Stages of Rheumatoid Arthritis

Rheumatoid arthritis (RA) is an autoimmune disorder that causes inflammation, pain, and stiffness in the joints—usually in your hands, wrists, knees, feet, and ankles.

Symptoms of RA can vary depending on the stage of the condition. In the early stages, symptoms can come and go. As the condition progresses, symptoms are likely to persist and worsen, sometimes causing long-term damage to the joints that unfortunately can't be reversed.

Early Rheumatoid Arthritis

During the beginning stages of RA, many people don't yet have a diagnosis. It might not be clear that you have RA versus another health condition that may be causing joint pain. Symptoms during this early period can vary greatly from person to person. The experiences are so different during early rheumatoid arthritis that your symptoms can develop in the following ways:

• Gradual, intermittent pain and stiffness in one or two joints that worsens over several weeks
• Sudden and intense pain in one or two joints
• Joint pain in one or two joints that occurs for a few days and only returns months later (known as palindromic symptoms)

Researchers apply the term “pre-RA” to people who have certain signs of rheumatoid arthritis (e.g., positive results on certain blood tests) who are very likely to eventually get full-blown RA, even if they don’t fully qualify for a diagnosis currently. The six months after an official diagnosis is sometimes also called “early RA.”

During this early period, immune activation is just beginning, and not as many parts of the immune system are involved. In a small minority of people with pre-RA or early RA, symptoms spontaneously go away without treatment, and no long-term damage occurs. However, studies are still investigating how frequent that is and why symptoms can go away in some people.

Established Rheumatoid Arthritis

In established rheumatoid arthritis, symptoms have been present for at least six months, and diagnosing the condition is easier. By the time of established rheumatoid arthritis, more parts of the immune system are activated. While treatments can help keep symptoms at bay, you still might experience some flares (periods where symptoms are active).

The severity of symptoms can still vary from person to person during this period of RA. Some people have pain in a relatively small number of joints, but others experience pain in several joints throughout their bodies. The intensity can also vary from mild to severe.

Pain during this stage can worsen over time, but not always. Your pain levels will often depend on whether you're receiving treatment and how your body responds to the treatments.

Advanced Rheumatoid Arthritis

If untreated, people who’ve had established RA for years can eventually develop advanced RA— sometimes also called “end-stage” RA. If you're in this stage of RA, your joints may have become permanently and severely damaged from active flares and excess inflammation.

Advanced RA can cause your joints to become deformed, damaging your bones and making it hard for you to move. If you experience symptoms in your hands, your fingers might come out of alignment and bend at odd angles.

Because this damage is permanent, advanced RA often causes persistent and severe pain. This stage can also cause more severe complications, like a higher risk of developing lung and heart disease or certain types of cancers.

X-Ray Stages

In some healthcare settings, your provider may talk about RA stages in numerical terms. This often occurs when you're getting an X-ray to understand how much joint inflammation you have. Greater damage corresponds to a higher stage number. You may receive a diagnosis in one of the following stages:

• Stage 1: Joint changes can’t be seen with X-ray (although slight changes might be seen with more precise imaging, like MRI).
• Stage 2: Some cartilage around the joint is destroyed, causing some stiffness and decreased range of motion, but the joint isn’t deformed.
• Stage 3: More of the bone and supporting tissue around the bone is destroyed, and the joint becomes deformed, worsening stiffness and range of motion.
• Stage 4: All the features of stage 3 are present, but some of the bones also become abnormally fused at odd angles, making it more difficult to move.

Generally speaking, pre-RA and early RA are categorized as stage 1. Established RA is usually stage 2. Advanced RA might correspond to stage 3 or stage 4.

Disease-Modifying Treatments

Disease-modifying antirheumatic drugs (DMARDs) are the first line of treatment for RA at any stage. These treatments decrease inflammation, flares, and the chance that your RA will become more advanced. Many types of DMARDs are available for RA. These include:

• Pharmaceutical DMARDs that you can take orally, such as Trexall (methotrexate)
• DMARDs made from living organisms (called biologics) that you take with an injection or infusion, such as Enbrel (etanercept) and Actemra (tocilizumab)
• Targeted synthetic DMARDs that you take orally, such as Xeljanz (tofacitinib)

Trexall (methotrexate) is the most common treatment when you first receive your diagnosis. If this medication doesn't work for you, your healthcare provider may switch to a biologic medication or add additional DMARDs to your treatment plan.

How Rheumatoid Arthritis Progresses

Rheumatoid arthritis progression can vary from person to person. For a few people who have pre-RA, joint pain may occur for a little while and then go away. When RA is fully established, symptoms will likely worsen over time.

Some people with established RA eventually develop advanced RA, because the repeated inflammation has permanently damaged their joints. This is much less common than it used to be, because of access to more modern treatments.

How To Slow the Progression

To slow down the progression of RA, healthcare providers offer treatments that help reduce the frequency and severity of flares. This generally requires taking one or more DMARDs to help alleviate symptoms. It’s important to start DMARD medications for RA as soon as possible. Early treatment can help reduce present symptoms and prevent long-term joint damage and disease progression.

You might need to try several different medications before you find the combination that works best for you. This process may be frustrating, but staying the course and finding the medication that's right for you can improve symptoms in the long run and reduce your risk of complications.

Your healthcare provider will assess the effectiveness of your treatment by using blood tests and imaging scans. It's also important to communicate with your healthcare provider if you still have symptoms despite taking medications to treat them. The information your body gives you might not always be accessible on a medical test, so speak up and advocate for yourself (or a loved one) if the treatment isn't helping.

How To Manage Rheumatoid Arthritis

Living well with RA is possible. You can use a variety of approaches to reduce pain, increase your ability to do the things you love and improve your quality of life. Your healthcare provider may recommend the following strategies:

• Try physical therapy to help relieve pain, increase mobility and strength, and help you move better
• See an occupational therapist to learn about orthopedic supports and assistive devices that can help you continue doing daily activities
• Talk to a mental health provider for guidance on how to reduce stress, get enough sleep, and eat nutritious foods that can offer anti-inflammatory effects
• Use other pain relief methods such as over-the-counter painkillers, heat therapy, massages, and acupuncture
• Move your body gently with activities like tai chi or yoga

When lifestyle changes and medications aren't improving your symptoms, it's important to talk to your healthcare provider about other options. Your provider may recommend surgery, especially if you have advanced RA. There are several surgeries available and the type you need will depend on your symptoms and disease severity.

When to Contact a Healthcare Provider

Seeing a healthcare provider for joint pain is an essential way to protect your overall joint and bone health—not to mention your emotional well-being.

If you’ve been officially diagnosed with RA, you’ll need to see a healthcare provider regularly. During these appointments, talk to your provider about your symptoms, how well your treatment is working, and if you experience any flares. They can adjust your treatment plan and offer other recommendations to improve symptoms.

It's also important to see your provider if you haven't received a diagnosis for RA but experience unexplained joint pain. While several other conditions can cause joint or muscle pain, you may also be experiencing an early stage of RA that can benefit from early treatment.

A Quick Review

Rheumatoid arthritis (RA) is an autoimmune disorder that damages the joints over time through repeated bouts of inflammation. Symptoms of RA can often depend on what stage of the disease you're in—whether that's early stage, established stage, or advanced stage.

DMARD medications can help improve symptoms at any stage. Getting treatment early and following your medication plan as advised can help reduce symptoms and prevent complications.