Nearly 18 million people worldwide live with rheumatoid arthritis, including more than 1.3 million in the United States. The chronic autoimmune disease causes the immune system to mistakenly attack the body’s own joint tissues, and through widespread inflammation, it can also damage major organs.

Rheumatoid arthritis, which has no known cure, is a major contributor to disability among older adults and can shorten life expectancy by six to seven years when inadequately managed. However, arthritis-related disability is largely preventable and treatable when identified early.

Most people associate arthritis with joint pain, but symmetry is the hallmark of rheumatoid arthritis, meaning the same joints on both sides of the body are typically affected.

Early symptoms of rheumatoid arthritis include:

• Symmetrical joint pain and stiffness


• Morning stiffness of the joints lasting at least an hour


• Tenderness and swelling in the joints

As the disease progresses, symptoms might include a decreased range of motion and visible joint deformities.

About 40 percent of people with rheumatoid arthritis also develop systemic signs and symptoms, especially during disease flares. These may include:

• Persistent fatigue


• Low-grade fever


• Unintended weight loss


• Skin nodules


• Digestive issues


• Difficulty sleeping


• Inflammation affecting the lungs, heart, blood vessels, kidneys, and nerves

In rheumatoid arthritis, genetics and environmental triggers activate immune cells and autoantibodies that attack the synovium, or joint lining. The inflamed synovium thickens into an abnormal tissue called pannus. Both the pannus and autoantibodies drive the release of inflammatory cytokines and tissue-destroying enzymes that damage cartilage and bone. This leads to joint space narrowing, pain, stiffness, reduced mobility, and systemic inflammation.

Rheumatoid arthritis often begins in the small joints of the hands, wrists, and feet, but it can involve any joint with a synovial membrane, including the shoulders, knees, and elbows.

1. Genetic Factors

The exact cause of rheumatoid arthritis is not yet fully understood. Genetics accounts for roughly 50 percent to 60 percent of rheumatoid arthritis risk, with numerous genetic variants identified. However, genes alone do not cause rheumatoid arthritis. Environmental triggers can activate these genes through epigenetic changes—molecular switches that turn genes on or off—creating a pathway from exposure to disease.

2. Environmental Triggers

Environmental triggers that have been linked to rheumatoid arthritis include:

Smoking and Secondhand Smoke

Smoking is a well-established environmental trigger for rheumatoid arthritis. It promotes citrullination, a chemical change in proteins—particularly in the lungs—that can provoke an immune response. This immune response can develop years before the first symptoms of rheumatoid arthritis appear. Both active smoking and secondhand smoke exposure, especially during childhood, increase rheumatoid arthritis risk and worsen disease severity.

Oral Health and Gum Disease

Chronic gum disease is closely associated with rheumatoid arthritis. The bacterium Porphyromonas gingivalis, commonly found in periodontitis, can trigger citrullination and the production of osteoclasts, cells that break down bone tissue. This creates a direct pathway from oral inflammation to joint inflammation.

Microbiome Disruption

The gut houses most of the immune system, and disruption of beneficial bacteria, or dysbiosis, in the gut or mouth can trigger immune dysfunction. Dysbiosis is seen in rheumatoid arthritis and can amplify inflammation, increase gut permeability, and allow bacterial fragments to enter the body, triggering immune reactions that help perpetuate the disease process.

Infections

Certain infections have been associated with rheumatoid arthritis development, including Epstein-Barr virus and SARS-CoV-2. Some studies also report higher rates of new rheumatoid arthritis cases in the year after Lyme disease. These infections may confuse the immune system, causing it to mistake the body’s own tissues for parts of the virus or bacteria—a phenomenon called molecular mimicry.

Inflammatory Diet

A diet high in ultra-processed foods, refined sugars, unhealthy fats, and salt promotes chronic inflammation and increases gut permeability, also known as “leaky gut.” This allows bacterial fragments into the bloodstream and amplifies inflammation. It can also disrupt the gut microbiome.

Vitamin D Deficiency

Insufficient sunlight exposure leading to low vitamin D levels is consistently associated with increased rheumatoid arthritis risk and disease severity. Vitamin D plays a key role in immune regulation, and deficiency leads to suboptimal immune function, allowing unchecked inflammation that can trigger rheumatoid arthritis.

Chronic Stress

Long-term psychological stress disrupts immune regulation and drives persistent inflammation. It raises pro-inflammatory cytokines and can make the immune system less responsive to the body’s natural anti-inflammatory signals, creating conditions that may promote autoimmune activity.

Hormonal Changes

Rheumatoid arthritis frequently emerges or worsens during hormonal shifts in women, including postpartum, perimenopause, and menopause. Estrogen and progesterone influence immune responses, and their fluctuation may activate autoimmune processes.

Toxic Exposures

Harmful environmental substances—including air pollution such as particulate matter and diesel exhaust; silica dust from mining, construction, or stonework; heavy metals; pesticides; and industrial chemicals—have been linked to increased rheumatoid arthritis risk and severity. These toxic exposures can cause oxidative stress, lung and airway inflammation, and immune activation.

Risk Factors

While the triggers above can directly initiate rheumatoid arthritis, the following characteristics increase the likelihood of developing it:

• Obesity: Research shows that excess body fat, especially around the abdomen, raises the risk of rheumatoid arthritis, worsens symptoms, increases disease activity, and may impair the response to certain medications. Body fat also releases chemicals that fuel inflammation, alter hormone balance, and put added stress on joints.


• Socioeconomic Status: Lower income and education levels are associated with increased rheumatoid arthritis risk, perhaps reflecting differences in smoking, workplace exposures, and stress.


• Sex: Women are about three times more likely to develop rheumatoid arthritis than men.


• Age: Rheumatoid arthritis can occur at any age, but most diagnoses occur between ages 30 and 50.


• Family History: Having a first-degree relative with rheumatoid arthritis increases the risk by about four times.


• Autoimmune Diseases: Having another autoimmune disease also raises the likelihood of developing rheumatoid arthritis. These conditions share a common underlying mechanism and have been observed in clinical studies to cluster together in the same person.

Arthritis simply means inflammation of the joints, but this single word covers more than 100 different conditions. Rheumatoid arthritis is one of the more common and impactful types. It differs from osteoarthritis, which is primarily a degenerative joint disease driven by wear and tear rather than an immune system attack.

Because rheumatoid arthritis is an autoimmune disease, autoantibodies would typically be expected on blood tests. However, in about one-third of people with rheumatoid arthritis, these antibodies are not present. This difference divides rheumatoid arthritis into two types: seropositive rheumatoid arthritis (with autoantibodies) and seronegative rheumatoid arthritis (without detectable autoantibodies). The seropositive type may be more aggressive and more likely to cause symptoms outside the joints.

Diagnosing rheumatoid arthritis involves combining a physical examination with targeted blood tests and imaging studies. It also requires ruling out other conditions with similar symptoms, such as psoriatic arthritis or lupus.

Doctors often use a standardized point system that considers joint involvement, blood markers, and symptom duration. In this system, a score of six or higher supports a diagnosis of rheumatoid arthritis.

Blood Tests

Blood tests help confirm a rheumatoid arthritis diagnosis, assess disease activity, and monitor how well treatments are working over time.

• Antibodies: The most clinically useful blood tests are rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibodies (anti-CCP). RF targets the body’s own antibodies, while anti-CCP targets citrullinated proteins and is more specific for rheumatoid arthritis. Anti-CCP may appear years before symptoms begin.


• Inflammatory Markers: C-reactive protein and erythrocyte sedimentation rate measure systemic inflammation to help assess disease activity, though high levels can also occur with other inflammatory conditions.


• Complete Blood Count (CBC): A CBC with differential checks red and white blood cells and platelets to detect complications or rule out other issues. Many people with rheumatoid arthritis develop anemia because inflammatory cytokines suppress red blood cell production and affect iron metabolism.

Imaging

Imaging studies help identify characteristic signs of rheumatoid arthritis, including symmetrical joint damage, bone thinning around the joints, joint space narrowing, swelling, cysts, and nodules. The following tools may be used:

• X-rays: Widely available and low cost, but less sensitive for early disease.


• Ultrasonography: More sensitive for early erosions and can show active inflammation.


• CT Scan: Rarely used due to radiation exposure, but offers high-resolution 3D imaging.


• MRI Scan: Most accurate for early detection and identifying bone marrow inflammation.

Functional Medicine Tests

Some functional medicine practitioners may use additional testing to identify underlying causes and guide personalized treatment plans. These may include comprehensive stool analysis to assess gut bacterial imbalances, vitamin D testing, heavy metal testing, hormone testing, food sensitivity testing, and methylation testing to evaluate how well the body handles detoxification and other key processes.

Treatment for rheumatoid arthritis should be personalized, based on the stage of disease, and started as early as possible. Many practitioners now use a treat-to-target strategy, setting a clear goal—usually remission or low disease activity—and adjusting treatment regularly until that goal is reached and maintained.

First-Line Therapies

Conventional first-line treatment for rheumatoid arthritis typically follows a stepped approach, starting with medications that manage pain and inflammation and progressing to drugs that slow disease activity.

• Pain Relief: Acetaminophen helps with pain but does not reduce inflammation.


• Anti-Inflammatory Drugs: Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen help reduce pain and inflammation.


• Steroids: Glucocorticoids such as prednisone can quickly suppress immune responses and inflammation and are often used short-term or during flares.


• Traditional disease-modifying anti-rheumatic drugs (DMARDs): DMARDs such as hydroxychloroquine, methotrexate, leflunomide, and sulfasalazine slow disease progression and may be used alone or in combination with biologics. These may take two to three months or longer to work.

Biologic and Targeted Therapies

If first-line therapies fail to control rheumatoid arthritis, treatment may progress to therapies that modify the disease process.

• Biologics: These medications block specific immune targets involved in rheumatoid arthritis, such as TNF, IL-6, B cells, or T-cell activation. Examples include etanercept, adalimumab, tocilizumab, rituximab, and abatacept.


• Targeted Synthetic DMARDs: Janus kinase inhibitors such as tofacitinib and baricitinib disrupt intracellular signaling pathways that drive inflammation.

Side effects of rheumatoid arthritis medications—from first-line drugs to biologic and targeted therapies—vary but may include a higher infection risk, liver dysfunction, blood abnormalities, gastrointestinal or respiratory symptoms, and neurological effects.

Supportive Care

Supportive care focuses on preserving joint function, reducing pain and fatigue, and improving daily quality of life alongside medical treatment.

Physical Therapy: Exercise programs, mobility training, and stretching or strengthening routines can improve joint function, reduce pain and fatigue, and support a better quality of life. Supervised therapy is especially helpful in moderate to severe cases.

Occupational Therapy: Occupational therapy supports joint protection, energy conservation, daily living, and independence. Splints and assistive devices may reduce pain and improve mobility.

Surgery: Surgery may be necessary in severe cases to repair or replace damaged joints.

Traditional and Complementary Treatments

Other treatments that have been studied for their potential effects on inflammation and joint symptoms in rheumatoid arthritis include the following:

• Tripterygium Wilfordii, or Thunder God Vine, used in traditional Chinese medicine (TCM), has demonstrated anti-inflammatory and immunomodulatory effects in rheumatoid arthritis.


• Wuweiganlu extract, a Tibetan medicine, has been shown to reduce joint inflammation and damage.


• Research indicates that acupuncture may help reduce pain and stiffness and improve function in rheumatoid arthritis.

Like other medical treatments, these TCM and Tibetan therapies come with potential risks and side effects, and should only be used under the supervision of a qualified practitioner.

While medications for rheumatoid arthritis can be life-saving and essential for preventing joint damage, they do not address the underlying factors contributing to immune dysregulation. Identifying and addressing the root causes through natural approaches may support better long-term outcomes and improved overall health.

Natural approaches for rheumatoid arthritis include targeted dietary strategies, evidence-based supplementation, gut-health support, and lifestyle modifications such as stress reduction, physical activity, and maintaining a healthy weight.

Dietary Modifications

An anti-inflammatory, high-fiber diet is one of the most effective ways to support immune balance, reduce disease activity, and improve the microbiome in rheumatoid arthritis. Two dietary approaches in particular have shown benefit:

1. Mediterranean Diet

​The Mediterranean diet emphasizes extra‑virgin olive oil, vegetables, beans, whole grains, and fatty fish. Several trials show it can lower disease activity and improve function over about three months.

2. Probiotics and Fermented Foods

Fermented foods such as yogurt, kefir, kimchi, and raw sauerkraut provide beneficial microbes. Prebiotic fibers, found in foods such as garlic, onions, and bananas, help nourish these microbes and support healthy microbial balance.

While certain probiotic strains may lower inflammation and help modulate the immune response, other strains may worsen symptoms. Therefore, supplementation should be guided by a qualified practitioner and informed by stool testing to assess a person’s microbial balance.

Foods to Avoid

Certain foods can increase inflammation, promote gut dysbiosis, or contribute to weight gain, which can worsen joint pain. For example, gluten—even in those without celiac disease—can increase intestinal permeability and immune activation. Research suggests a gluten‑free diet may reduce antibodies, improve symptoms, and lower disease activity in some people with rheumatoid arthritis.

Evidence on conventional dairy is mixed, but antibodies to milk may cross‑react with rheumatoid arthritis-related antibodies in some people and increase disease activity. Other foods commonly associated with increased inflammation include:

• Processed foods


• Sugary foods and baked goods


• Fried foods and trans fats


• Seed oils


• Excess salt


• Red and processed meats


• Alcohol

Beneficial Nutrients and Compounds

Several nutrients and botanicals have demonstrated benefits for reducing rheumatoid arthritis symptoms, lowering inflammatory markers, and supporting immune balance.

• Borage Oil: Borage oil is rich in gamma-linolenic acid with anti-inflammatory effects and, in some studies, has shown benefits comparable to NSAIDs.


• Fish Oil: The omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) found in fish oil can reduce pain, morning stiffness, and inflammatory cytokines.


• Polyphenols: Compounds such as curcumin, quercetin, resveratrol, and epigallocatechin-3-gallate (EGCG) from green tea help regulate immune activity and provide antioxidant support.


• Boswellia: Resin from Boswellia serrata has demonstrated anti-inflammatory and analgesic effects in rheumatoid arthritis, including reduced pain and swelling and improved joint function.


• Ginger: Ginger has anti-inflammatory properties and has shown evidence for reducing disease activity.


• Vitamin D: Vitamin D plays a key role in immune function; deficiency is common in rheumatoid arthritis and is associated with increased disease activity.


• Antioxidants: Selenium, zinc, and vitamins A, C, and E help counter oxidative stress, which contributes to joint damage.


• Bone-Support Nutrients: Calcium, magnesium, and vitamins D and K help maintain bone density and counter bone loss from rheumatoid arthritis and long-term steroid use.

Nutrients That Support Gut Barrier Integrity

Several nutrients can support intestinal lining repair, reduce permeability, and help restore immune balance. With professional guidance, these can be obtained through diet or supplementation, and include:

• Glutamine: An amino acid found in protein-rich foods such as meat, fish, and eggs.


• Zinc: A mineral found in oysters, beef, pumpkin seeds, and beans.


• Butyrate: A short-chain fatty acid found in butter and ghee and made when gut bacteria ferment fiber from vegetables and other plant foods.


• Vitamin D: Found in fatty fish and egg yolks and made in the body after sunlight exposure.

Other Supportive Approaches

Several supportive therapies have been studied for their potential to reduce pain and stiffness, improve mobility, or support symptom management in rheumatoid arthritis. These include:

• Yoga: Studies on yoga for rheumatoid arthritis show improvements in pain, stiffness, function, and quality of life.


• Exercise: Regular, low-impact movement such as walking, gentle stretching, or light resistance exercises can improve pain, mobility, and physical function.


• Heat and Cold Therapy: At-home heat applications, such as warm packs or warm showers, may help loosen stiff joints and relax muscles, while cold applications, such as ice packs, may help reduce swelling and numb sharp pain.


• Massage: Research on Swedish massage, aromatherapy massage, and foot reflexology suggests potential benefits for pain reduction and improved function in rheumatoid arthritis.

Many other natural approaches exist, and individual responses vary. Even natural compounds may cause side effects, interact with medications, or be inappropriate for certain conditions. Always consult your health care provider or pharmacist for personalized guidance.

Research shows that mindset influences pain, fatigue, function, and treatment response. It affects how the brain processes pain signals, how the nervous and immune systems respond to stress, and how consistently a person follows through with recommended care.

How rheumatoid arthritis is perceived is linked to different outcomes, even when joint counts and laboratory tests are similar. People who view the condition as highly threatening, uncontrollable, or poorly understood tend to report greater disability and distress. Those who perceive some degree of control, whether personal or treatment-related, generally cope better and participate more actively in their care.

Pain catastrophizing is a pattern of thinking in which pain is interpreted as overwhelming, unmanageable, and likely to worsen. In rheumatoid arthritis, this pattern is linked with higher pain intensity, more anxiety and depression, and greater functional impairment. In contrast, higher self-efficacy, or the confidence that one can manage symptoms and daily tasks despite pain, is associated with less pain and fatigue, better adherence to treatment, and improved function.

Mindset also plays an important role in rheumatoid arthritis-associated fatigue, which is often severe. Several studies show that higher levels of resilience, hope, optimism, and perceived social support are associated with lower fatigue and better quality of life, even after accounting for disease activity.

While rheumatoid arthritis cannot always be prevented, addressing known triggers and modifiable risk factors may help lower the risk of developing the disease.

The following approaches may be protective:

• Know Your Personal Risk: In people with a family history of rheumatoid arthritis or other autoimmunity, testing for anti-CCP antibodies may help identify rheumatoid arthritis earlier, when treatment and lifestyle changes have the best chance of preventing or slowing progressive joint damage. Some functional medicine practitioners also use expanded immune-reactivity panels to evaluate broader autoimmune risk.


• Smoking Cessation: Avoiding smoking and secondhand smoke exposure, as smoking is the strongest modifiable environmental risk factor.


• Weight Management: Maintaining a healthy weight to reduce inflammatory burden and joint stress.


• Anti-Inflammatory Diet: Following a dietary pattern that reduces systemic inflammation and supports immune balance.


• Toxic Exposure Avoidance: Minimizing exposure to air pollution and toxic chemicals.


• Vitamin D Optimization: Maintaining adequate vitamin D levels through sunlight exposure, diet, or supplementation.


• Gut Health Support: Supporting healthy microbial balance and gut barrier integrity.


• Stress Management: Using techniques that reduce chronic psychological stress.


• Oral Hygiene: Maintaining good dental health to reduce the risk of periodontal disease.


• Protective Supplementation: Working with a qualified practitioner to identify beneficial nutrients based on individual needs and risk factors.

These lifestyle modifications can also lower the risk of other chronic conditions and may play an important role in managing rheumatoid arthritis and reducing complications.

Without treatment, ongoing inflammation can lead to permanent joint damage and disability. Additionally, because rheumatoid arthritis is a systemic inflammatory disease, it can also affect many organs and tissues beyond the joints. Complications are common, often overlap, and require active monitoring.

Cardiovascular Complications

Rheumatoid arthritis more than doubles the risk of cardiovascular disease. Chronic inflammation accelerates atherosclerosis, or plaque buildup in the arteries, and raises the risk of heart attack, congestive heart failure, and pericarditis, or inflammation of the heart lining.

Pulmonary Complications

Lung involvement is frequent and may include:

• Interstitial Lung Disease: Scarring of lung tissue that interferes with oxygen exchange.


• Pulmonary Fibrosis: Progressive lung scarring that can impair breathing.


• Pleuritis and Pleural Effusions: Inflammation of the lung lining or fluid buildup around the lungs.

Bone Health

Systemic inflammation and long-term steroid use can accelerate bone loss, contributing to osteoporosis in about one-third of people with rheumatoid arthritis, and increasing fracture risk.

Eye Complications

Eye involvement, if untreated, can cause pain, light sensitivity, and vision problems. Manifestations may include:

• Keratoconjunctivitis Sicca: Significant eye dryness.


• Episcleritis and Scleritis: Inflammation of the outer layers of the eye.


• Keratitis: Inflammation of the cornea.


• Secondary Sjögren’s Syndrome: An autoimmune condition affecting tear and saliva production.

Neurological Complications

Rheumatoid arthritis can affect the nervous system through compressed nerves, reduced blood flow, medication effects, or direct autoimmune activity. Common manifestations include:

• Carpal Tunnel Syndrome: Compression of the median nerve at the wrist.


• Peripheral Neuropathy: Nerve damage causing numbness, tingling, or weakness.


• Cervical Myelopathy: Spinal cord compression caused by neck instability.

Skin Manifestations

Skin-related complications may include:

• Rheumatoid Nodules: Firm lumps that develop over pressure points.


• Periungual Inflammation: Redness and inflammation around the nails.


• Rheumatoid Vasculitis: Inflammation of blood vessels that can cause purplish spots, ulcers, or—in severe cases—digital gangrene because of reduced blood flow.

Blood-Related Complications

Chronic inflammation and some rheumatoid arthritis medications can lead to blood-related complications, including:

• Anemia: Reduced red blood cell production linked to inflammation.


• Felty’s Syndrome: A triad of an enlarged spleen, low white blood cell count, and rheumatoid arthritis.


• Abnormal Blood Cell Counts: Conditions such as neutropenia (low neutrophil count), eosinophilia (elevated eosinophils), thrombocytopenia (low platelet count), and thrombocytosis (elevated platelets linked to active inflammation).


• Increased Risk of Blood Clots: A higher risk of blood clots, particularly when platelet levels are elevated.


• Increased Risk of Cancer: A higher risk of certain cancers, including lymphoma (cancer of the lymphatic system).

Gastrointestinal Complications

While many gastrointestinal issues arise from medication effects, rheumatoid arthritis itself can lead to rare, serious problems, including:

• Rheumatoid Vasculitis: Inflammation of the blood vessels manifesting in the intestines, a rare but serious form of systemic vasculitis that can cause ischemia or bowel perforation.


• Amyloid A Amyloidosis: Abnormal protein deposits in the gastrointestinal tract that can cause diarrhea, protein-losing enteropathy, and malabsorption.

Other Systemic Complications

Rheumatoid arthritis can affect multiple systems beyond the joints, leading to complications that benefit from early recognition and ongoing monitoring.

• Oral Manifestations: Salivary gland swelling and dry mouth.


• Renal Complications: Kidney involvement, including glomerulonephritis or interstitial renal disease, affecting up to one-quarter of people with rheumatoid arthritis.


• Sleep Disruption: Pain and stiffness that interfere with sleep, along with inflammation that disrupts normal sleep-wake regulation.