Treatment of Inflammatory Arthritis
Methotrexate should be the first-line treatment for patients with inflammatory arthritis at risk of persistent disease, ideally started within 3 months of symptom onset. 1
Initial Treatment Approach
First-Line Therapy
Alternative First-Line Options
For patients with contraindications to methotrexate:
- Leflunomide
- Sulfasalazine 2
Treatment Strategy
Early Treatment
- Patients with inflammatory arthritis should be referred to a rheumatologist within 6 weeks of symptom onset 1
- DMARDs should be started within 3 months in patients at risk of persistent disease, even if they don't fulfill classification criteria for a specific rheumatologic disease 1
- Early treatment is crucial - the "window of opportunity" is within the first year of disease onset 2
Symptom Management
NSAIDs can be used for symptomatic relief but should be prescribed:
- At the minimum effective dose
- For the shortest time possible
- After evaluation of gastrointestinal, renal, and cardiovascular risks 1
Glucocorticoids:
- Reduce pain, swelling, and structural progression
- Should be used at the lowest effective dose
- For temporary periods (<6 months) as adjunctive treatment
- Intra-articular injections can be considered for local symptoms 1
Combination Therapy
When to Consider Combination Therapy
- If the treatment target is not reached by 6 months with first-line therapy 2
- Triple therapy (MTX + sulfasalazine + hydroxychloroquine) has shown superior efficacy compared to MTX alone or dual combinations 4, 5
- 78% of patients on triple therapy achieved ACR 20% response at 2 years compared to 60% with MTX + hydroxychloroquine and 49% with MTX + sulfasalazine 5
Biologic DMARDs
Consider adding biologic DMARDs (bDMARDs) if inadequate response to conventional DMARDs:
For patients with heart failure (NYHA class III or IV):
- Non-TNF inhibitor bDMARDs are preferred over TNF inhibitors 1
Monitoring and Treatment Goals
Treatment Target
- The main goal is to achieve clinical remission (DAS28 <2.6) or low disease activity 1, 2
- Regular monitoring of disease activity should include:
- Tender and swollen joint counts
- Patient and physician global assessments
- ESR and CRP
- Assessment every 1-3 months until target is reached 1
Safety Monitoring
- Regular blood counts, liver function, and renal function tests 2
- Screen for tuberculosis and hepatitis B before starting biologics 2
- Monitor immunoglobulin levels before and during rituximab treatment 2
Special Considerations
Pulmonary Disease
- Methotrexate can still be used in patients with mild and stable airway or parenchymal lung disease 1
- Patients should be informed of increased risk of methotrexate pneumonitis 1
Subcutaneous Nodules
- If progressive subcutaneous nodules develop while on methotrexate, consider switching to a non-methotrexate DMARD 1
Non-Pharmacological Interventions
- Dynamic exercises and occupational therapy should be considered as adjuncts to drug treatment 1
- Smoking cessation, dental care, weight control, and vaccination status assessment are important 1
- Patient education programs for coping with pain, disability, and maintaining work ability 1
Common Pitfalls to Avoid
- Delayed Treatment: Don't wait for fulfillment of classification criteria to start DMARDs in patients at risk of persistent disease 1
- Inadequate Methotrexate Dosing: Many patients receive suboptimal dosing; ensure appropriate dose escalation 3
- Premature Discontinuation: Continue oral MTX for at least 6 months before determining treatment failure 3
- Ignoring Route of Administration: Consider subcutaneous MTX if oral administration fails due to intolerance or inadequate response 3
- Overlooking Non-Pharmacological Approaches: These are important adjuncts to medication therapy 1