From the Guidelines
The treatment plan for polyarthritis should prioritize a multifaceted approach, starting with nonsteroidal anti-inflammatory drugs (NSAIDs) and potentially progressing to disease-modifying antirheumatic drugs (DMARDs) like methotrexate, as conditionally recommended by the 2019 American College of Rheumatology guideline 1.
Initial Treatment
- NSAIDs, such as ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily), are used to reduce inflammation and pain.
- For more severe cases, DMARDs like methotrexate (starting at 7.5-10mg weekly, potentially increasing to 20-25mg) may be prescribed, as methotrexate is conditionally recommended over leflunomide or sulfasalazine 1.
Disease Management
- Corticosteroids, such as prednisone (5-20mg daily), can provide rapid relief during flares but are used short-term due to side effects.
- Biologic agents, including TNF inhibitors (etanercept, adalimumab) or IL-6 inhibitors (tocilizumab), are options for refractory cases, with combination therapy with a biologic conditionally recommended over biologic monotherapy 1.
Lifestyle Modifications
- Physical therapy is essential to maintain joint function and muscle strength.
- Occupational therapy helps patients adapt to daily activities.
- Regular monitoring of disease activity and medication side effects is crucial, with laboratory tests every 1-3 months initially.
- Lifestyle modifications, including maintaining a healthy weight, regular low-impact exercise, and a balanced anti-inflammatory diet rich in omega-3 fatty acids, can complement medical treatment.
Recent Guidelines
- The 2025 expert consensus recommendations for the diagnosis and treatment of chronic non-bacterial osteitis (CNO) in adults suggest starting NSAIDs/COXIBs in maximum tolerated and approved dosage, with consideration of second-line treatment in patients with spinal bone lesions or significant accumulated skeletal damage 1.
- The guidelines also recommend evaluating treatment response at 2-4 weeks and considering tapering or on-demand treatment in case of sustained sufficient response 1.
From the FDA Drug Label
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 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
d) in the treatment of pediatric patients with polyarticular-course1 juvenile rheumatoid arthritis who have responded inadequately to salicylates or other nonsteroidal anti-inflammatory drugs
The treatment plan for polyarthritis may include:
- Adalimumab (HULIO): for reducing signs and symptoms of moderately to severely active polyarticular juvenile idiopathic arthritis in patients 2 years of age and older, alone or in combination with methotrexate.
- Sulfasalazine: for the treatment of pediatric patients with polyarticular-course juvenile rheumatoid arthritis who have responded inadequately to salicylates or other nonsteroidal anti-inflammatory drugs.
- The dosage of HULIO is based on weight, with recommended dosages of 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.
- Methotrexate, glucocorticoids, NSAIDs, and/or analgesics may be continued during treatment with HULIO 2.
- Sulfasalazine may be used in patients who have responded inadequately to salicylates or other nonsteroidal anti-inflammatory drugs 3 3.
From the Research
Treatment Plan for Polyarthritis
The treatment plan for polyarthritis, particularly rheumatoid arthritis (RA), involves a combination of medications and therapies aimed at managing pain, inflammation, and stiffness, as well as slowing disease progression.
- Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): NSAIDs are used for the management of pain and inflammation in RA 4, 5. They can provide rapid relief but do not slow the progression of the disease.
- Disease-Modifying Antirheumatic Drugs (DMARDs): DMARDs, including methotrexate, hydroxychloroquine, sulfasalazine, and leflunomide, are used as first-line therapy for all newly diagnosed cases of RA 4. They can slow the clinical and radiographic progression of RA.
- Biological-Response Modifiers: These targeted agents, such as infliximab, etanercept, and adalimumab, selectively inhibit specific molecules of the immune system and are effective in treating RA, especially when combined with traditional DMARDs 4, 6, 7.
- Glucocorticoids: Glucocorticoids are used to treat RA and can provide rapid relief from inflammation and stiffness 4.
- Combination Therapy: Early aggressive therapy with a combination of drugs or biological agents may be warranted for the effective treatment of RA 4, 6.
- Safety of Concurrent Medications: The use of NSAIDs, including aspirin, with methotrexate appears to be safe provided appropriate monitoring is performed, although high doses of aspirin should be avoided due to potential adverse effects on liver and renal function 8.
Approach to Treatment
The approach to treating polyarthritis, especially RA, has evolved to favor early aggressive therapy, including early referral to a rheumatologist and the use of DMARDs, glucocorticoids, and biological agents 4, 6. A shared care model between general practitioners and rheumatologists can provide the best outcomes 6. Personalized treatment strategies, considering the cellular, cytokine, genomic, and transcriptomic profile of the patient, may predict treatment response to biologic or targeted DMARDs of different mechanisms of action 7.