What are the treatment options for arthritis?

Treatment Options for Arthritis

The core management of arthritis should include exercise, weight management if overweight, and education about the condition, with pharmacological treatments added as needed based on arthritis type and symptom severity. 1

Types of Arthritis and Initial Assessment

Different types of arthritis require different treatment approaches:

• Osteoarthritis (OA): Most common form, affecting joints through cartilage wear
• Rheumatoid Arthritis (RA): Autoimmune condition requiring disease-modifying treatments
• Ankylosing Spondylitis: Inflammatory arthritis affecting spine and sacroiliac joints
• Juvenile Idiopathic Arthritis: Arthritis in children requiring specialized approaches

Non-Pharmacological Treatments

Core Treatments for All Arthritis Types

• Exercise therapy: Local muscle strengthening and general aerobic fitness 1

  • Land-based exercises are conditionally recommended over aquatic therapy 1
  • Active supervised exercises are preferred over passive interventions 1

• Weight management: Essential for overweight/obese patients with OA 1

• Patient education: Providing information about the condition to counter misconceptions 1

Additional Non-Pharmacological Options

• Physical therapy: Conditionally recommended regardless of medication use 1
• Heat or cold applications: For localized pain relief 1
• Assistive devices: Canes, braces, joint supports for specific functional limitations 1
• Orthoses: Particularly for hand OA affecting the first CMC joint 1
• Psychological interventions: Cognitive behavioral therapy for pain management 1

Pharmacological Treatment Options

For Osteoarthritis

1. First-line:

   • Topical NSAIDs: For knee and hand OA (lower systemic side effects) 1
   • Paracetamol (Acetaminophen): Regular dosing may be needed, though evidence shows modest efficacy 1, 2

2. Second-line:

   • Oral NSAIDs: Use at lowest effective dose for shortest time possible 1, 3
     • Consider gastroprotection with proton pump inhibitors
     • Examples: Naproxen, ibuprofen shown effective for OA 3, 4
   • Topical capsaicin: For knee OA 1

3. Advanced options:

   • Intra-articular glucocorticoid injections: For knee and hip OA 1
   • Duloxetine: For pain management 1
   • Tramadol: When other options inadequate 1

For Rheumatoid Arthritis

1. First-line:

   • Methotrexate (MTX): Cornerstone DMARD therapy 1

2. Combination therapy:

   • Triple therapy: MTX + sulfasalazine + hydroxychloroquine 1

3. Biologic DMARDs (if inadequate response to conventional DMARDs):

   • TNF inhibitors: Adalimumab, etanercept, infliximab 1, 5
   • Other biologics: Abatacept, tocilizumab, rituximab 1

4. Symptom management:

   • NSAIDs: For pain and inflammation 1, 3
   • Short-term glucocorticoids: For flares 1

For Ankylosing Spondylitis

1. First-line:

   • NSAIDs: Primary pharmacological therapy 1

2. Second-line:

   • TNF inhibitors: For inadequate response to NSAIDs 1

3. Local treatments:

   • Intra-articular glucocorticoid injections: For peripheral arthritis 1

Treatment Algorithm

1. Initial approach for all arthritis patients:

   • Implement core non-pharmacological treatments (exercise, weight management if needed)
   • Provide education about the condition

2. For OA pain management:

   • Start with topical NSAIDs (for knee/hand) or acetaminophen
   • If inadequate response, add or switch to oral NSAIDs at lowest effective dose
   • Consider intra-articular injections for persistent symptoms

3. For RA:

   • Begin DMARD therapy (typically methotrexate) early
   • Add additional DMARDs or biologics if disease activity persists
   • Use NSAIDs and short-term glucocorticoids for symptom management

Important Considerations and Pitfalls

• NSAID safety concerns: All oral NSAIDs carry risks of gastrointestinal, cardiovascular, and renal adverse effects; use lowest effective dose for shortest time 1, 3

• Medication selection in elderly: Consider comorbidities and potential drug interactions when selecting treatments 1

• Glucocorticoid limitations: Long-term use (beyond 1-2 years) increases risks of cataracts, osteoporosis, fractures, and cardiovascular disease 1

• Treatment expectations: Set realistic goals; treatments aim to control symptoms and improve function rather than cure arthritis

• Regular monitoring: Assess treatment response and adjust therapy accordingly, particularly with DMARDs and biologics

By following this comprehensive approach to arthritis management, focusing on both non-pharmacological and pharmacological interventions tailored to the specific type of arthritis, patients can experience significant improvements in pain, function, and quality of life.