What is the initial treatment for polyarticular arthritis?

From the Guidelines

The initial treatment for polyarticular arthritis should involve early initiation of disease-modifying antirheumatic drugs (DMARDs) like methotrexate, as it is considered the anchor drug and should be part of the first treatment strategy in patients at risk of persistent disease. According to the 2016 update of the EULAR recommendations for the management of early arthritis 1, methotrexate is the preferred DMARD due to its effectiveness and safety profile. The recommended starting dose of methotrexate is 7.5-10mg weekly, potentially increasing to 20-25mg weekly. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen, or celecoxib can be used as adjunct therapy to reduce inflammation and pain, but should be used at the minimum effective dose for the shortest time possible due to their potential gastrointestinal, renal, and cardiovascular risks 1.

Some key points to consider in the treatment of polyarticular arthritis include:

• Early referral to a rheumatologist within 6 weeks after the onset of symptoms is crucial for timely diagnosis and treatment 1
• Clinical examination and ultrasonography can be used to detect arthritis and confirm the diagnosis 1
• Risk factors for persistent and/or erosive disease, such as the number of swollen joints, acute phase reactants, rheumatoid factor, and ACPA, should be considered in management decisions 1
• The main goal of DMARD treatment is to achieve clinical remission, and regular monitoring of disease activity, adverse events, and comorbidities should guide decisions on choice and changes in treatment strategies 1

In terms of specific treatment recommendations, the 2019 American College of Rheumatology guideline for the treatment of juvenile idiopathic arthritis suggests that methotrexate is conditionally recommended over leflunomide and sulfasalazine for the treatment of polyarthritis 1. However, it is essential to note that the treatment regimen should be tailored based on the severity of symptoms, the patient's age, comorbidities, and the specific type of arthritis diagnosed through laboratory tests and imaging.

Overall, the treatment of polyarticular arthritis requires a comprehensive approach that includes early initiation of DMARDs, adjunct therapy with NSAIDs, and regular monitoring of disease activity and comorbidities. The use of methotrexate as the anchor drug in the treatment of polyarticular arthritis is supported by the most recent and highest quality evidence 1.

From the FDA Drug Label

1. 2 Juvenile Idiopathic Arthritis HULIO is indicated for reducing signs and symptoms of moderately to severely active polyarticular juvenile idiopathic arthritis in patients 2 years of age and older. HULIO can be used alone or in combination with methotrexate.
2. 2 Juvenile Idiopathic Arthritis The recommended subcutaneous dosage of HULIO for patients 2 years of age and older with polyarticular juvenile idiopathic arthritis (JIA) is based on weight as shown below. MTX, glucocorticoids, NSAIDs, and/or analgesics may be continued during treatment with HULIO Pediatric Weight (2 Years of Age and older) Recommended Dosage 15 kg (33 lbs) to less than 30 kg (66 lbs) 20 mg every other week 30 kg (66 lbs) and greater 40 mg every other week

The initial treatment for polyarticular arthritis may include HULIO (adalimumab), which can be used alone or in combination with methotrexate. The recommended dosage of HULIO for patients 2 years of age and older with polyarticular juvenile idiopathic arthritis is based on weight, with options for 20 mg every other week for patients weighing 15 kg to less than 30 kg, and 40 mg every other week for patients weighing 30 kg or greater 2.

From the Research

Initial Treatment for Polyarticular Arthritis

The initial treatment for polyarticular arthritis typically involves the use of disease-modifying antirheumatic drugs (DMARDs) such as methotrexate. According to 3, methotrexate is considered the first-line antirheumatic drug and is effective in relieving pain, reducing the number of affected joints, and providing functional improvement.

Key Recommendations

Key recommendations for the treatment of rheumatoid arthritis, which can be applied to polyarticular arthritis, include:

• Starting effective treatment immediately with DMARDs to reduce disability 4
• Using effective doses of methotrexate (oral or subcutaneous) with folic acid as the initial treatment 4
• Rapidly escalating treatment with various DMARDs if methotrexate alone is not effective in controlling the disease 4
• Aiming for a treat-to-target strategy with a goal of low disease activity or remission by frequently monitoring disease activity and escalating treatment 4

Treatment Options

Treatment options for polyarticular arthritis may also include:

• Biological-response modifiers such as etanercept, which has been shown to be effective in reducing disease activity and improving quality of life 5
• Combination therapy with methotrexate and a biological agent, which may be more effective than methotrexate monotherapy in patients with severe disease 3, 5
• Other DMARDs such as sulfasalazine, leflunomide, and hydroxychloroquine, which may be used in combination with methotrexate or as alternative treatments 6