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Understanding RA Stages and Progression

Reviewed by: HU Medical Review Board | Last reviewed: April 2021 | Last updated: April 2021

Rheumatoid arthritis (RA) is a chronic (long-term) autoimmune disease. Autoimmune means that your immune system begins to attack and damage your own healthy cells.

Damage from RA can continue over time and lead to worse symptoms. These symptoms are caused by the inflammation of the disease. While RA is known as a joint disease, many areas of the body are affected by it. As the disease progresses, treatment for RA may change.1,2

Early diagnosis and progression

RA can lead to bone erosion (loss of bone) and joint destruction over time if left untreated or not well managed. Recognizing and treating early symptoms is essential to stop or slow the progression of the disease.1,2

RA does not progress the same for everyone. The overall course of the disease can vary from person to person, depending on several factors:1

  • Genes
  • Number and severity of symptoms
  • Presence of inflammatory proteins in the blood

Staging of rheumatoid arthritis

Doctors use a staging system to decide the severity and progression of the disease. Based on your symptoms and what X-rays or other imaging show, your doctor will decide which stage of RA you have.1,3

Stage 1: Mild symptoms

Stage 1 in RA is the earliest stage of the disease. Inflammation begins in this stage, but is not yet visible on X-ray or other imaging.

Stage 2: Swelling gets worse

In this stage, swelling and joint stiffness are worse than the mild, periodic symptoms in stage 1.

Stage 3: Symptoms you can see

Cartilage and bone destruction begin in this stage. This leads to deformity of the joint. Rheumatoid nodules (lumps under the skin) may also occur.

Stage 4: Joint destruction and bone fusion

The joints stop functioning in this stage. Bone fusion (ankylosis) is common.1,3

Treatment and RA progression

Controlling inflammation is the key to treatment for all stages. Depending on the severity of joint damage and your overall symptoms, treatment may vary.1,3

Early-stage treatment (stage 1, early stage 2)

Managing inflammation in the early stages of the disease is key to prevent long-term joint damage from RA. Treatment may include:3

  • Low-dose steroids (strong anti-inflammatory drugs)
  • Low-dose disease-modifying antirheumatic drugs (DMARDs). A common DMARD is methotrexate. This drug was first used as a cancer-fighting drug, but it is now a first-line treatment for RA.
  • Lifestyle changes such as stopping smoking. Studies have shown that smoking is a risk factor for RA, and it could make your treatment less effective.

Moderate stage treatment (late stage 2, early stage 3)

Damage to the cartilage may appear during these stages, decreasing joint movement. Treatment may include:3

  • Steroid injections
  • Biologic DMARDs. Biologics are drugs made from living cells. These cells can come from parts of the blood, proteins, viruses, or tissue. This process turns the cells into drugs that can prevent, treat, and cure disease. Biologics are given by injection or IV (through the vein).
  • Physical therapy may be helpful if your pain is well-controlled.

Late-to-end stage treatment (stages 3 and 4)

Pain and joint destruction or deformity occur in these stages. Treatment varies greatly, depending on symptoms:3

  • Pain management is a priority
  • Joint replacement may be needed

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