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Rheumatoid arthritis (RA) is an autoimmune disease, meaning the immune system mistakenly attacks the body’s own tissues. It mainly affects the joints and can progress through four stages. Common symptoms of RA includ joint inflammation, swelling, and pain, along with other others. These symptoms usually get worse as the disease moves through each stage. Your rheumatologist will figure out the stage of your RA, which is based on how severe it is.
Each case of RA is unique, and some cases take years to progress. There’s no fixed timeline of RA progression. Thanks to improved treatment options, RA often doesn’t progress to the later stages of the disease. Although there’s no cure for RA, several treatment options can help limit disease progression and slow down joint damage. Treatment plans can vary by stage.
Here’s some information on the four stages of RA that you can discuss in more detail with your doctor and rheumatology healthcare team.
Diagnosing RA in its early stage can be hard because there’s no visible damage in joints or bones that can be seen on imaging tests like an X-ray. Early signs of RA tend to be mild.
The main symptoms of early RA include morning joint stiffness, swelling, and painful joints in the hand, foot, or knee that may get better as the day goes on. Early RA symptoms may also come and go.
RA can start years before any joint problems show up. In the early stage, the immune system targets the thin lining of the joints — called the synovium — and causes inflammation. X-rays may not show RA this early, but ultrasound or MRI scans can sometimes reveal joint swelling or fluid that helps with early diagnosis.
Treatment options in early RA might include nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, or short-term corticosteroids to treat joint pain. Conventional disease-modifying antirheumatic drugs (DMARDs) and biologic drugs or biosimilar drugs, such as TNF inhibitors, may be recommended. Biosimilars are medicines made to work almost the same as certain biologic drugs, but they often cost less than the original versions.
In the past, biologics and biosimilars were reserved for more advanced cases of RA, but newer research has shown they can be a safe and effective early treatment in the early stages of RA. However, they are often not the first treatment in the early stages because they cost more and can cause more side effects.
Janus kinase (JAK) inhibitors are the newest class of drugs used in the treatment of RA, but they are not used as a first-line treatment in the early stages of RA. While biologics and biosimilars need to be taken by injection or infusion, JAK inhibitors can be taken orally. You and your doctor can work together to determine which treatment option would be best for you
Always talk with your doctor about the potential side effects of any medication that you’re trying for the first time.
The moderate stage of RA is marked by damage to the cartilage in the joints, which begins to limit mobility and range of motion. This loss of mobility can affect daily activities like household chores, walking distances, gardening, or participating in sports. At this point, there may be osteoporosis (minor bone damage), but there are no signs of joint deformity.
Along with an increase in swelling and fatigue, other symptoms are likely to show up at this stage. Some people get lumps on their elbows, known as rheumatoid nodules. In some cases, other organs in the body may be affected by inflammation, including the eyes, skin, lungs, and heart.
In moderate RA, damage to joints and bones can often be seen on X-rays. MRI and ultrasound are more sensitive and may show even more detail. Many people with RA have rheumatoid factor (RF), an antibody linked to inflammation, and/or anti-CCP antibodies, proteins linked to RA that attack the body’s tissues, in their blood. These antibodies can be found with blood tests.
Treatment of moderate RA can include NSAIDs, short-term corticosteroids, conventional (or nonbiologic) DMARDs, biologics, biosimilars, or JAK inhibitors. Your doctor may recommend a combination of medications if needed.
In stage 3 RA, the cartilage wears away. Bone damage can be seen on X-rays. Severely damaged joints can become deformed. For example, damage to the small joints in the hand can cause the fingers to become permanently crooked or bent. Deformed joints can put pressure on nerves and cause neuropathy (nerve damage), which may lead to nerve pain. Severe RA is a painful stage of the disease, and neuropathy can cause additional discomfort, weakness, and numbness.
In stage 3 RA, joint pain and stiffness make it harder to move. Gripping utensils, turning doorknobs, lifting objects, or opening a jar can be difficult or even dangerous. Assistive devices are often needed to perform many tasks. Some people wear splints to support weak joints. Mobility aids — such as canes, walkers, and orthopedic inserts or supportive footwear — can help with walking and standing in the later stages of RA.
At this stage, managing pain and slowing joint damage remain top priorities. DMARDs — including JAK inhibitors, a type of targeted synthetic DMARD — may be used if earlier treatments, such as biologics, haven’t worked. Pain medications can help relieve discomfort caused by both inflammation and joint damage. Joint replacement surgery may also be considered to improve function and quality of life.
In end-stage RA, a joint may become completely damaged and stop functioning. This can lead to joint fusion — called ankylosis — where bone or fibrous tissue causes the joint to become fixed in place. By this stage, inflammation often subsides, but mobility is severely limited. People may continue to experience stiffness, discomfort, or loss of independence in the affected joints, along with other features seen in stage 3.
Pain management is the main treatment in this stage, including pain relievers, muscle relaxers, and low-dose antidepressants. While different types of pain management can help — and low-dose antidepressants may ease ongoing pain — DMARDs are still used to control ongoing inflammation. In the final stage, surgery is often needed to improve joint function and reduce pain.
If you’re living with RA, you’ve probably wondered: How fast does rheumatoid arthritis progress? Your doctor will monitor you for signs of progression to understand how best to treat your condition.
Researchers don’t fully understand what causes RA. Cleveland Clinic lists these risk factors for the condition:
Some of these factors can also affect the course of RA. For people living with a higher body weight, research shows that losing weight may reduce RA activity.
Smoking is linked to a worse outcome in people with RA and can reduce the effectiveness of RA medications such as conventional DMARDs and tumor necrosis factor (TNF)-alpha inhibitors. Lifestyle changes, such as a healthy diet and regular physical activity, are also linked to better results with RA treatment.
Doctors can evaluate the health of bones and joints by using imaging tests like X-rays and MRIs. Rheumatologists can also predict disease progression with blood tests that measure levels of inflammation and inflammatory antibodies. These types of tests may show a likelihood for more severe RA, and include:
The Disease Activity Score 28 (DAS28) is a tool doctors use to monitor rheumatoid arthritis progression. It combines a 28-joint count for swelling and tenderness, a blood test for inflammation (such as ESR or CRP), and a general health assessment to produce a score between 0 and 9.4. Higher scores indicate more active disease.
Based on test results, your doctor may suggest changing your treatment plan to improve results. If you’re not happy with your current plan, talk to your doctor. It’s not safe to change or stop treatment without medical guidance. The right treatment can slow RA, ease symptoms, and help you stay active and independent.
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Diagnosed in the past year at age 47. Already need a partial knee replacement. The pain in my joints and the fatigue have become bothersome. Love and prayers for all those affected by RA.
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