Rheumatoid arthritis strikes women far more often than men. In fact, about 70 to 80 percent of people affected by the autoimmune disease are female. Yet men do get RA, although usually later, and less severely, than women.

RA affects men and women much the same way, says Dimitrios Pappas, MD, a rheumatologist at New York Presbyterian/Columbia University Hospital in New York. “The approach for diagnosis, the treatment, you monitor the disease, is essentially the same,” he says. Joint pain, inflammation and fatigue are common RA symptoms for men as well as women.

However, men typically develop RA later in life than women do, typically between ages 45 and 65. In many cases, disease severity is greater in women than in men. A recent study showed that men are more likely to experience sustained remission early in the disease process than women. While the disease looks very much the same in men as in women, there are certain treatment-related discussions that rheumatologists have with men that differ from those they have with female patients.

Why do fewer men get RA? “We don’t understand it completely, but the genetic burden that makes you predisposed to get rheumatoid arthritis is higher in women than in men,” says James O’Dell, MD, chief of rheumatology at University of Nebraska Medical Center in Lincoln. “Autoimmune diseases in general are more common in women…But when men get rheumatoid arthritis, it looks very much the same.”

Men tend to respond to therapy, including disease-modifying antirheumatic drugs (DMARDs), better than female patients, says. Dr. O’Dell. “We do have a better result with men, but we don’t know why. Every time we have looked at this issue, men tend to have more favorable outcomes. But the differences from patient to patient are pretty subtle.”

A 2012 study in the medical journal Arthritis Care & Research showed that men were more likely than women to achieve sustained remission early in the disease process. The study, which looked at 10,299 RA patients (2,406 men and 7,893 women), also noted that later in the disease process, men did not experience a greater rate of remission. In addition, women reported more severe disease at the baseline than men, echoing Dr. O’Dell’s observation.

Remission is achieved when a patient reports tender joint count, swollen joint count, C-reactive protein levels, and scores on the Patient Global Assessment scale at levels equal to or less than one, according to ACR/EULAR 2011 criteria. However, another study published online in March 2012 in the medical journal Arthritis Research & Therapy determined that sustained RA remission is relatively rare overall. Looking at 871 RA patients, 19 percent of which were male, the study’s authors concluded that less than 50 percent of the study participants were still in remission a year after achieving it. So whether one is male or female with RA, ongoing monitoring of one’s disease by a rheumatologist may be important.

Careful About Contraception

As with their female patients, rheumatologists typically prescribe DMARDs to men with RA once they are diagnosed. The first-line drug to treat RA inflammation is methotrexate. Because methotrexate is teratogenic, or may cause birth defects in a developing fetus, physicians do have a frank talk about protection with their male RA patients.

“Usually, when we put men on methotrexate, we advise them not to conceive a child. But if they want to conceive a child, then before attempting to do so, they should be off methotrexate for three to six months,” says Dr. Pappas. “Every time I put a man on methotrexate, I talk about toxicities and, ‘Are you planning to have kids?’ If they say they have an immediate plan, we don’t start methotrexate.”

Methotrexate blocks the metabolism of folic acid, a nutrient important for the division of cells in the developing fetus, says Dr. Pappas. “Methotrexate may get into the baby’s system” if the father is taking the drug when he conceives a child, so a clear discussion about avoiding conception, including the diligent use of contraception during sexual activity, is important to have with male patients, he says.

Other DMARD options for men with RA include sulfasalazine (Azulfidine), but this drug can lower sperm count, so the male patient’s child-making plans must be discussed, Dr. O’Dell adds. This effect on sperm is reversible. He notes that RA and its various drug treatments present a much greater challenge in female patients. “In women, we have the whole issue of pregnancy and nursing,” and females often must come off their drugs for a year or more, during which time their RA may flare. “There could be accumulated joint damage in this period for women,” says Dr. O’Dell.

Compliance Challenges

While men and women may experience RA in much the same way, there are some subtle differences in lifestyle or communication that rheumatologists note.

“Men may be more likely to be involved in work that involves physical labor,” says Dr. Pappas. Construction or other occupations that require heavy lifting or manipulation of large equipment could be difficult if a man’s RA is not controlled. This trend may have been more of a concern for rheumatologists in the past than now, Dr. Pappas adds. “The medications for RA that we have today are so powerful that we can usually get these men back to work as if they didn’t have rheumatoid arthritis, possibly in a few weeks.”

Twenty years ago, men receiving an RA diagnosis would worry about their ability to keep working or living an active, normal life, but now, rheumatologists can express optimism about their ability to control the disease, Dr. Pappas says.

One difference that Dr. O’Dell notices is some male patients, particularly those who are older men, is a too-casual approach to their disease. Compliance can be an issue for men with RA if they don’t take their disease seriously just because it seems controlled.

“I may have to work a bit harder for that man with RA to take it seriously,” he says. “Perhaps not if he’s lucky enough to be married to a woman who’s going to ensure that he takes his medications. I have more male patients whose wives run that part of their care. For whatever reason, women tend to be the ones to take responsibility for health care in couples, but usually, these people are older.”

Recommendations about regular physical activity for RA patients are the same for men and women, Dr. O’Dell adds. Exercise, including those that maintain cardiovascular health, strength and range of motion, helps keep joints flexible and overall health in good condition. Improved physical function may encourage male RA patients to be compliant with both medications and exercise suggestions, says Dr. O’Dell.

“I have so many men coming into my office talking about their golf games. When men refer to taking their therapy or not, and I guarantee that they’d lower their handicaps if they did their therapy, then that does the trick.”