Rheumatoid arthritis (RA) is a systemic autoimmune disease that affects the joints and is characterized by inflammation. The intensity of symptoms varies among people. Age, gender, heredity, and environmental exposure to things like air pollution, smoking cigarettes, and work-related risks are risk factors for RA. Reducing pain and preventing or delaying more joint degeneration are the main objectives of treatment for RA because there is no complete cure for this.In many cases, rheumatoid arthritis results in permanent disability since it affects not just the joints but also the internal organs.

Reducing joint pain and inflammation, optimizing joint function, and avoiding joint deformity and destruction are the objectives of RA treatment. Combinations of medication, weight-bearing exercise, illness education, and rest are used in treatment plans.

These are the main classifications of medications:

• DMARDS- disease-modifying anti-rheumatic drugs
• Glucocorticoids
• NSAIDs- Nonsteroidal anti-inflammatory drugs
• Analgesics
• Biologic response modifiers 

First line management

NSAIDS and Corticosteroids

First-line therapy aims to reduce inflammation and relieve discomfort generally.NSAIDs such as acetylsalicylate (Aspirin), naproxen (Naprosyn), ibuprofen (Advil and Motrin), and etodolac (Lodine), are medications that are regarded as fast-acting. Due to its ability to block prostaglandins, aspirin works well as an anti-inflammatory for RA in large dosages. High doses of aspirin can cause gastrointestinal discomfort, tinnitus, and hearing loss. Nausea, stomach pain, ulcers, and gastrointestinal bleeding are typical adverse effects.

Steroids

Corticosteroids are a more potent anti-inflammatory medicine than NSAIDs, but they have more side effects. As a result, they should only be administered briefly and at low doses during RA flare-ups or exacerbations.Examples of steroids are:

• Tablets and liquids –
• Injections – Methylprednisolone.
• Inhalers – Beclometasone and fluticasone.
• Creams, lotions and gels – Hydrocortisone for skin.
• Nasal sprays – Beclometasone and fluticasone.

Corticosteroid injections can be used to treat localized inflammatory conditions. They can induce immune suppression, weight gain, diabetes, and bone weakness.

Opioid analgesics

While dextropropoxyphene, codeine, and tramadol are examples of mild opioids that may be useful in the short term for managing RA pain, their drawbacks exceed their advantages.

Second line management(DMARDS)

The main goal of second-line therapy is to induce remission by delaying or arresting the progression of joint deformity and destruction. Since medications take weeks or months to start working, they are referred to as slow-acting.

The first medication in the second line is methotrexate.This immunosuppressive medication has adverse effects that include cirrhosis, liver issues, and bone marrow degradation. As a result, regular blood tests are necessary.An antimalarial medication called hydroxychloroqyine or Plaquenil, can be used to treat RA over the long term. Issues with the skin, central nervous system, and gastrointestinal tract are typical adverse effects. When this medication is used in large amounts, it can specifically harm the eyes. Patients using this drug should see an ophthalmologist on a regular basis.

Irritable bowel syndrome is usually treated with a DMARD called sulfasalazine, also known as azilfidine. This DMARD can be used in combination with anti-inflammatory medications to treat RA. Side effects of this medicine include dermatitis, gastrointestinal issues, and central nervous system dysfunction.

Newer medicines

An oral drug called leflunomide reduces RA symptoms and slows the disease’s progression. Hypertension, gastrointestinal distress, liver damage, leukopenia, interstitial lung disease, neuropathy, dermatitis, and bone marrow damage are some of the side effects.
Biological DMARDs, or biologics, are a class of medication that can effectively slow down the advancement of RA-induced joint deterioration. However, the issue of major side effects, like an elevated risk of infections, comes with biologics. Neurologic conditions like lymphoma and multiple sclerosis are other frequent adverse effects.One messenger protein that encourages joint inflammation is tumor necrosis factor. Examples for The biologic drugs tocilizumab (Actemra), adalimumab (Humira), etanercept (Enbrel), and infliximab (Remicade) 

How to taper steroids gradually?

Initial Symptoms (before starting Ayurveda)	Allopathy medicine	Tapering plan	Reduced Symptoms after having Ayurveda medicine
Fatigue Feverish feeling Less appetite Heaviness of body Coating over tongue Joint pain Swelling Constipation	Steroid >40mg	Taper 5-10mg/day every 1-2 weeks	Increased appetite (by 1 week of treatment) No fatigue (1 week) No feverish feeling (3-4 days) Body becomes light (3-4 days) Tongue becomes clear (1 week) Swelling reduces (1 week) Pain reduces (4 weeks) Bowel becomes clear (1 week)
	20-40mg/day	5mg/day every 1-2 weeks
	10-20mg/day	2.5mg/day every 2-3 weeks
	5-10mg/day	1mg/day every 2-4 weeks
	<5mg/day	0.5mg/day every 2-4 weeks

In intial days we administer Deepana pachana medicines then it is followed by bhrihmana line of treatment.The shift from Deepana pachana to brahmana line of management is purely based on the symptoms presented by the patient.so treatment medicine and duration of treatment may change based on person’s condition. patient should follow personalized pathya apathyas which are recommended during treatment .Otherwise, you will not get the desired result properly on time.

How ayurveda can be a substitute in such cases?

There are numerous negative effects to the drugs used in allopathy for RA.If a patient comes to Sree Subhramania Ayurveda Nursing Home with these adverse effects, the doctor recommends gradually reducing the dose. Suddenly discontinuing medication might induce withdrawal symptoms such as physical discomfort, nausea, and exhaustion.Long-term usage of allopathic medications may conceal symptoms and result in Agnimandya. So, once we reduce the steroid dose, we administer Deepana pachana drugs to correct the agnimandhya, which is the first step in naturally rectifying the body’s metabolism. Later, we give a personalized therapy that includes herbal internal medication and panchakarma therapies to fully address the problem.