What is the recommended treatment for inflammatory arthralgia?

Treatment of Inflammatory Arthralgia

For inflammatory arthralgia, NSAIDs should be used as first-line treatment, with continuous daily use recommended during active disease periods rather than on-demand use. 1

First-Line Treatment: NSAIDs

• NSAIDs are strongly recommended as the initial pharmacological intervention for inflammatory arthralgia
• No specific NSAID has demonstrated superior efficacy over others 1
• Choice should be based on:
  • Patient's previous NSAID experience
  • Individual risk factors for adverse effects
  • Comorbidities

NSAID Options and Dosing 1:

• Naproxen: 375-1100 mg/day in two doses
• Diclofenac: Starting at 150 mg/day in divided doses, maintenance 75-100 mg/day
• Indomethacin: 150 mg/day in divided doses
• Ibuprofen: 1800 mg/day in divided doses
• Celecoxib: 200-400 mg/day in divided doses
• Etoricoxib: 90 mg/day (or temporarily 120 mg/day)

Administration Strategy:

• Daily NSAID treatment is preferred during active disease periods rather than on-demand use 1
• Dosing may be adjusted based on symptom severity
• For patients with increased gastrointestinal risk, consider:
  • Non-selective NSAIDs plus gastroprotective agent
  • Selective COX-2 inhibitor 1

Second-Line Treatment Options

For Patients with Inadequate Response to NSAIDs:

1. TNF Inhibitors (TNFi)

   • Strongly recommended for patients with active disease despite NSAID treatment 1
   • Options include:
     • Adalimumab: 40 mg subcutaneously every other week 2
     • Etanercept: 50 mg/week subcutaneously 1
     • Infliximab: 3-5 mg/kg intravenously at weeks 0,2, and 6, then every 6-8 weeks 1
     • Golimumab: 50 mg/4 weeks subcutaneously 1
     • Certolizumab: 400 mg/4 weeks or 200 mg/2 weeks subcutaneously 1

2. Intravenous Bisphosphonates (IVBP)

   • Particularly effective for patients with spinal involvement 1
   • Options include:
     • Pamidronate: 3× 30 mg on 3 consecutive days, every 3 months
     • Zoledronate: 5 mg intravenously, according to symptoms

3. Conventional Synthetic DMARDs

   • Generally not recommended for purely axial disease 1
   • Sulfasalazine may be considered for patients with peripheral arthritis 1
   • Consider for patients with contraindications to TNFi or those who decline TNFi therapy

Treatment Algorithm

1. Start with NSAIDs at full anti-inflammatory doses

   • Trial for at least 2-4 weeks
   • If inadequate response to one NSAID, try a second NSAID

2. If inadequate response to at least two different NSAIDs over 1-2 months:

   • For predominantly axial symptoms: Initiate TNFi therapy
   • For peripheral arthritis: Consider sulfasalazine before TNFi
   • For spinal lesions with risk of vertebral collapse: Consider IVBP

3. If primary non-response to first TNFi:

   • Switch to IL-17 inhibitor (secukinumab or ixekizumab) 1

4. If secondary loss of response to first TNFi:

   • Consider switching to another TNFi 1

Special Considerations

• Analgesics (paracetamol/acetaminophen, opioids) may be considered for residual pain when NSAIDs are insufficient, contraindicated, or poorly tolerated 1

• Local glucocorticoid injections may be beneficial for localized musculoskeletal inflammation 1

• Systemic glucocorticoids are not recommended for axial disease but may be considered for inflammatory arthritis related to COVID-19 3

• For COVID-19 related inflammatory arthralgia: Low-dose glucocorticoids and DMARDs have shown success 3

Monitoring and Follow-up

• Regular assessment of disease activity using validated measures
• Monitor for NSAID adverse effects, particularly gastrointestinal and cardiovascular
• For patients on TNFi, monitor for infections and other potential adverse effects

Common Pitfalls to Avoid

1. Delaying effective treatment beyond NSAIDs when response is inadequate
2. Using systemic corticosteroids for axial disease
3. Failing to consider peripheral arthritis when selecting therapy
4. Not recognizing potential causes of inflammatory arthralgia (e.g., COVID-19 infection) 3
5. Continuing ineffective therapy without appropriate escalation

By following this treatment approach, most patients with inflammatory arthralgia should experience significant improvement in pain, function, and quality of life.