What is the treatment for elevated inflammatory markers?

Treatment for Elevated Inflammatory Markers

The treatment of elevated inflammatory markers should be directed at the underlying cause of inflammation rather than treating the markers themselves, with therapy tailored to the specific disease process identified. 1

Identifying the Underlying Cause

Elevated inflammatory markers such as C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), or other acute phase reactants are not diseases themselves but indicators of underlying inflammatory processes. Before initiating treatment, it's essential to:

• Determine if elevation is due to:
  • Autoimmune/rheumatologic disease
  • Infection
  • Cardiovascular disease
  • Malignancy
  • Other inflammatory conditions

Treatment Approaches Based on Underlying Condition

Rheumatologic/Autoimmune Diseases

For conditions like psoriatic arthritis, treatment follows a stepwise approach 1:

1. First-line options:

   • NSAIDs for symptomatic relief
   • Methotrexate as first-line disease-modifying therapy

2. Second-line options (if inadequate response):

   • TNF inhibitors (etanercept, adalimumab, infliximab)
   • IL-17 inhibitors (secukinumab, ixekizumab)
   • IL-12/23 inhibitors (ustekinumab)
   • JAK inhibitors (tofacitinib)

3. Treatment targets:

   • Normalization of inflammatory markers
   • Resolution of clinical symptoms

Autoinflammatory Diseases

For IL-1 mediated autoinflammatory diseases 1:

1. Treatment options:

   • IL-1 blocking therapies (anakinra, canakinumab, rilonacept)
   • Dose and frequency adjusted to control disease activity

2. Treatment targets:

   • Complete remission (absence of clinical symptoms and normal inflammatory markers)
   • CRP levels <5-10 mg/L indicating adequate control

COVID-19 Related Inflammation

For inflammatory phase of COVID-19 1:

1. Treatment options:

   • Dexamethasone 6 mg daily for 10 days (for patients requiring oxygen)
   • Anti-IL-6 therapies (tocilizumab, sarilumab) for severe cases with CRP ≥75 mg/L
   • Anti-IL-1 (anakinra) for patients with high inflammatory state

2. Treatment targets:

   • Reduction in inflammatory markers
   • Improvement in clinical status

Giant Cell Arteritis and Polymyalgia Rheumatica

For GCA and PMR 1:

1. Treatment options:

   • Glucocorticoids as initial therapy
   • Steroid-sparing agents (methotrexate, tocilizumab)

2. Treatment targets:

   • Maintenance of remission with minimal effective dose
   • Monitoring of inflammatory markers for disease activity assessment

Ulcerative Colitis

For UC monitoring and management 1:

1. Monitoring strategy:

   • Combined biomarker and symptom assessment
   • Fecal calprotectin <150 mg/g or normal fecal lactoferrin to rule out active inflammation

2. Treatment decisions:

   • Endoscopic assessment if elevated biomarkers with mild symptoms
   • Treatment adjustment for elevated biomarkers with moderate-severe symptoms

Native Vertebral Osteomyelitis

For management of inflammatory markers in NVO 1:

1. Monitoring approach:

   • Monitor ESR and CRP after approximately 4 weeks of antimicrobial therapy
   • ESR >50 mm/hour and CRP >2.75 mg/dL after 4 weeks may indicate higher risk of treatment failure

2. Treatment considerations:

   • Persistent elevation alone does not necessarily indicate treatment failure
   • Clinical assessment should guide treatment decisions

Cardiovascular Risk Assessment

For patients with elevated inflammatory markers and cardiovascular risk 1:

1. Assessment approach:

   • hs-CRP as preferred inflammatory marker
   • Cutpoints: low risk (<1.0 mg/L), average risk (1.0-3.0 mg/L), high risk (>3.0 mg/L)

2. Treatment considerations:

   • Statins for patients with elevated hs-CRP and intermediate cardiovascular risk
   • Lifestyle modifications (weight loss, exercise, smoking cessation)

Common Pitfalls to Avoid

1. Treating the marker, not the disease

   • Elevated inflammatory markers are indicators, not the primary target of therapy

2. Ignoring non-specific elevations

   • Minor elevations may not require treatment if clinically insignificant

3. Over-reliance on markers alone

   • Clinical assessment remains essential; markers should complement, not replace clinical judgment

4. Failure to repeat testing

   • Single elevated values may be misleading; consider repeat testing 2-4 weeks apart

5. Missing the underlying cause

   • Extensive workup may be needed to identify the source of inflammation

Remember that normalization of inflammatory markers should be part of a treat-to-target approach aimed at achieving clinical remission, preventing organ damage, and improving quality of life.