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Rheumatoid Arthritis Stages and Progression

Medically reviewed by Ariel D. Teitel, M.D., M.B.A.
Written by Ashley Knox
Posted on April 7, 2021

Rheumatoid arthritis (RA) is an inflammatory autoimmune disease that leads to joint inflammation, swelling, and pain, which often appear symmetrically on both sides of the body. RA has four stages, with joint damage becoming progressively worse with each stage. Rheumatologists determine each stage of RA depending on how severe it is.

Although there is no cure for RA, several treatments can help limit the disease progression and slow the damage to joints. Those treatments can vary from stage to stage.

Stage 1: The Early Stage

Diagnosing RA in its early stage can be difficult because there is no damage to the joints yet and symptoms are mild. The main symptoms in early RA include some stiffness and swelling in the joints and some pain and fatigue. The small joints of the hand tend to be affected first.

During early RA, the immune system has begun attacking the thin layers of cells that line each joint — called the synovium — leading to synovial inflammation. Any damage to the joint would not show up on an X-ray.

Treatment

An early diagnosis can allow a rheumatologist to begin treatment that slows the progression of RA. Disease-modifying antirheumatic drugs (DMARDs) like sulfasalazine (Azulfidine), hydroxychloroquine (Plaquenil), and especially methotrexate are recommended for early treatment of low disease activity. Nonsteroidal anti-inflammatory drugs such as aspirin may be used to relieve pain.

Stage 2: The Moderate Stage

The moderate stage of RA is marked by damage to the cartilage in the joints, which begins to limit mobility and range of motion. At this point, there may be minor damage to the bones (osteoporosis), but there is no joint deformity. Damage is detectable on MRIs and X-rays in moderate RA. Lumps called rheumatoid nodules can also form.

Treatment

If your RA progresses and DMARDs don’t help, the American College of Rheumatology recommends also taking a biologic as well. Certain biologics can block an inflammation-causing protein called tumor necrosis factor (TNF), thereby decreasing inflammation. Fittingly, these biologics are called TNF inhibitors. The U.S. Food and Drug Administration has approved several TNF inhibitors, including:

Your doctor may prescribe low doses of a steroid such as prednisone for a short time to help relieve symptoms of moderate to severe RA. Flare-ups — periods of worse symptoms — may also be managed by short-term use of low-dose steroids. Because steroids can have negative side effects, it's generally best to take the smallest dose possible for pain relief.

Stage 3: The Severe Stage

In the severe stage of RA, the cartilage has eroded and the bones also begin to erode. Since the joint is severely damaged, it can become deformed. For example, erosion of small joints in the hand can cause the fingers to permanently curl in. Severe RA is a painful stage of disease, and the damage to the joints makes daily activities more difficult.

Treatment

Doctors will focus on pain management but may also recommend surgery to replace or fuse the joint to reduce pain.

Stage 4: The End Stage

When the joint is completely eroded, RA has reached its end stage. The inflamed tissue is completely destroyed and the bone is also eroded. There may also be fibrous tissue that fuses bone in the joint and contributes to severely limited mobility.

Treatment

Pain management is the main concern in this stage. Joint-replacement therapy may help relieve pain and restore some function to the joint.

Predicting the Course of RA

Although the cause of RA is not known, risk factors include being female, having certain genetic traits, and being older in age. People who smoke or are obese also have an increased risk of RA, so avoiding smoking and maintaining a healthy weight are important both before and after an RA diagnosis.

Doctors can look at the health of bones and joints using imaging tests, such as X-rays and MRI scans. Rheumatologists can also predict disease progression by performing blood tests and observing physical symptoms.

A doctor can measure inflammation levels by looking at the amount of C-reactive protein (CRP) in the blood, as well as the blood’s erythrocyte sedimentation rate (ESR). Higher levels of CRP and ESR mean there is more inflammation in the body, which can mean that RA disease activity is more severe.

Doctors can also measure the number of autoantibodies (antibodies that are attacking the joints) an individual has. One test measures anti-citrullinated protein antibodies, which are also called anti-cyclic citrullinated peptides (or anti-CCP). Rheumatologists can also measure another antibody called rheumatoid factor.

If the CRP or ESR levels show worsening inflammation and joint damage, doctors can adjust treatment to better protect the joints.

Talk To People Who Understand

By joining myRAteam — the social network for people with rheumatoid arthritis and their loved ones — you can connect with more than 191,000 members who understand life with RA. Every day, members come together to ask questions, give advice, and share their stories.

What stage is your RA, and how are you managing it? Share your experience in the comments below, or share your story on myRAteam.

Posted on April 7, 2021
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Ariel D. Teitel, M.D., M.B.A. is the clinical associate professor of medicine at the NYU Langone Medical Center in New York. Review provided by VeriMed Healthcare Network. Learn more about him here.
Ashley Knox is a doctoral candidate at the University of Colorado, where she studies the noncoding RNAs involved in gammaherpesvirus pathogenesis. Learn more about her here.

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