The 4 Stages and Progression of Rheumatoid Arthritis

As RA progresses, the body changes. Some changes you can see and feel, while others you cannot. Each stage of RA comes with different treatment goals.

Stage 1

Stage 1 is early-stage RA. Many people feel joint pain, stiffness, or swelling. During stage 1, there’s inflammation inside the joint. The tissue in the joint swells up. For example, when there is stage 1 RA in the hands, a person may feel stiffness and pain in the finger joints and knuckles. These sensations can usually disappear with movement.

When the tissue in the joint swells up, there’s no damage to the bones, but the joint lining (the synovium) is inflamed.

Because symptoms are not obvious during this stage, people who develop RA may not be aware of it initially, and doctors may find it difficult to diagnose it at this stage.

However, if a doctor diagnoses this disease and the person receives appropriate treatment within 12 weeks, there is a good chance that the disease may go into remission.

Stage 2

Stage 2 is moderate-stage RA. In this stage, the synovium’s inflammation causes damage to the joint cartilage and bone. Cartilage is the tissue that covers the end of bones at the joint site. The bone next to where cartilage ends in the joint is the first area that experiences damage due to RA.

When people have cartilage damage, they may experience pain and loss of mobility. The range of motion in the joints may become limited. For example, RA in the hands may show up in the form of stiffness and difficulty bending the fingers.

Despite these symptoms, blood tests may not show any sign of RA antibodies at this stage. The RA antibodies may be negative because a small subset of people with RA are and may remain zero-negative. The most common progression is for RA antibodies to be present years before symptoms develop. This is known as zero-negative RA.

Stage 3

Once RA progresses to stage 3, experts consider it severe. At this point, the damage extends to the cartilage, and bone destruction progresses. Since the cushion between bones wears away, the bones rub together.

There may be more pain and swelling. Some people may experience muscle weakness and more mobility loss.

The bones can experience damage (erosion), and some changes in formation may occur. Examples, which may be permanent, include twisted fingers and thickened knuckles. Other symptoms may include compressed tendons at the wrist, with symptoms of carpal tunnel syndrome or tendon rupture.

The rupture of extensor tendons on the fingers due to synovitis at the wrist is a major risk, but doctors can prevent it if they identify it early.

Stage 4

At stage 4, there’s no longer inflammation in the joint. This is end-stage RA, when joints no longer work as they should.

In end-stage RA, people may still experience pain, swelling, stiffness, and mobility loss. There may be lower muscle strength. The joints may experience destruction, and the bones may fuse (ankylosis).

Depending on the progression and location of the end-stage RA, a person may lose the function of their hands or have a difficult time bending their knees or flexing their hips.

Progression through all four stages can take many years, and some people don’t progress through all stages. Fused bones, or ankylosis, for example, occurs in only 0.8% of all individuals with RA.

Some people have periods of no RA activity. In some cases, this may mean that RA is in remission.

Most people with RA experience a gradual worsening of symptoms. There may be periods of relief, when RA is more manageable. At other times, RA symptoms may flare up and be more intense.

How your condition progresses depends on many factors, including:

• family history of RA
• age at diagnosis
• stage of RA at diagnosis
• any disease triggers that are specific to you
• the presence of certain antibodies in your blood
• whether you smoke or not

By considering these factors, your doctor can help you better understand how your condition is progressing.

However, keep in mind that it’s impossible to predict exactly how RA will progress over time in any person. Even if you have family members with RA, your condition may progress differently from theirs.

The Johns Hopkins Arthritis Center notes that the usual course of RA progression includes flare-ups of high disease activity. Over time, those flare-ups become lengthier and more challenging.

Another common pattern occurs when people experience strong attacks in the early stages of RA, followed by periods with minimal disease activity.

Less than 10% of people with RA fall into spontaneous remission within the first 6 months of the onset of their symptoms. Remission from RA has a precise medical definition.

In general, it means that RA disease activity stops. People with RA who do not demonstrate the disease markers anti-cyclic citrullinated peptide antibody and rheumatoid factor have a greater chance of remission.

When treating RA, your doctor will consider different medication options and recommend a treatment plan for you.

Your treatment plan will depend on:

• the stage of RA
• your symptom severity and degree of inflammation
• how long you’ve been living with RA
• whether you have other medical conditions, such as heart disease

Common treatments for RA perform different roles:

• Nonsteroidal anti-inflammatory drugs and steroids can reduce inflammation.
• Disease-modifying antirheumatic drugs can help protect joint tissue by suppressing your body’s immune and inflammatory responses, which slows RA progression.
• Biologic drugs work specifically on the immune system to change the body’s inflammatory response.
• Surgery may be an option in later stages of RA.

The goal of surgery may be to:

• improve day-to-day functioning
• reduce pain
• repair damage caused by RA

Surgery may:

• remove the synovium or nodules
• repair tendons
• fuse joints
• replace a joint entirely

Lifestyle is another aspect of managing RA. Your doctor may recommend certain lifestyle choices to complement your treatment plan, including:

• exercising moderately
• keeping stress in check
• maintaining a moderate weight
• eating an anti-inflammatory diet
• smoking cessation programs

Remission in RA involves periods of little to no disease activity, and sometimes no RA-related antibodies are in blood tests. If this period lasts more than a few months, experts consider it sustained remission.

The frequency of sustained remission in RA has been low, but it’s increasing over time. Current rates of remission range from 10% to 60% or more.

Sustained remission, and especially minimal-medication remission, include better outcomes for day-to-day function and survival.

Currently, there’s no standard definition of sustained remission. Criteria that experts generally use to determine remission in clinical trials include:

• fewer than one swollen or tender joint
• scored on a 0 to 10 scale, related arthritis activity is 1 or less, self-reported by the person living with RA
• little or no increase in levels of C-reactive protein, a marker of inflammation

A combination of early diagnosis and targeted treatment can give you the best chance of sustained remission. Once you meet the sustained remission criteria, your doctor will work with you to determine if and when they recommend a reduction in medication.

RA is a progressive disease, but it doesn’t progress the same way in all people.

Treatment options and lifestyle approaches can help you manage RA symptoms and slow or even prevent disease progression.

Your doctor will develop a personalized plan for you based on your symptoms and other factors.

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