Disease-modifying antirheumatic drugs (DMARDs) are a common treatment for rheumatoid arthritis (RA) that can help reduce swelling and pain. These drugs work by suppressing the overactive immune response that damages joints in RA.

Yet DMARDs don’t always work on the first try. If you’ve been taking DMARDs but are still experiencing pain, you might need to take a few different drugs or a combination of them to get relief from your symptoms.

If the medication you’re on isn’t working or has stopped effectively managing your joint pain, it’s time to make an appointment with your doctor. Here are a few questions to ask during your visit.

How will I know if it’s time to switch my treatment?

During your visit, your doctor will likely ask about your RA symptoms and how they’ve changed since you started your current medication. Your doctor will also look at your joints for these signs of RA:

  • swelling
  • redness
  • warmth

Your doctor might also have you undergo a few tests to see whether your joint damage has gotten worse. This may include:

  • blood tests to look for signs of inflammation
  • X-rays to look for joint damage
  • MRI or ultrasound to see what effects RA is having on your body

Do I need to increase the dose?

Your doctor might have started you on a low dose of methotrexate or another DMARD. Beginning with a low dosage will relieve your symptoms without causing too many side effects.

If you don’t feel better on your current dose, your doctor may increase the dosage.

It can take a few weeks for the new dosage to take effect. Within three months, your doctor will be able to see whether it is effectively managing your RA.

Should I add another DMARD?

When your disease is still very active, your doctor can add another DMARD to the one you’re taking. Many different types of DMARDs are available, including:

  • azathioprine (Azasan)
  • cyclosporine (Neoral, Sandimmune, Gengraf)
  • hydroxychloroquine (Plaquenil)
  • leflunomide (Arava)
  • methotrexate (Rheumatrex, Trexall)
  • sulfasalazine (Azulfidine)

You can also try a drug in a newer DMARD class, called biologic DMARDs. These genetically engineered proteins target the specific parts of the immune system that signal inflammation.

TNF inhibitors are one group of biologics. These drugs block a chemical called tumor necrosis factor (TNF), which triggers inflammation. They include:

  • certolizumab (Cimzia)
  • adalimumab (Humira)
  • etanercept (Enbrel)
  • golimumab (Simponi)
  • infliximab (Remicade)

Sarilumab (Kevzara) and tocilizumab (Actemra) act on an immune system protein called interleukin-6 (IL-6). Anakinra (Kineret) affects another immune system protein, interleukin-1 (IL-1).

Rituximab (Rituxan) and abatacept (Orencia) act on white blood cells that are involved in inflammation.

Janus kinase inhibitors are a new type of DMARD. Tofacitinib (Xeljanz) and baricitinib (Olumiant) block pathways called Janus kinases (JAKs) that play a role in joint inflammation.

Before you switch to a new drug, ask your doctor these questions:

  • How is this medication different from the one I was on before?
  • How might it help my RA?
  • What side effects can it cause?
  • How can I recognize and manage possible side effects from the medication?
  • Are there potential interactions with other medications I’m taking?
  • Are there any other medications that might help relieve my symptoms?

Should I try another type of RA drug?

DMARDs aren’t the only option for treating RA. Other medications can also bring down inflammation.

Your doctor might recommend one of these drugs in addition to a DMARD:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs reduce inflammation and pain. Some, like ibuprofen (Advil, Motrin) and naproxen sodium (Aleve), are available over the counter. Others require a prescription from your doctor. NSAIDs come in pain-relieving creams too.
  • Corticosteroids. Prednisone and other steroid drugs quickly bring down inflammation. These medications can also cause side effects like weight gain, bone thinning, and high blood pressure. Because of side effects, doctors prescribe steroids for only short periods of time to get RA symptoms under control. Corticosteroids can also be given as an injection to reduce inflammation in a specific joint.

What else can I do to manage my RA?

Your doctor might also recommend one of these strategies to manage your condition:

Exercise

Regular physical activity will strengthen the muscles that support your joints. Walking, swimming, and other low-impact exercises are safest for people with RA. Stretching is also important for maintaining flexibility and range of motion.

Rest

Stay active, but be mindful of your limits. Take breaks, especially when you’re in the middle of an RA flare. Resting will help take the pressure off your joints and give your body time to recover.

Diet

No specific diet can treat RA, but healthy eating is always a good strategy. Foods that are high in antioxidants can help combat inflammation. These include fresh fruits and vegetables, whole grains, and fish. Avoid foods that are high in sugar and saturated fat, which promote inflammation.

Ice or heat

Hold an ice pack or heating pad to your inflamed joint a few times a day. Cold numbs painful areas, while heat relaxes tense muscles and increases blood flow to the area.

Here are a few questions to ask your doctor:

  • Should I make any changes to my fitness routine?
  • How often should I exercise?
  • Which exercises are safest for me?
  • Which ones should I avoid?
  • Should I see a physical therapist or other expert to help me get started on an exercise program?
  • What types of foods should I be eating?
  • Should I see a dietitian to help me plan out a healthier diet?

Is it time to consider surgery?

If joint damage becomes severe enough to interfere with your daily life and medications don’t help, it might be time to consider surgery. Your doctor can tell you whether you’re a good candidate for one of these procedures:

  • joint fusion, which joins the bones to stabilize a joint when replacement surgery isn’t an option
  • tendon repair surgery
  • synovectomy, which removes the inflamed joint lining
  • joint replacement, which removes the damaged parts of the joint and replaces them with metal or plastic parts

Ask your doctor what benefits and risks each type of surgery can have. If you’re a good candidate for one of these procedures, your rheumatologist might refer you to an orthopedic surgeon.

The takeaway

Although RA isn’t curable, your doctor has many treatments to manage your symptoms and prevent joint damage and disability.

To ensure that you’re on the most effective treatment, see your doctor for regular checkups. Bring a list of questions with you and take notes during your appointment.

Tell your doctor about any new symptoms you’re having. Let your doctor know about any side effects you’ve experienced, and be honest if you’ve had trouble sticking to your treatment plan.

Understanding your situation will help your doctor change your treatment to make it more effective and easier to follow.