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Sock's Toxicity And Drugs In RA:
Treatment
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There is no known cure for rheumatoid arthritis. To date, the goal of treatment in rheumatoid arthritis is to reduce joint inflammation and pain, maximize joint function, and prevent joint destruction and deformity. Early medical intervention has been shown to be important. Optimal treatment for the disease involves a combination of medications, rest, joint strengthening exercises, joint protection, and patient (and family) education.
 
Treatment is customized according to many factors such as disease activity, types of joints involved, general health, age, and patient occupation. Treatment is most successful when there is close cooperation between the doctor, patient, and family members.
 
Two classes of medications are used in treating rheumatoid arthritis: fast-acting "first-line drugs," and slow-acting "second-line drugs (also referred to as Disease-Modifying Antirheumatic Drugs or DMARDs)." The first-line drugs, such as aspirin and cortisone (corticosteroids), are used to reduce pain and inflammation.
 
The slow-acting second-line drugs, such as gold, methotrexate and hydroxychloroquine (Plaquenil) promote disease remission and prevent progressive joint destruction, but they are not anti-inflammatory agents.
 
The degree of destructiveness of rheumatoid arthritis varies from patient to patient. Patients with less destructive forms of the disease can be managed with rest and anti-inflammatory agents only. In general, however, patients fair better when treated earlier with second-line drugs (disease-modifying antirheumatic drugs), even within months of the diagnosis.
 
Patients with more aggressive disease require second-line drugs, such as methotrexate, in addition to anti-inflammatory agents. Sometimes these second-line drugs are used in combination. In some patients with severe joint deformity, surgery may be necessary.
 
"First-line" Drugs: Acetylsalicylate (Aspirin), naproxen (Naprosyn), ibuprofen (Advil, Medipren, Motrin), and etodolac (Lodine) are examples of nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs are medications that can reduce tissue inflammation, pain and swelling. NSAIDs are not cortisone.
 
Aspirin, in doses higher than that used in treating headaches and fever, is an effective antiinflammatory medication for rheumatoid arthritis. Aspirin has been used for joint problems since the ancient Egyptian era.
 
The newer NSAIDs are just as effective as aspirin in reducing inflammation and pain, and require fewer dosages per day. Patients' responses to different NSAID medications vary. Therefore, it is not unusual for a doctor to try several NSAID drugs in order to identify the most effective agent with the fewest side effects.
 
The most common side effects of aspirin and other NSAIDs include stomach upset, abdominal pain, ulcers, and even gastrointestinal bleeding. In order to reduce stomach side effects, NSAIDs are usually taken with food.
 
Additional medications are frequently recommended to protect the stomach from the ulcer effects of NSAIDs. These medications include antacids, sucralfate (Carafate), protein-pump inhibitors (Prevacid, and others), and misoprostol (Cytotec).
 
While "first-line" medications (NSAIDs and corticosteroids) can relieve joint inflammation and pain, they do not necessarily prevent joint destruction or deformity. Rheumatoid arthritis requires medications other than NSAIDs and corticosteroids to stop progressive damage to cartilage, bone, and adjacent soft tissues.
 
 The medications needed for ideal management of the disease are also referred to as Disease-modifying Anti-rheumatic Drugs or DMARDs. They come in a variety of forms and are listed below. These "second-line" or "slow-acting" medicines may take weeks to months to become effective. They are used for long periods of time, even years, at varying doses. If effective, DMARDs can promote remission, thereby retarding the progression of joint destruction and deformity.
 
Sometimes a number of second-line medications are used together as combination therapy. As with the first-line medications, the doctor may need to use different second-line medications before treatment is optimal.
 
Hydroxychloroquine (Plaquenil) is related to quinine, and is also used in the treatment of malaria. It is used over long periods for the treatment of rheumatoid arthritis. Possible side effects include upset stomach, skin rashes, muscle weakness, and vision changes. Even though vision changes are rare, patients taking Plaquenil should be monitored by an eye doctor (ophthalmologist).
 
Sulfasalazine (Azulfidine) is an oral medication traditionally used in the treatment of mild to moderately severe inflammatory bowel diseases, such as ulcerative colitis and Crohn's colitis. Azulfidine is used to treat rheumatoid arthritis in combination with antiinflammatory medications. Azulfidine is generally well tolerated. Common side effects include rash and upset stomach. Because Azulfidine is made up of sulfa and salicylate compounds, it should be avoided by patients with known sulfa allergies.
 
Methotrexate has gained popularity among doctors as an initial second-line drug because of both its effectiveness and relatively infrequent side effects. It also has an advantage in dose flexibility (dosages can be adjusted according to needs). Methotrexate is an immune suppression drug. It can affect the bone marrow and the liver, even rarely causing cirrhosis. All patients taking methotrexate require regular blood test monitoring of blood counts and liver function blood tests.
 
Gold salts have been used to treat rheumatoid arthritis throughout most of the past century. Gold thioglucose (Solganal) and gold thiomalate (Myochrysine) are given by injection, initially on a weekly basis for months to years.
 
Oral gold, auranofin (Ridaura) was introduced in the 1980's. Side effects of gold (oral and injectable) include skin rash, mouth sores, kidney damage with leakage of protein in the urine, and bone marrow damage with anemia and low white cell count. Patients receiving gold treatment are regularly monitored with blood and urine tests. Oral gold can cause diarrhea. These gold drugs have lost such favor that many companies no longer manufacture them.
 
D-penicillamine (Depen, Cuprimine) can be helpful in selected patients with progressive forms of rheumatoid arthritis. Side effects are similar to those of gold. They include fever, chills, mouth sores, a metallic taste in the mouth, skin rash, kidney and bone marrow damage, stomach upset, and easy bruising. Patients on this medication require routine blood and urine tests. D-penicillamine can rarely cause symptoms of other autoimmune diseases.
 
Immunosuppressive medicines are powerful medications that suppress the body's immune system. A number of immunosuppressive drugs are used to treat rheumatoid arthritis. They include methotrexate (Rheumatrex, Trexall) as described above, azathioprine (Imuran), cyclophosphamide (Cytoxan), chlorambucil (Leukeran), and cyclosporine (Sandimmune).
 
Because of potentially serious side effects, immunosuppressive medicines are generally reserved for patients with very aggressive disease, or those with serious complications of rheumatoid inflammation, such as blood vessel inflammation (vasculitis).
 
The exception is methotrexate, which is not frequently associated with serious side effects and can be carefully monitored with blood testing. Methotrexate has become a preferred second-line medication as a result.
 
Immunosuppressive medications can depress bone marrow function and cause anemia, a low white cell count and low platelets counts. A low white count can increase the risk of infections, while a low platelet count can increase the risk of bleeding.
 
Methotrexate can also lead to liver cirrhosis and allergic reactions in the lung. Cyclosporin can cause kidney damage and high blood pressure. Because of potentially serious side effects, immuno- suppressive  medications are used in low doses, usually in combination with anti-inflammatory agents

Newer "second-line" drugs for the treatment of rheumatoid arthritis include leflunomide (Arava) etanercept (Enbrel), infliximab (Remicade), anakinra (Kineret), and adalimumab (Humira).
 
Leflunomide (Arava) is available to relieve the symptoms and halt the progression of the disease. It seems to work by blocking the action of an important enzyme that has a role in immune activation. Arava can cause liver disease, diarrhea, hair loss, and/or rash in some patients. It should not be taken just before or during pregnancy because of possible birth defects.
 
Other medications that represent a novel approach to the treatment of rheumatoid arthritis and are the products of modern biotechnology. Etanercept (Enbrel), infliximab (Remicade), and adalimumab (Humira, marketed as of January, 2003) intercept a protein (tumor necrosis factor, or TNF) that causes inflammation before it acts on its natural receptor to "switch on " inflammation.
 
 These medications are referred to as biological response modifiers. Symptoms can be significantly, and often rapidly, improved in patients using these drugs. Etanercept (Enbrel) must be injected subcut-aneously twice a week. Infliximab (Remicade) is given by infusion directly into a vein (intravenously). Adalimumab (Humira) is injected subcutaneously either every other week or weekly.
 
Each of these medications will be evaluated by doctors in practice to determine what role they may have in treating various stages of rheumatoid arthritis. Recent studies demonstrate that biological response modifiers also prevent the progressive joint destruction of rheumatoid arthritis.
 
They are currently recommended for use after other medications have not been effective. The biological response modifiers (TNF-inhibitors) are expensive treatments. They are also frequently used in combination with methotrexate and other DMARDs.
 
Anakinra (Kineret) is another biologic treatment that is used to treat moderate to severe rheumatoid arthritis. Anakinra (Kineret) works by binding to a cell messenger protein (IL-1, a proinflammation cytokine). Anakinra (Kineret) is injected under the skin daily. Anakinra (Kineret) can be used alone or with other DMARDs.
 
The Prosorba column therapy involves pumping blood drawn from a vein in the arm into an apheresis machine, or cell separator. This machine separates the liquid part of the blood (the plasma) from the blood cells. The Prosorba column is a plastic cylinder about the size of a coffee mug that contains a sand-like substance coated with a special material called Protein A. Protein A is unique in that it binds unwanted antibodies from the blood that promote the arthritis.
 
 The Prosorba column works to counter the effect of these harmful antibodies. The Prosorba column is indicated to reduce the signs and symptoms of moderate to severe rheumatoid arthritis in adult patients with long standing disease who have failed or are intolerant to disease-modifying anti-rheumatic drugs (DMARDs). The exact role of this treatment is being evaluated by doctors.
 
There is no special diet for rheumatoid arthritis. Fish oil may have anti-inflammatory effects, but so far this has only been shown in laboratory experiments studying inflammatory cells. Likewise, the benefits of cartilage preparations remain unproven. Symptomatic pain relief can often be achieved with oral acetaminophen (Tylenol) or over-the-counter topical preparations, which are rubbed into the skin.
 
Antibiotics, in particular the tetracycline drug minocycline (Minocin), have been tried for rheumatoid arthritis recently in clinical trials. Early results have demonstrated mild to moderate improvement in the symptoms of arthritis. Minocycline has been shown to impede important mediator enzymes of tissue destruction, called metalloproteinases, in the laboratory as well as in humans.
 
The areas of the body, other than the joints, that are affected by rheumatoid inflammation are treated individually. Sjogren's syndrome  can be helped by artificial tears and humidifying rooms of the home or office. Regular eye check-ups and early antibiotic treatment for infection of the eyes are important.
 
Inflammation of the tendons (tendinitis), bursae (bursitis) and rheumatoid nodules can be injected with cortisone. Inflammation of the lining of the heart and/or lungs may require high doses of oral cortisone.
 
Proper, regular exercise is important in maintaining joint mobility, and in strengthening the muscles around the joints. Swimming is particularly helpful because it allows exercise with minimal stress on the joints.
Physical and occupational therapists are trained to provide specific exercise instructions and can offer splinting supports. For example, wrist and finger splints can be helpful in reducing inflammation and maintaining joint alignment.
 
Devices, such as canes, toilet seat raisers, and jar grippers can assist daily living. Heat and cold applications are modalities that can ease symptoms before and after exercise.
 
Surgery may be recommended to restore joint mobility or repair damaged joints. Doctors who specialize in joint surgery are orthopedic surgeons. The types of joint surgery range from arthroscopy to partial and complete replacement of the joint.
 
Arthroscopy is a surgical technique whereby a doctor inserts a tube-like instrument into the joint to see and repair abnormal tissues. For more information,( Arthroscopy. )
 
"Total joint replacement" is a surgical procedure whereby a destroyed joint is replaced with artificial materials. For example, the small joints of the hand can be replaced with plastic material. Large joints, such as the hips or knees, are replaced with metals.
 
Finally, minimizing emotional stress can help improve the overall health of the patient with rheumatoid arthritis. Support and extracurricular groups afford patients time to discuss their problems with others and learn more about their illness.
 
Scientists throughout the world are studying many promising areas of new treatment approaches for rheumatoid arthritis. These areas include treatments that block the action of the special inflammation factors, such as tumor necrosis factor (TNFalpha) and interleukin-1 (IL-1), as described above.
 
Many other drugs are being developed that act against certain critical white blood cells involved in rheumatoid inflammation. Also, new NSAIDs with mechanisms of action which are different from current drugs are on the horizon.
 
Studies involving various types of the connective tissue collagen are in progress and show encouraging signs of reducing rheumatoid disease activity. Finally, genetic research and engineering is likely to bring forth many new avenues of earlier diagnosis and accurate treatment in the near future.
 
Rheumatoid arthritis is an autoimmune disease that can cause chronic inflammation of the joints and other areas of the body. Rheumatoid arthritis can affect persons of all ages. The cause of rheumatoid arthritis is not known.
 
Rheumatoid arthritis is a chronic disease, characterized by periods of disease flares and remissions. In rheumatoid arthritis, multiple joints are usually, but not always, affected in a symmetrical pattern.
 
Chronic inflammation of rheumatoid arthritis can cause permanent joint destruction and deformity. The "rheumatoid factor" is an antibody blood test that can be found in 80 % of patients with rheumatoid arthritis.
 
The treatment of rheumatoid arthritis optimally involves a combination of patient education, rest and exercise, joint protection, medications, and occasionally surgery. Perhaps,hopefully,in the near future, scientists  can find a "cure" for RA.

Factors Involved in Treatment:
 
A joint is where two bones meet to allow movement of body parts. Arthritis means joint inflammation. The joint inflammation of rheumatoid arthritis causes swelling, pain, stiffness, and redness in the joints. The inflammation of rheumatoid disease can also occur in tissues around the joints, such as the tendons, ligaments, and muscles. In some patients with rheumatoid arthritis, chronic inflammation leads to the destruction of the cartilage, bone and ligaments causing deformity of the joints.
 
Some scientists believe that the tendency to develop rheumatoid arthritis may be genetically inherited. It is suspected that certain infections or factors in the environment might trigger the immune system to attack the body's own tissues, resulting in inflammation in various organs of the body such as the lungs or eyes.
 
Regardless of the exact trigger, the result is an immune system that is geared up to promote inflammation in the joints and occasionally other tissues of the body. Immune cells, called lymphocytes, are activated and chemical messengers (cytokines, such as tumor necrosis factor/TNF and interleukin-1/IL-1) are expressed in the inflamed areas. 
    
The symptoms of rheumatoid arthritis come and go, depending on the degree of tissue inflammation. When body tissues are inflamed, the disease is active. When tissue inflammation subsides, the disease is inactive (in remission). Remissions can occur spontaneously or with treatment, and can last weeks, months, or years.
 
During remissions, symptoms of the disease disappear, and patients generally feel well. When the disease becomes active again (relapse), symptoms return. The return of disease activity and symptoms is called a flare. The course of rheumatoid arthritis varies from patient to patient, and periods of flares and remissions are typical.
 
When the disease is active, symptoms can include fatigue, lack of appetite, low grade fever, muscle and joint aches, and stiffness. Muscle and joint stiffness are usually most notable in the morning and after periods of inactivity. Arthritis is common during disease flares.
 
During flares, joints frequently become red, swollen, painful, and tender. This occurs because the lining tissue of the joint (synovium) becomes inflamed, resulting in the production of excessive joint fluid (synovial fluid). The synovium also thickens with inflammation (synovitis).
 
In rheumatoid arthritis, multiple joints are usually inflamed in a symmetrical pattern (both sides of the body affected). The small joints of both the hands and wrists are often involved. Simple tasks of daily living, such as turning door knobs and opening jars can become difficult during flares.
 
The small joints of the feet are also commonly involved. Occasionally, only one joint is inflamed. When only one joint is involved, the arthritis can mimic the joint inflammation caused by other forms of arthritis such as gout or joint infection.
 
Chronic inflammation can cause damage to body tissues, cartilage and bone. This leads to a loss of cartilage and erosion and weakness of the bones as well as the muscles, resulting in joint deformity, destruction, and loss of function.
 
Rarely, rheumatoid arthritis can even affect the joint that is responsible for the tightening our vocal cords to change the tone of our voice, the cricoarytenoid joint. When this joint is inflamed, it can cause hoarseness of voice.
 
Since rheumatoid arthritis is a systemic disease, its inflammation can affect organs and areas of the body other than the joints.
 
Inflammation of the glands of the eyes and mouth can cause dryness of these areas and is referred to as Sjogren's syndrome.
 
Rheumatoid inflammation of the lung lining (pleuritis) causes chest pain with deep breathing or coughing. The lung tissue itself can also become inflamed and sometimes nodules of inflammation (rheumatoid nodules) develop in the lungs.
 
Inflammation around the heart (pericarditis) causes chest pain which changes when lying down or leaning forward. The disease can reduce the number of red blood cells (anemia), and white blood cells.
 
Decreased white cells can be associated with an enlarged spleen (referred to as Felty's syndrome) and can increase the risk of infections.
 
Firm lumps under the skin (rheumatoid nodules) can occur around the elbows and fingers where there is frequent pressure. Even though these nodules usually do not cause symptoms, occasionally they can become infected.
 
A rare, serious complication, usually with long-standing rheumatoid disease, is blood vessel inflammation (vasculitis). Vasculitis can impair blood supply to tissues and lead to tissue death. This is most often initially visible as tiny black areas around the nail beds or as leg ulcers.

A advice I received from a friend : Don't do like I first,did,and waste your time and your money on too many of over-the-counter vitamins and supplements. Make sure you get good medical care combined with exercise. Keep company with those who make you feel better. Make sure you're around people who care. I have a wonderfully supportive family, and that's what keeps me going.
 
The ability for people to actually work with their physicians and take on some of the responsibility of managing their disease on their own shoulders. I know in my own experience I have regular visits with my rheumatologist and my orthopedic surgeon, but all the other time in between those visits pretty much the care is left on my shoulders. I have really worked very hard in conjunction with my medical professionals to develop my overall plan, and I think that if people can do that and learn to cooperate their care and manage it on a day-to-day basis, then the years and decades will become much easier.
 
Fatigue ;Well, I think one of the things that has helped me the most is really is to pay attention to what causes the fatigue, and then be very good at scheduling your time or managing your time and plan ahead. Don't try to take on too much, but just take on little bits at a time, building up to a bigger assignment or something. In other words, just sort of segment your time out, and that way you won't have too much to do all at one time and become overly fatigued.
 
It's an ongoing battle, and when you wake up in the morning and you just think, "I can't do it," it's your attitude, and you have to say, "I can." And it's just amazing once you do those sit-ups or that walk or whatever how you are able to function and never give up that hope that you can function.
 
Sadness is an experience that all of us feel from time to time, usually having to do with some disappointment or some loss. That will interrupt a person's mood intermittently, but gradually they get back to functioning in a normal sense.
 
If someone is beginning to develop a depressive illness, some of the biological things that happen are sleep begins to be interfered with, eating habits change, and interest in every-day-life diminishes. Usually the normal things that the patient is able to be involved in don’t seem as important.
 
They have decreased concentration, and they often feel irrationally guilty and ruminate about things. They're tearful; they're crying; they feel more irritable. And, in an extreme sense, ther are people who are worried about self-destruction but yet afraid to mention that to anyone that they're close to or to their physician.
 
Getting support from family members and friends is very important. Often, feeling understood gratifies people so much - they feel like other people care about them. It's often very important that they discuss the frustration and the depression with their physician. The doctor may suggest that they see someone like a psychiatrist so they can have an opportunity to really pour their heart out about what's troubling them and what they're frightened of.
 
The other thing that needs to be considered is the use of antidepressant medication, though not necessarily right away. This often can be quite helpful in lifting someone's mood and also can be helpful in terms of pain control even though it doesn't necessarily do anything for the underlying arthritis process. 
 
Not everyone needs a antidepressant,it depends on their coping skills. It depends on what their previous history has been. If you have someone who has never been ill and all of a sudden has this diagnosis mentioned to them, the way that they react to it will often reflect how they've dealt with other traumas in their life.
 
If there is someone who has had multiple illnesses, this additional illness can often give them an overwhelming sense of "What's going to happen to me?" and a complete loss of control. People like to feel like they're in control of themselves and in control of their health. When this starts to be preyed upon, everyone feels a little bit of loss of self and somewhat of a loss of self-esteem. But we're talking about degrees here.
 
People living with rheumatoid arthritis have normal life stresses, as we all do, but we know that one symptom of stress is muscle tension. As these muscles in rheumatoid arthritis patients pull on the ligaments, the joints, and the tendons, they decrease mobility. This can lead to more pain, more depression, and more stress.
 
When a patient has an illness that's grossly interfering with their functioning, the important thing is to try and find an area where the patient can feel some gain in what's happening - so they feel like some form of control is coming back into their life. That often helps the mood. "At least I was able to do this much today. If I practice this, maybe by next week I'll be able to do a little bit more."
 
There's a sense of pride and self-esteem in trying. There's a sense of gaining something over the illness. I think those things are helpful. Learn to relax. I believe stress does have an impact on my symptoms, and I try to control that by exercise and proper diet and enough rest, and when I do fill my days too full, I do find that I get overly tired.
 
I do have to stop sometimes and get just a little extra rest. And when I do get overly stressed, I think that the symptom that crops up for me is that I do get a little bit tired. I don't immediately have aches and pains and swelling, but I do feel it a little bit in the fatigue department.
 
People with arthritis are frustrated. They don't want to feel bad. They don't want side effects. They're not sure what to do. So that's where you have to ask the expert. And we really don't have any proof that diet, as a single agent without anything else, does anything to stop arthritis. We wish it did, but it doesn't.
 
Advice I received from my doctor : Whether a good diet in addition to medical care is important, I would never argue. But as a sole therapy, I don't have any proof that it helps except maybe in the smallest minority (people allergic to certain foods ), and I would feel bad if you went in that direction. Why don't you go in the direction of the majority?
 
Remember, you're not committing yourself for life. If you start to feel well, you can always stop it to see if you need it. But that's the perspective. Put it in the same perspective that you would any other decision you'd make in your life about anything else. Where would you go for information? How would you evaluate it? What would you do?
 
The harm with alternative therapies is not what it does to your body, but if you look across at a population study and ask, "How much time from the onset of therapy did it take you to see the doctor to get the diagnosis, and what prevented you from going to the doctor?" the number one thing that sticks out is alternative therapy.
 
The patients who take diet, the patients who take the copper bracelet, stay away from the doctor the longest period of time and don't get a proper diagnosis. That's the harm in strictly, alternative therapies. It doesn't get you to the correct opinion.
 
I'm not saying that it may not have some role in addition to other therapy,( there are many good complementary therapies that are helpful when used in conjunction with conventional medical therapy ) but it keeps you from the doctor.
 
After trying some scientifically unproven,alternative therapy and concluding  that the disease is getting progressively worse,the patient,visits the physician and expect him to  reverse the now,deformed joint. That's what the harm of these things really is. A joint once deformed can't be reversed !

Cooking dinner. Mowing the lawn. Mopping the floor. They may seem minor, but everyday tasks can take a toll on your body. And when your joints are stiff and painful from arthritis, running a household can seem like an overwhelming job. The biggest mistake many people with arthritis make is trying to do everything at once.
 
It's a cycle - they do too much, then they become over-fatigued or cause a flare. Once their energy is back and the pain is gone, they try to make up for lost time - and then they get fatigued again and have another flare.
 
The good news is that you can take many steps to make the work in and around your home easier to manage. Follow these guidelines:
Organize:By planning ahead you can organize your tasks in ways that will conserve energy. For instance, clean one area or floor at a time. If you're doing laundry in the basement, combine tasks that can be done there to avoid hikes up and down the stairs.
 
Ask yourself: How many tasks can I realistically accomplish in this room or on this floor without causing a flare or becoming over-fatigued?
 
Prioritize:Accept the fact that you won’t be able to get everything done in one day. Decide which are the most important tasks to accomplish and focus on them. Other items can wait until another time.
 
Ask yourself: What chores really have to be done now? And what tasks can be delayed?
 
Distribute:Break tasks into smaller segments that can be accomplished over a number of days. For example, carrying laundry can strain your joints. When clothes are wet, they can be heavy and hard to maneuver into the dryer. And if your washer and dryer are in your basement, you can spend a lot of time running up and down the stairs.
 
To ease the strain, do a load of laundry every other day instead of all in one day. Another option -set time limits for yourself. For instance, clean the closet for 30 minutes each day until the job is done.
Ask yourself: How can this job be spread over a number of days?
 
Alternate;Two ways to classify and alternate tasks are:
Light tasks and medium tasks. Alternate light tasks with medium tasks. If you do a heavy task, plan on taking a break after completing it and follow it up with a lighter task. This gives your joints a break and allows you to work longer.
 
Standing tasks and sitting tasks. If you stand up while washing the dishes, then plan on sitting down, when you can, while preparing a meal. This keeps one set of joints from taking all of the strain.
 
Whether you do a chore standing or sitting often is determined by habit. You may be used to folding laundry while standing by your bed, but remember that you can also do it while sitting.
 
Ask yourself: What order should I do these tasks in? ;Pace yourself 
Remember to take regular rest breaks. This doesn't mean you have to lie down and sleep, just make sure to relax the set of joints you just used. Length of rest varies person by person - listen to your body. Stop for a break before you're tired or hurt.
 
Ask yourself: When will I take my breaks? Delegate;Another way to distribute work is to ask for assistance or hire someone to help you. This is especially important with strenuous activities that put stress on your joints and can cause pain and fatigue.
 
Family and friends are good sources for help. Don't forget that even young children can be given regular chores.
 
Ask yourself: Who else can do this task? Duplicate. Keep several sets of cleaning supplies distributed around the house so that you won't have to carry them far. For example, keep a toilet brush and cleanser in each bathroom.
 
Ask yourself: What cleaning supplies do I use in more than one room?
Here are some additional tips for functioning in and around your home. Depending upon which joints are most affected, some tips may be more helpful than others:
 
In the kitchen:Use electric appliances. For instance, use a food processor to do your chopping. Buy prepared foods and convenience items. For example, buy salad mix that is pre-washed and shredded.
Use scissors to open a package instead of tearing it open with your hands. Ask for groceries in a paper versus a plastic bag. You can carry it between your forearm and hip to avoid straining your hands.
 
Plan ahead to avoid multiple last-minute tasks when preparing a large meal. Reduce stress on your joints by placing your mixing bowl on a damp cloth in the sink while you stir. The cloth will keep the bowl from slipping, and holding the spoon like a dagger takes stress off your hands.
 
Use nonstick sprays, foil and disposable baking pans to make cleaning up easier. Use a cart with wheels to move heavy items from one place to another. Buy a cutting board with a gripping surface that holds food firmly as you cut. Use a microwave whenever possible to avoid stooping at the oven. Use hot water to loosen a jar lid and pressure from your palm to open it, or use a jar opener. Buy lightweight pots, pans, bowls and dishes.
 
Around the house:Organize closets and cabinets so that the heavy and most frequently used objects are easy to reach - between the middle of your thigh and shoulder. Insert a dish towel in drawer or door handles to make them easier to pull open.
 
Leave your most frequently used items out on the counter in the kitchen and bathroom and on your dresser in the bedroom. Limit yourself to one major cleaning task a day. Use long-handled tools for reaching.
 
Outside:Gather your tools together in a wheelbarrow so that you're not making several trips back and forth. Use tools that are going to minimize stress on your joints. Examples are ergonomic rakes and shovels. Tape yardsticks onto your gardening utensils so that you won't have to bend over as much to use them.
 
Put pipe insulation tubing around tool handles to make them easier to hold. Leave the hose in the yard instead of dragging it out of storage each time you use it. Put a chair at each end of a garden row. It will help you get up from the ground.
 
Do your gardening in small containers that you can keep at an accessible level or use raised beds. Weed after it rains or the garden has been watered -soft soil means less tugging.

Using assistive devices can make performing many daily activities - such as reading a book, opening a jar or buttoning a jacket -less frustrating. Contact your pharmacy or health care professional for information on ordering these items. Many aids can also be purchased at a medical supply store.
 
Use thick, padded grips. Many kitchen tools are now available with thick, padded handles. You can devise your own creations by wrapping foam tubing, the kind used for pipe insulation, around all kinds of hand-held household items -from toothbrushes, hairbrushes and combs to pens, key rings and kitchen utensils.
 
Learn tricks for turning lids, handles and knobs. The key is leverage - the longer the handle, the less force you need. You can buy extended handles for doorknobs and stove controls, gadgets to open car doors and under-the-counter jar openers that grip a jar’s lid as you physically turn the jar.
 
Use aids to help you dress. These can help if you have trouble bending and reaching. Aids include shoehorns with an extension handle, devices that help you pull up hosiery, shoes you close with Velcro rather than shoelaces and tools that grip buttons and zippers. You can also have elasticized Velcro tabs sewn onto shirt cuffs or have buttons sewn on with elasticized thread. Use a walking stick or cane.

One thing to emphasize is that rheumatoid arthritis is a very complicated and varied disease, so that each individual will present different challenges. In different people there may be different parts of what's causing inflammation so that in some people it may be driven by one factor more than another.
 
In all likelihood it's going to be the exception rather than the rule, where physicians can use a single medication.  With rheumatoid arthritis, since the immune system is so complicated, we should look at it as conducting war.
 
We may be successful in one front and then be losing on another front, so that as in any war we have to fight it on a number of different levels, and that's why physicians may have to use combination therapies.
 
The anti-inflammatories are there to catch any inflammation that breaks through the primary defenses, which are the disease-modifying drugs, and doctors try to use just one, but if that doesn't work, they'll use others, and they work at different levels.
 
Whereas Enbrel inhibits TNF, methotrexate inhibits T-cells so we can attack the immune system - not attack, but control the immune system in a lot of different ways at the same time. But doctors always try to keep it as simple as they can.
 
One important factor overlooked in medication,and efficacy is that there is pain caused by mechanical and inflammatory forces involved. As we grow older there is a lot of mechanical pain caused by on-going degenerative forces ( degenerative osteoarthritis -secondary OA.) Our current conventional and biologic medications aren't going to eliminate that part of the complex pain equation.
 
Many RA patients have this so called "secondary OA" or mechanical problem. We as patients will in all probability will not be able to escape that part of pain. In other words,is pain caused by mechanical,or inflammatory forces. If it a mechanical problem we have to attack the problem in different other ways; exercise,heat,cold,anagesics etc.