What is the approach to generalized arthralgia (joint pain)?

From the Guidelines

The approach to generalized arthralgia begins with a thorough history and physical examination to distinguish inflammatory from non-inflammatory causes, and first-line treatment typically involves acetaminophen or NSAIDs, with consideration of referral to rheumatology for persistent symptoms. Initial laboratory testing should include complete blood count, comprehensive metabolic panel, erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor, and anti-nuclear antibody 1. Imaging studies like X-rays of affected joints may be indicated. Non-pharmacological interventions include physical therapy, weight management for overweight patients, and gentle exercise like swimming or walking, as recommended by the 2022 American College of Rheumatology guideline for exercise, rehabilitation, diet, and additional integrative interventions for rheumatoid arthritis 1.

Some key points to consider in the management of generalized arthralgia include:

• The importance of a "food first" approach, emphasizing the use of high-quality foods to obtain necessary nutrients, rather than relying on dietary supplements 1
• The potential benefits of additional integrative interventions, such as standardized self-management programs, cognitive-behavioral therapy (CBT), mind-body approaches, acupuncture, massage therapy, and thermal modalities, although the evidence supporting these interventions is of low certainty 1
• The need for interprofessional treatment teams, including rheumatology clinicians, physical and occupational therapists, dieticians, clinical exercise physiologists, psychologists, massage therapists, acupuncturists, and others, to provide comprehensive care for patients with rheumatoid arthritis 1
• The importance of considering the individual patient's preferences and values when making treatment decisions, and engaging in shared decision-making with patients when deciding whether to use certain interventions 1

In terms of pharmacological treatment, the 2013 update of the EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs suggests that, in the absence of poor prognostic factors, a change to another conventional synthetic disease-modifying antirheumatic drug (csDMARD) strategy should be considered if the treatment target is not achieved with the first DMARD strategy 1. However, this guideline is more focused on the management of rheumatoid arthritis, and may not be directly applicable to all cases of generalized arthralgia.

Overall, the approach to generalized arthralgia should be tailored to the individual patient's needs and circumstances, taking into account the underlying cause of the symptoms, as well as the patient's preferences and values.

From the Research

Approach to Generalized Arthralgia

The approach to generalized arthralgia, or joint pain, involves a combination of pharmacologic and non-pharmacologic therapies.

• The first-line pharmacologic agent for the symptomatic treatment of mild to moderate pain is acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID) 2.
• For patients with rheumatoid arthritis, disease-modifying antirheumatic drugs (DMARDs) are used as first-line therapy, and may include methotrexate, hydroxychloroquine, sulfasalazine, and leflunomide 3.
• Combination therapy with multiple DMARDs may be used to achieve better efficacy than with monotherapy, and may include combinations such as methotrexate, sulfasalazine, and hydroxychloroquine, or methotrexate and cyclosporine 4, 5.
• Biologic-response modifiers, such as tumor necrosis factor (TNF)-alpha inhibitors, may also be used in combination with DMARDs to treat rheumatoid arthritis 3, 6.

Treatment Options

Treatment options for generalized arthralgia may include:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) to manage pain and inflammation
• Disease-modifying antirheumatic drugs (DMARDs) to slow clinical and radiographic progression of rheumatoid arthritis
• Biologic-response modifiers to selectively inhibit specific molecules of the immune system
• Glucocorticoids to control pain, inflammation, and stiffness
• Analgesics to manage pain

Considerations

When initiating therapy for generalized arthralgia, considerations should include:

• The underlying cause of the joint pain
• Patient risk factors for NSAID-related adverse effects
• The potential benefits and risks of combination therapy with multiple DMARDs or biologic-response modifiers 4, 5, 6