What are the recommended treatments for arthritis?

Recommended Treatments for Arthritis

The core treatment approach for arthritis should include a combination of non-pharmacological interventions (exercise, weight management) and pharmacological therapies (starting with paracetamol/NSAIDs), with disease-modifying antirheumatic drugs (DMARDs) initiated early for inflammatory arthritis to prevent joint damage and disability.

Types of Arthritis and Initial Assessment

Different types of arthritis require different treatment approaches:

• Osteoarthritis (OA): Degenerative joint disease affecting cartilage
• Rheumatoid Arthritis (RA): Autoimmune inflammatory arthritis
• Juvenile Idiopathic Arthritis (JIA): Inflammatory arthritis in children

Key assessment factors:

• Number of swollen and tender joints
• ESR or CRP levels
• Rheumatoid factor and anti-CCP antibodies (for suspected RA)
• Radiographic evidence of erosions

Non-Pharmacological Treatments

Core Treatments (Strongly Recommended)

• Exercise therapy:

  • Local muscle strengthening
  • General aerobic fitness
  • Dynamic exercises for all arthritis types 1, 2

• Weight management:

  • Weight loss interventions for overweight/obese patients 1, 2
  • Healthy, well-balanced, age-appropriate diet 1, 3

• Patient education:

  • Information about the condition and treatment options
  • Self-management strategies 1, 2

Additional Non-Pharmacological Options

• Physical/occupational therapy 1, 4
• Local heat or cold applications 1
• Assistive devices (walking sticks, tap turners) 1, 2
• Appropriate footwear with shock-absorbing properties 1
• Bracing, joint supports, or insoles for biomechanical joint pain 1

Pharmacological Treatment

For Osteoarthritis

1. First-line:

   • Paracetamol (acetaminophen) - regular dosing may be needed 1
   • Topical NSAIDs for knee and hand OA 1, 5

2. Second-line (if first-line insufficient):

   • Oral NSAIDs at lowest effective dose for shortest possible time 1, 6
   • COX-2 inhibitors with proton pump inhibitor 1
   • Consider cardiovascular, GI, and renal risk factors before prescribing 6, 7

3. Additional options:

   • Topical capsaicin 1
   • Intra-articular corticosteroid injections 1, 5

For Rheumatoid Arthritis

1. Early intervention:

   • DMARDs should be started as early as possible in patients at risk of persistent/erosive disease 1, 2
   • Methotrexate is the anchor drug (first choice) 1, 2, 8
   • Initial dose: 15 mg/week with folic acid 1 mg/day 2

2. For symptom relief:

   • NSAIDs after evaluation of GI, renal, and cardiovascular status 1, 6
   • Systemic glucocorticoids as temporary adjunctive treatment 1, 2
   • Intra-articular glucocorticoid injections for local inflammation 1

3. Treatment goal:

   • Achieve remission or low disease activity 2
   • Regular monitoring every 1-3 months until remission achieved 1, 2

Medication Monitoring

• NSAIDs: Monitor CBC, liver function, renal function every 6-12 months 1
• Methotrexate: Monthly hematology, liver and renal function tests every 1-2 months 8
  • Watch for signs of toxicity: nausea, fatigue, dizziness, skin/eye yellowing 8

Special Considerations

Drug Interactions and Precautions

• NSAIDs may increase risk of GI bleeding, cardiovascular events, and renal impairment 6, 7
• Methotrexate interactions with NSAIDs, penicillins, probenecid may increase toxicity 8
• Avoid NSAIDs in severe renal impairment 2

Treatment Algorithm

1. Initial approach: Start with non-pharmacological core treatments for all patients
2. For OA: Add paracetamol/topical NSAIDs → oral NSAIDs if needed → consider adjunctive treatments
3. For RA: Start DMARDs early (methotrexate first-line) + symptomatic treatment with NSAIDs/glucocorticoids
4. Monitor regularly: Assess disease activity, medication efficacy, and adverse effects

Common Pitfalls to Avoid

• Delaying DMARD therapy in RA (should start within 3 months of symptom onset)
• Using NSAIDs without considering cardiovascular, GI, and renal risks
• Neglecting non-pharmacological approaches (exercise, weight management)
• Inadequate monitoring of medication side effects
• Mistaken daily use of weekly methotrexate (can be fatal) 8

By following these evidence-based recommendations and tailoring treatment to the specific type of arthritis, patients can achieve better pain control, improved function, and potentially slow disease progression.