There's an overriding rule for RA treatment: The earlier, the better. Find out why starting early with rheumatoid arthritis drugs like DMARDs can stop crippling joint damage before it starts.

At age 19, Dana Symons suddenly felt pain in one hand. “I thought it was tendinitis, so I went to a hand specialist,” says the now 27-year-old, who lives in Grand Rapids, Mich. When the pain switched hands, the hand specialist knew to send her to a rheumatologist. “While we were waiting for the results of my blood work, the pain started spreading to other joints throughout my body,” Symons recalls. She soon got her diagnosis: rheumatoid arthritis.

Symons’ rheumatologist quickly started her on methotrexate (Rheumatrex), a disease-modifying anti-rheumatic drug (DMARD) often used to treat the disease. Since then, she’s switched medications a few times, but her rheumatoid arthritis has remained well-controlled. “I have a flare now and then, but I am able to maintain most of my functionality and live a pretty normal life,” she says.

More than eight years after her diagnosis, Symons attributes her successful RA management in part to early treatment. As time marches on, scientists know more about the best ways to treat rheumatoid arthritis. The latest thinking: The earlier the treatment for rheumatoid arthritis, the better.

“The older treatment model was less aggressive — doctors would see how the patient with rheumatoid arthritis felt and test treatments for a longer time,” says Diane Horowitz, MD, director of the Arthritis Center at North Shore University Hospital in Manhasset, N.Y.  Doctors started with milder drugs that primarily addressed symptoms and gradually worked their way up to DMARDs, a class of medications that addresses the cause of rheumatoid arthritis within the immune system.

Today, doctors are much more proactive. “We start treating earlier, and we have shortened the timeframe we give treatments to work before we move on to something more aggressive,” Dr. Horowitz says. The two main drug treatment options are DMARDs and biologics, with DMARDs being the more popular choice. “DMARDs work by stopping inflammatory cells from being produced," she says, "and biologics work more by stopping the immune system from being overactive.”

Rheumatologists today also practice what is called “treat to target” to manage rheumatoid arthritis. “Treat to target involves setting specific goals and milestones, such as the number of swollen joints or certain lab results, and making aggressive changes to treatment in order to reach those goals,” Horowitz explains.

Symons’ treatment is an example of that approach. As her rheumatoid arthritis symptoms became less well-controlled, her rheumatologist has switched her to a different drug therapy.

Why Exactly Is Early Treatment for Rheumatoid Arthritis So Important?

“Early treatment for RA makes all the difference in the world,” says Nathan Wei, MD, director of the Arthritis Treatment Center in Frederick, Md. “The longer RA goes untreated, the greater the chance of permanent joint changes and disability." Early, aggressive treatment, usually with DMARDs, reduces the chance of disability and other potential consequences of rheumatoid arthritis.

More specifically, here are a few reasons that make early treatment for rheumatoid arthritis so valuable:

• It alleviates pain. “The joint swelling associated with rheumatoid arthritis is very uncomfortable," Horowitz notes, "so the sooner we can ease it, the better.”
• It prevents disability. “If rheumatoid arthritis goes untreated, it can lead to joint erosion that can cause decreased function down the road,” she says.
• It prevents the consequences of long-term inflammation. “Long-term inflammation due to rheumatoid arthritis is a risk factor for cardiovascular disease, plus it can be a burden psychologically,” Horowitz says.

Weighing Risks and Benefits of Early Treatment for RA

Although experts now realize the importance of early treatment for rheumatoid arthritis, doctors are still cautious about putting people with RA on powerful rheumatoid arthritis medications without due diligence. “Patients don’t walk into a rheumatologist’s office and walk out with a prescription for a biologic or DMARD on their first visit — we need to gather some information before we start these drugs,” Horowitz says.

She adds there are risks for delaying treatment for rheumatoid arthritis and, despite the importance of early treatment, there are risks for starting treatment prematurely. “Overall, it’s best to wait until there is an established rheumatoid arthritis diagnosis, complete with lab work and X-rays, to start treatment,” she says.

Side effects of drugs to treat rheumatoid arthritis include liver toxicity (which means that alcohol use is discouraged), upset stomach, and low blood cell counts. People taking DMARDs are also advised against getting pregnant.

“We also have to make sure there is no infection, such as tuberculosis or hepatitis, before we put someone on drugs to suppress the immune system,” Horowitz says. And, she says, there's no specific timeline for when someone with rheumatoid arthritis should start early treatment. “It depends on how long the patient has had symptoms — some people have more aggressive disease than others," she notes.

Beyond DMARDs: Rheumatoid Arthritis and Lifestyle Changes

If you’ve been diagnosed with rheumatoid arthritis, your rheumatologist will decide whether you need early treatment with DMARDs. But aside from medications, there are steps you can take on your own:

• Rheumatoid arthritis and exercise: “Exercise is an unknown ‘secret’ in RA treatment,” Dr. Wei says. “The myth is that rheumatoid arthritis patients shouldn't exercise, but quite the opposite is true. A number of studies have demonstrated that low-impact cardiovascular exercise, resistance, and stretching can all benefit patients with the disease.” Talk to your doctor before starting any exercise regimen, however. 

• Rheumatoid arthritis and diet: “The role of diet in rheumatoid arthritis remains controversial, but certain foods — such as fish with omega-3 fatty acids, fresh fruits and berries, and other foods that contain antioxidants — are excellent ‘non-medicine’ ways of maintaining joint health if you have RA,” Wei says.

Scientists still haven’t found a cure for rheumatoid arthritis, but with early treatment, the symptoms of the disease can be well-controlled. “The best thing to do if you have symptoms of rheumatoid arthritis, such as joint pain, morning stiffness, fatigue, and fever, is to see your primary doctor, who will refer you to a rheumatologist,” Horowitz says.

Symons agrees. “If you have symptoms of rheumatoid arthritis, get to a rheumatologist as soon as possible and make sure you follow up because, if you get early treatment, you are much more likely to achieve low disease activity or remission,” she says.