | s2cid = 21179821 | title = Complementary and alternative medicine use in rheumatoid arthritis: proposed mechanism of action and efficacy of commonly used modalities | journal = Rheumatology International | volume = 30 | issue = 5 | pages = 571–586 | date = March 2010 | pmid = 19876631 | doi = 10.1007/s00296-009-1206-y }}</ref>

A 2005 Cochrane review states that [[low level laser therapy]] can be tried to improve pain and morning stiffness due to rheumatoid arthritis as there are few side-effects.<ref>{{cite journal | vauthors = Brosseau L, Robinson V, Wells G, Debie R, Gam A, Harman K, Morin M, Shea B, Tugwell P | title = Low level laser therapy (Classes I, II and III) for treating rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | volume = 4 | issue = 4 | pages = CD002049 | date = October 2005 | pmid = 16235295 | doi = 10.1002/14651858.CD002049.pub2 | pmc = 8406947 }}</ref>

There is limited evidence that [[tai chi]] might improve the range of motion of a joint in persons with rheumatoid arthritis.<ref>{{cite journal | vauthors = Mudano AS, Tugwell P, Wells GA, Singh JA | title = Tai Chi for rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | volume = 9 | pages = CD004849 | date = September 2019 | issue = 9 | pmid = 31553478 | pmc = 6759565 | doi = 10.1002/14651858.CD004849.pub2 }}</ref><ref>{{cite journal | vauthors = Lee MS, Pittler MH, Ernst E | title = Tai chi for rheumatoid arthritis: systematic review | journal = Rheumatology | volume = 46 | issue = 11 | pages = 1648–1651 | date = November 2007 | pmid = 17634188 | doi = 10.1093/rheumatology/kem151 | doi-access = free }}</ref> The evidence for acupuncture is inconclusive<ref>{{cite journal | vauthors = Lee MS, Shin BC, Ernst E | title = Acupuncture for rheumatoid arthritis: a systematic review | journal = Rheumatology | volume = 47 | issue = 12 | pages = 1747–1753 | date = December 2008 | pmid = 18710899 | doi = 10.1093/rheumatology/ken330 | doi-access = free }}</ref> with it appearing to be equivalent to sham acupuncture.<ref>{{cite journal | vauthors = Macfarlane GJ, Paudyal P, Doherty M, Ernst E, Lewith G, MacPherson H, Sim J, Jones GT | title = A systematic review of evidence for the effectiveness of practitioner-based complementary and alternative therapies in the management of rheumatic diseases: rheumatoid arthritis | journal = Rheumatology | volume = 51 | issue = 9 | pages = 1707–1713 | date = September 2012 | pmid = 22661556 | doi = 10.1093/rheumatology/kes133 | collaboration = Arthritis Research UK Working Group on Complementary Alternative Therapies for the Management of the Rheumatic Diseases | doi-access = free }}</ref>

A Cochrane review in 2002 showed some benefits of the electrical stimulation as a rehabilitation intervention to improve the power of the hand grip and help to resist fatigue.<ref>{{cite journal | vauthors = Brosseau LU, Pelland LU, Casimiro LY, Robinson VI, Tugwell PE, Wells GE | title = Electrical stimulation for the treatment of rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 2 | pages = CD003687 | date = 2002 | volume = 2010 | pmid = 12076504 | doi = 10.1002/14651858.CD003687 | pmc = 8725644 }}</ref> D‐penicillamine may provide similar benefits as DMARDs but it is also highly toxic.<ref>{{cite journal | vauthors = Suarez-Almazor ME, Spooner C, Belseck E | title = Penicillamine for treating rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 4 | pages = CD001460 | date = 2000-10-23 | volume = 2011 | pmid = 11034719 | doi = 10.1002/14651858.cd001460 | pmc = 8407185 }}</ref> Low-quality evidence suggests the use of therapeutic ultrasound on arthritic hands.<ref name=":6">{{cite journal | vauthors = Casimiro L, Brosseau L, Robinson V, Milne S, Judd M, Well G, Tugwell P, Shea B | title = Therapeutic ultrasound for the treatment of rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 3 | pages = CD003787 | date = 2002-07-22 | pmid = 12137714 | doi = 10.1002/14651858.cd003787 }}</ref> Potential benefits include increased grip strength, reduced morning stiffness and number of swollen joints.<ref name=":6" /> There is tentative evidence of benefit of [[transcutaneous electrical nerve stimulation]] (TENS) in RA.<ref name=":7">{{cite journal | vauthors = Johnson MI, Walsh DM | title = Pain: continued uncertainty of TENS' effectiveness for pain relief | journal = Nature Reviews. Rheumatology | volume = 6 | issue = 6 | pages = 314–316 | date = June 2010 | pmid = 20520646 | doi = 10.1002/14651858.cd004377 | pmc = 8826159 }}</ref> Acupuncture‐like TENS (AL-TENS) may decrease pain intensity and improve muscle power scores.<ref name=":7" />

Low-quality evidence suggests people with active RA may benefit from assistive technology.<ref name=":8">{{cite journal | vauthors = Tuntland H, Kjeken I, Nordheim LV, Falzon L, Jamtvedt G, Hagen KB | title = Assistive technology for rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 4 | pages = CD006729 | date = October 2009 | volume = 2009 | pmid = 19821383 | doi = 10.1002/14651858.cd006729.pub2 | pmc = 7389411 }}</ref> This may include less discomfort and difficulty such as when using an eye drop device.<ref name=":8" /> Balance training is of unclear benefits.<ref>{{cite journal | vauthors = Silva KN, Mizusaki Imoto A, Almeida GJ, Atallah AN, Peccin MS, Fernandes Moça Trevisani V | title = Balance training (proprioceptive training) for patients with rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 5 | pages = CD007648 | date = May 2010 | pmid = 20464755 | doi = 10.1002/14651858.cd007648.pub2 }}</ref>

===Dietary supplements===

====Fatty acids====
There has been a growing interest in the role of long-chain [[omega-3 polyunsaturated fatty acids]] to reduce inflammation and alleviate the symptoms of RA. Metabolism of omega-3 polyunsaturated fatty acids produces docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), which inhibits pro-inflammatory eicosanoids and cytokines (TNF-a, IL-1b and IL-6), decreasing both lymphocyte proliferation and reactive oxygen species.<ref name=":15">{{cite journal | vauthors = Martin RH | title = The role of nutrition and diet in rheumatoid arthritis | journal = The Proceedings of the Nutrition Society | volume = 57 | issue = 2 | pages = 231–234 | date = May 1998 | pmid = 9656325 | doi = 10.1079/pns19980036 | doi-broken-date = 1 November 2024 | s2cid = 2000161 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Tedeschi SK, Costenbader KH | title = Is There a Role for Diet in the Therapy of Rheumatoid Arthritis? | journal = Current Rheumatology Reports | volume = 18 | issue = 5 | pages = 23 | date = May 2016 | pmid = 27032786 | doi = 10.1007/s11926-016-0575-y | s2cid = 39883142 }}</ref> These studies showed evidence for significant clinical improvements on RA in inflammatory status and articular index. [[Gamma-linolenic acid]], an omega-6 fatty acid, may reduce pain, tender joint count and stiffness, and is generally safe.<ref>{{cite journal | vauthors = Soeken KL, Miller SA, Ernst E | title = Herbal medicines for the treatment of rheumatoid arthritis: a systematic review | journal = Rheumatology | volume = 42 | issue = 5 | pages = 652–659 | date = May 2003 | pmid = 12709541 | doi = 10.1093/rheumatology/keg183 | url = http://www.crd.york.ac.uk/CRDWeb/ShowRecord.asp?AccessionNumber=12003000980 | access-date = March 23, 2013 | publisher = [[National Institute for Health and Care Research]] | url-status = live | doi-access = free | archive-url = https://web.archive.org/web/20140116101729/http://www.crd.york.ac.uk/CRDWeb/ShowRecord.asp?AccessionNumber=12003000980 | archive-date = January 16, 2014 }}</ref> For omega-3 polyunsaturated fatty acids (found in fish oil, flax oil and hemp oil), a meta-analysis reported a favorable effect on pain, although confidence in the effect was considered moderate. The same review reported less inflammation but no difference in joint function.<ref name="Senft">{{cite journal | vauthors = Senftleber NK, Nielsen SM, Andersen JR, Bliddal H, Tarp S, Lauritzen L, Furst DE, Suarez-Almazor ME, Lyddiatt A, Christensen R | title = Marine Oil Supplements for Arthritis Pain: A Systematic Review and Meta-Analysis of Randomized Trials | journal = Nutrients | volume = 9 | issue = 1 | pages = 42 | date = January 2017 | pmid = 28067815 | pmc = 5295086 | doi = 10.3390/nu9010042 | doi-access = free }}</ref> A review examined the effect of marine oil omega-3 fatty acids on pro-inflammatory eicosanoid concentrations; [[Leukotriene B4|leukotriene<sub>4</sub>]] (LTB<sub>4</sub>) was lowered in people with rheumatoid arthritis but not in those with non-autoimmune chronic diseases.<ref name="Jiang">{{cite journal | vauthors = Jiang J, Li K, Wang F, Yang B, Fu Y, Zheng J, Li D | title = Effect of Marine-Derived n-3 Polyunsaturated Fatty Acids on Major Eicosanoids: A Systematic Review and Meta-Analysis from 18 Randomized Controlled Trials | journal = PLOS ONE | volume = 11 | issue = 1 | pages = e0147351 | year = 2016 | pmid = 26808318 | pmc = 4726565 | doi = 10.1371/journal.pone.0147351 | doi-access = free | bibcode = 2016PLoSO..1147351J }}</ref> Fish consumption has no association with RA.<ref name="DiG">{{cite journal | vauthors = Di Giuseppe D, Crippa A, Orsini N, Wolk A | title = Fish consumption and risk of rheumatoid arthritis: a dose-response meta-analysis | journal = Arthritis Research & Therapy | volume = 16 | issue = 5 | pages = 446 | date = September 2014 | pmid = 25267142 | pmc = 4201724 | doi = 10.1186/s13075-014-0446-8 | doi-access = free }}</ref> A fourth review limited inclusion to trials in which people eat ≥2.7&nbsp;g/day for more than three months. Use of pain relief medication was decreased, but improvements in tender or swollen joints, morning stiffness and physical function were not changed.<ref name="Lee">{{cite journal | vauthors = Lee YH, Bae SC, Song GG | title = Omega-3 polyunsaturated fatty acids and the treatment of rheumatoid arthritis: a meta-analysis | journal = Archives of Medical Research | volume = 43 | issue = 5 | pages = 356–362 | date = July 2012 | pmid = 22835600 | doi = 10.1016/j.arcmed.2012.06.011 }}</ref> Collectively, the current evidence is not strong enough to determine that supplementation with omega-3 fatty acids or regular consumption of fish are effective treatments for rheumatoid arthritis.<ref name="Senft"/><ref name="Jiang"/><ref name="DiG"/><ref name="Lee"/>

====Herbal====
The [[American College of Rheumatology]] states that no herbal medicines have health claims supported by high-quality evidence and thus they do not recommend their use.<ref name=ACRCAM/> There is no scientific basis to suggest that herbal supplements advertised as "natural" are safer for use than conventional medications as both are chemicals. Herbal medications, although labelled "natural", may be toxic or fatal if consumed.<ref name=ACRCAM>{{cite web|title=Herbal Remedies, Supplements and Acupuncture for Arthritis|url=http://www.rheumatology.org/Practice/Clinical/Patients/Diseases_And_Conditions/Herbal_Remedies,_Supplements_and_Acupuncture_for_Arthritis/|publisher=American College of Rheumatology|access-date=May 3, 2013|url-status=live|archive-url=https://web.archive.org/web/20130505001915/http://www.rheumatology.org/Practice/Clinical/Patients/Diseases_And_Conditions/Herbal_Remedies,_Supplements_and_Acupuncture_for_Arthritis/|archive-date=May 5, 2013}}</ref> Due to the false belief that herbal supplements are always safe, there is sometimes a hesitancy to report their use which may increase the risk of adverse reactions.<ref name=Ef2010/>

===Pregnancy===
More than 75% of women with rheumatoid arthritis have symptoms improve during pregnancy but might have symptoms worsen after delivery.<ref name="McGraw Hill"/> [[Methotrexate]] and [[leflunomide]] are teratogenic (harmful to foetus) and not used in pregnancy. It is recommended women of childbearing age should use contraceptives to avoid pregnancy and to discontinue its use if pregnancy is planned.<ref name="Wasserman" /><ref name="chapter94" /> Low dose of [[prednisolone]], [[hydroxychloroquine]] and [[sulfasalazine]] are considered safe in pregnant women with rheumatoid arthritis. Prednisolone should be used with caution as the side effects include infections and fractures.<ref>{{cite journal | vauthors = Gotzsche PC, Johansen HK | title = Short-term low-dose corticosteroids vs placebo and nonsteroidal antiinflammatory drugs in rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 3 | pages = CD000189 | date = 2005-01-24 | volume = 2005 | pmid = 15266426 | doi = 10.1002/14651858.cd000189.pub2 | pmc = 7043293 }}</ref>

===Vaccinations===
People with RA have an increased risk of infections and mortality and recommended vaccinations can reduce these risks.<ref>{{cite journal | vauthors = Perry LM, Winthrop KL, Curtis JR | title = Vaccinations for rheumatoid arthritis | journal = Current Rheumatology Reports | volume = 16 | issue = 8 | pages = 431 | date = August 2014 | pmid = 24925587 | pmc = 4080407 | doi = 10.1007/s11926-014-0431-x }}</ref> The inactivated [[influenza vaccine]] should be received annually.<ref>{{cite journal | vauthors = Grohskopf LA, Olsen SJ, Sokolow LZ, Bresee JS, Cox NJ, Broder KR, Karron RA, Walter EB | title = Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP) -- United States, 2014-15 influenza season | journal = MMWR. Morbidity and Mortality Weekly Report | volume = 63 | issue = 32 | pages = 691–697 | date = August 2014 | pmid = 25121712 | pmc = 4584910 }}</ref> The [[pneumococcal vaccine]] should be administered twice for people under the age 65 and once for those over 65.<ref>{{cite journal | vauthors = Black CL, Yue X, Ball SW, Donahue SM, Izrael D, de Perio MA, Laney AS, Lindley MC, Graitcer SB, Lu PJ, Williams WW, Bridges CB, DiSogra C, Sokolowski J, Walker DK, Greby SM | title = Influenza vaccination coverage among health care personnel--United States, 2013-14 influenza season | journal = MMWR. Morbidity and Mortality Weekly Report | volume = 63 | issue = 37 | pages = 805–811 | date = September 2014 | pmid = 25233281 | pmc = 5779456 }}</ref> Lastly, the live-attenuated [[zoster vaccine]] should be administered once after the age 60, but is not recommended in people on a [[tumor necrosis factor alpha]] blocker.<ref>{{cite journal | vauthors = Hales CM, Harpaz R, Ortega-Sanchez I, Bialek SR | title = Update on recommendations for use of herpes zoster vaccine | journal = MMWR. Morbidity and Mortality Weekly Report | volume = 63 | issue = 33 | pages = 729–731 | date = August 2014 | pmid = 25144544 | pmc = 5779434 }}</ref>