How to Treat Rheumatoid Pannus

Just as inflammation can cause rheumatoid pannus tissue to develop, decreasing inflammation can cause the pannus to go away. Typically, the best approach is to decrease inflammation throughout the entire body, not just in the affected joint(s).

Most rheumatoid arthritis treatments address body-wide inflammation. These treatments will help reduce or eliminate pannus as well as other RA symptoms, such as fatigue. Rarely, surgery to remove pannus from a joint is recommended.

See Rheumatoid Arthritis (RA) Treatment

Rheumatoid Arthritis Drugs and Pannus

Medications are the first line of treatment for the rheumatoid arthritis inflammation that results in pannus tissue. These drugs either treat the symptoms of inflammation or stop inflammation from happening.

The medications prescribed to treat rheumatoid arthritis fall into 5 categories:

1. Non-steroidal anti-inflammatory drugs (NSAIDs)
2. Disease-modifying antirheumatic drugs (DMARDs)
3. Oral corticosteroids
4. Biologics
5. JAK inhibitors

Biologic drugs and JAK inhibitors are typically recommended only if the first 3 types of medications have failed to lower inflammation and decrease symptoms.

In general, if RA pannus does not go away, it is considered a sign that the medication regimen needs to be changed.

See 5 Types of Medication That Treat Rheumatoid Arthritis (RA)

Injections and RA Pannus

Sometimes rheumatoid arthritis medications are able to significantly reduce inflammation but pannus tissue, swelling, and pain persist in one or two joints. A corticosteroid injection into the joint(s) may decrease stubborn RA inflammation and eliminate or significantly reduce pannus tissue and the associated symptoms.

See Cortisone Injections (Steroid Injections)

Natural Home Remedies for Rheumatoid Arthritis Pannus

Many strategies for relieving the inflammation that leads to rheumatoid pannus can be done at home. These strategies sometimes require big lifestyle changes. They are typically recommended in addition to taking medications.

Research supports these natural home treatment strategies:

• Making changes to diet and eating more anti-inflammatory foods, such as high fiber fruits and vegetables ¹ Ning H, Van Horn L, Shay CM, Lloyd-Jones DM. Associations of dietary fiber intake with long-term predicted cardiovascular disease risk and C-reactive protein levels (from the National Health and Nutrition Examination Survey Data [2005-2010]). Am J Cardiol. 2014 Jan 15;113(2):287-91. PMCID: PMC1456807 doi: 10.1016/j.amjcard.2013.09.020. ^{, 2} Ma Y, Griffith JA, Chasan-Taber L, Olendzki BC, Jackson E, Stanek EJ 3rd, Li W, Pagoto SL, Hafner AR, Ockene IS. Association between dietary fiber and serum C-reactive protein. Am J Clin Nutr. 2006 Apr;83(4):760-6. PMCID: PMC1456807 doi: 10.1093/ajcn/83.4.760. PMID: 16600925 ^{, 3} Häger J, Bang H, Hagen M, et al. The Role of Dietary Fiber in Rheumatoid Arthritis Patients: A Feasibility Study. Nutrients. 2019;11(10):2392. Published 2019 Oct 7. doi:10.3390/nu11102392 ^{, 4} Athanassiou P, Athanassiou L, Kostoglou-Athanassiou I. Nutritional Pearls: Diet and Rheumatoid Arthritis. Mediterr J Rheumatol. 2020;31(3):319-324. Published 2020 May 15. DOI: 10.31138/mjr.31.3.319
• Quitting smoking, vaping, and/or exposure to other toxins that trigger inflammation ⁵ Scott A, Lugg ST, Aldridge K, et al. Pro-inflammatory effects of e-cigarette vapour condensate on human alveolar macrophages. Thorax. 2018;73(12):1161-1169. doi:10.1136/thoraxjnl-2018-211663 ^{, 6} Shahandeh N, Chowdhary H, Middlekauff HR. Vaping and cardiac disease. Heart. 2021 Feb 11:heartjnl-2020-318150. doi: 10.1136/heartjnl-2020-318150. Epub ahead of print. PMID: 33574049 ^{, 7} Kelly CA, Nisar M, Arthanari S, et al. Rheumatoid arthritis related interstitial lung disease—Improving outcomes over 25 years: A large multicentre UK study. Rheumatology. 2020 doi: 10.1093/rheumatology/keaa577 ^{, 8} Mori S, Koga Y, Sugimoto M. Different risk factors between interstitial lung disease and airway disease in rheumatoid arthritis. Respir. Med. 2012;106:1591–1599. doi: 10.1016/j.rmed.2012.07.006. As cited in Mena-Vázquez N, Rojas-Gimenez M, Romero-Barco CM, et al. Predictors of Progression and Mortality in Patients with Prevalent Rheumatoid Arthritis and Interstitial Lung Disease: A Prospective Cohort Study. J Clin Med. 2021;10(4):874. Published 2021 Feb 20. doi: 10.3390/jcm10040874 ^{, 9} Sharma A, Lee J, Fonseca AG, et al. E-cigarettes compromise the gut barrier and trigger inflammation. iScience. 2021;24(2):102035. Published 2021 Jan 6. PMID: 33537654 doi:10.1016/j.isci.2021.102035
• Getting regular exercise, which has been shown to reduce inflammation ¹⁰ Benatti FB, Pedersen BK. Exercise as an anti-inflammatory therapy for rheumatic diseases-myokine regulation. Nat Rev Rheumatol. 2015 Feb;11(2):86-97. doi: 10.1038/nrrheum.2014.193. Epub 2014 Nov 25. PMID: 25422002. ^{, 11} Mathur N, Pedersen BK. Exercise as a mean to control low-grade systemic inflammation. Mediators Inflamm. 2008;2008:109502. doi: 10.1155/2008/109502. Epub 2009 Jan 11. PMID: 19148295; PMCID: PMC2615833. ^{, 12} Stavropoulos-Kalinoglou A, Metsios GS, Veldhuijzen van Zanten JJ. et al. Individualised aerobic and resistance exercise training improves cardiorespiratory fitness and reduces cardiovascular risk in patients with rheumatoid arthritis. Ann Rheum Dis 2013;72:1819–25. As cited in Farrow M, Biglands J, Tanner S, et al. Muscle deterioration due to rheumatoid arthritis: assessment by quantitative MRI and strength testing. Rheumatology (Oxford). 2021;60(3):1216-1225. doi: 10.1093/rheumatology/keaa364
• Improving sleep habits, which may boost the immune system function ¹³ Miletínová E, Bušková J. Functions of Sleep. Physiol Res. 2021 Mar 8. Epub ahead of print. PMID: 33676389. and keep inflammation in check ¹⁴ Wright KP Jr, Drake AL, Frey DJ, Fleshner M, Desouza CA, Gronfier C, Czeisler CA. Influence of sleep deprivation and circadian misalignment on cortisol, inflammatory markers, and cytokine balance. Brain Behav Immun. 2015 Jul;47:24-34. doi: 10.1016/j.bbi.2015.01.004. Epub 2015 Jan 29. PMID: 25640603; PMCID: PMC5401766. ^{, 15} Frey DJ, Fleshner M, Wright KP Jr. The effects of 40 hours of total sleep deprivation on inflammatory markers in healthy young adults. Brain Behav Immun. 2007 Nov;21(8):1050-7. doi: 10.1016/j.bbi.2007.04.003. Epub 2007 May 23. PMID: 17524614. ^{, 16} Mullington JM, Simpson NS, Meier-Ewert HK, Haack M. Sleep loss and inflammation. Best Pract Res Clin Endocrinol Metab. 2010 Oct;24(5):775-84. doi: 10.1016/j.beem.2010.08.014. PMID: 21112025
• Using stress-reducing strategies, such as meditation, nature walks, or listening to music, which may limit the body’s release of stress hormones, which contribute to inflammation ¹⁷ Mancuso CA, Duculan R, Jannat-Khah D, Barbhaiya M, Bass AR, Mehta B. Rheumatic Disease-Related Symptoms During the Height of the COVID-19 Pandemic. HSS J. 2020 Sep 18;16(Suppl 1):1-9. doi: 10.1007/s11420-020-09798-w. Epub ahead of print. PMID: 32982613 ^{, 18} Hassett AL, Clauw DJ. The role of stress in rheumatic diseases. Arthritis Res Ther. 2010;12(3):123. doi: 10.1186/ar3024
• Nurturing positive social relationships and limiting negative ones that can increase stress and inflammation levels ¹⁹ Fagundes CP, Bennett JM, Derry HM, Kiecolt-Glaser JK. Relationships and Inflammation across the Lifespan: Social Developmental Pathways to Disease. Soc Personal Psychol Compass. 2011;5(11):891-903. doi: 10.1111/j.1751-9004.2011.00392.x ^{, 20} Pietromonaco PR, Collins NL. Interpersonal mechanisms linking close relationships to health. Am Psychol. 2017;72(6):531-542. PMID: 28880100 doi: 10.1037/amp0000129 ^{, 21} Shrout MR, Renna ME, Madison AA, Alfano CM, Povoski SP, Lipari AM, Agnese DM, Yee LD, Carson WE 3rd, Kiecolt-Glaser JK. Relationship satisfaction predicts lower stress and inflammation in breast cancer survivors: A longitudinal study of within-person and between-person effects. Psychoneuroendocrinology. 2020 Aug;118:104708. Epub 2020 May 19. PMID: 32474348; PMCID: PMC7307603. doi: 10.1016/j.psyneuen.2020.104708

See Dietary Supplements for Treating Arthritis

Limited evidence from small studies also suggests that certain supplements, such as turmeric and ginger, may reduce inflammation in some people. ²² Daily JW, Yang M, Park S. Efficacy of Turmeric Extracts and Curcumin for Alleviating the Symptoms of Joint Arthritis: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. J Med Food. 2016;19(8):717–729. doi: 10.1089/jmf.2016.3705 ^{, 23} Nelson J, Sjöblom H, Gjertsson I, Ulven SM, Lindqvist HM, Bärebring L. Do Interventions with Diet or Dietary Supplements Reduce the Disease Activity Score in Rheumatoid Arthritis? A Systematic Review of Randomized Controlled Trials. Nutrients. 2020 Sep 29;12(10):2991. PMID: 33003645; PMCID: PMC7600426. doi: 10.3390/nu12102991 ^{, 24} Asteriou E, Gkoutzourelas A, Mavropoulos A, Katsiari C, Sakkas LI, Bogdanos DP. Curcumin for the Management of Periodontitis and Early ACPA-Positive Rheumatoid Arthritis: Killing Two Birds with One Stone. Nutrients. 2018;10(7):908. Published 2018 Jul 16. doi: 10.3390/nu10070908 ^{, 25} Yang M, Akbar U, Mohan C. Curcumin in Autoimmune and Rheumatic Diseases. Nutrients. 2019;11(5):1004. Published 2019 May 2. doi: 10.3390/nu11051004 ^{, 26} Al-Nahain A, Jahan R, Rahmatullah M. Zingiber officinale: A Potential Plant against Rheumatoid Arthritis. Arthritis. 2014;2014:159089. doi: 10.1155/2014/159089 ^{, 27} Aryaeian N, Mahmoudi M, Shahram F, Poursani S, Jamshidi F, Tavakoli H. The effect of ginger supplementation on IL2, TNFα, and IL1β cytokines gene expression levels in patients with active rheumatoid arthritis: A randomized controlled trial. Med J Islam Repub Iran. 2019;33:154. Published 2019 Dec 27. doi: 10.34171/mjiri.33.154 Before taking a supplement, consult with a physician or pharmacist about possible drug interactions. Stop taking a supplement if benefits do not appear within 3 to 6 months.

When Surgery (Synovectomy) Is Recommended

If rheumatoid pannus does not go away with medications or injections, surgery to remove the inflammatory tissue may be recommended. This surgery is called synovectomy.

While rarely recommended, synovectomy can help relieve symptoms such as pain and stiffness in joints such as the knee, ²⁸ Lipina M, Makarov M, Mukhanov V, Karpashevich A, Maglevaniy S, Amirdjапоvа V, Archipov S. Arthroscopic synovectomy of the knee joint for rheumatoid arthritis. Int Orthop. 2019 Aug;43(8):1859-1863. PMID: 30284004. doi: 10.1007/s00264-018-4160-z elbow, ²⁹ Ishii K, Inaba Y, Mochida Y, Saito T. Good long-term outcome of synovectomy in advanced stages of the rheumatoid elbow. Acta Orthop. 2012;83(4):374-378. PMID: 22880708. doi: 10.3109/17453674.2012.702391 and wrist. ³⁰ Shim JW, Park MJ. Arthroscopic Synovectomy of Wrist in Rheumatoid Arthritis. Hand Clin. 2017 Nov;33(4):779-785. doi: 10.1016/j.hcl.2017.07.005 Synovectomy does not seem to have much effect on body-wide (systemic) inflammation that can be measured by blood tests. ³¹ Lipina M, Makarov M, Makarov S, Novikov A. The degree of cartilage degradation assessed by serum biomarker levels changes after arthroscopic knee synovectomy in rheumatoid arthritis patients. Int Orthop. 2017 Nov;41(11):2259-2264. Epub 2017 Sep 9. PMID: 28889180. doi: 10.1007/s00264-017-3634-8

The benefits of synovectomy may last years. Studies of synovectomy in the knee found benefits lasted 3 to 5 years. ³² Fiocco U, Cozzi L, Rigon C, et al. Arthroscopic synovectomy in rheumatoid and psoriatic knee joint synovitis: long-term outcome. Br J Rheumatol. 1996 May;35(5):463-70. PMID: 8646438. doi: 10.1093/rheumatology/35.5.463 ^{, 33} Kuzmanova SI. Arthroscopic treatment of rheumatoid synovitis. Folia Med (Plovdiv). 2003;45(3):48-54. PMID: 15366666. Another study examining synovectomy in the elbow found that benefits lasted 10 years or longer in some patients, potentially allowing them to postpone joint replacement surgery. ²⁹ Ishii K, Inaba Y, Mochida Y, Saito T. Good long-term outcome of synovectomy in advanced stages of the rheumatoid elbow. Acta Orthop. 2012;83(4):374-378. PMID: 22880708. doi: 10.3109/17453674.2012.702391

Synovectomy may be done in one of two ways:

1. An open synovectomy uses a single, large incision in the skin over the joint. The advantage of this approach is that more pannus tissue can be removed and results seem to last longer. However, the surgeon must cut through muscle and other soft tissues, making the recovery period longer and less comfortable.
2. An arthroscopic synovectomy involves making just a few small (typically 1 cm) incisions. The small incisions involve less cutting of soft tissues. Recovery tends to be faster and easier. However, the surgeon may not be able to remove as much pannus during an arthroscopic procedure.

One study ³⁴ Chalmers PN, Sherman SL, Raphael BS, Su EP. Rheumatoid synovectomy: does the surgical approach matter?. Clin Orthop Relat Res. 2011;469(7):2062-2071. doi: 10.1007/s11999-010-1744-3 suggests that pannus is more likely to grow back in joints that have undergone arthroscopic synovectomy.

While not all physicians agree, ³⁴ Chalmers PN, Sherman SL, Raphael BS, Su EP. Rheumatoid synovectomy: does the surgical approach matter?. Clin Orthop Relat Res. 2011;469(7):2062-2071. doi: 10.1007/s11999-010-1744-3 some recommend that synovectomy be done in the early stages of RA, before much joint damage has taken place.

Read more about Surgery for Rheumatoid Arthritis (RA)