We analyzed NAD metabolism in patients with rheumatoid arthritis (RA), its association with disease activity and clinical outcomes of RA, and the therapeutic potential of pharmacologic NAD boosting. Our study included 253 participants. In the first cohort, comprising 153 RA patients and 56 healthy donors, we assessed NAD levels and NAD -related gene pathways. We analyzed 92 inflammatory molecules by proximity extension assay. In the second cohort, comprising 44 RA patients starting anti-tumor necrosis factor (anti-TNF) drugs, we evaluated changes in NAD levels and their association with clinical response after 3 months. Mechanistic studies were performed ex vivo on peripheral blood mononuclear cells (PBMCs) from patients with RA to test the beneficial effects of NAD boosters, such as nicotinamide and nicotinamide riboside. Reduced NAD levels were found in RA samples, in line with altered activity and expression of genes involved in NAD consumption (sirtuins, polyADP-ribose polymerase, CD38), transport (connexin 43), and biosynthesis (NAMPT, NMNATs). Unsupervised clustering analysis identified a group of RA patients with the highest inflammatory profile, the lowest NAD levels, and the highest disease activity (as shown by the Disease Activity Score in 28 joints). NAD levels were modulated by anti-TNF therapy in parallel with the clinical response. In vitro studies using PBMCs from RA patients showed that nicotinamide riboside and nicotinamide increased NAD levels via NAMPT and NMNAT and reduced their prooxidative, proapoptotic, and proinflammatory status. RA patients display altered NAD metabolism, directly linked to their inflammatory and disease activity status, which was reverted by anti-TNF therapy. The preclinical beneficial effects of NAD boosters, as shown in leukocytes from RA patients, along with their proven clinical safety, might pave the way for the development of clinical trials using these compounds.