What is the initial treatment for inflammatory arthritis?

Initial Treatment for Inflammatory Arthritis

Methotrexate (MTX) is the anchor drug and should be the first treatment for patients with inflammatory arthritis at risk of persistent disease, ideally started within 3 months of symptom onset. 1

First-Line Treatment Algorithm

• Refer patients with joint swelling, pain, or stiffness to a rheumatologist within 6 weeks of symptom onset 1

• Perform clinical examination to detect synovitis, which may be confirmed by ultrasonography if needed 1

• Assess risk factors for persistent/erosive disease including:

  • Number of swollen and tender joints 1
  • Elevated ESR or CRP 1
  • Presence of rheumatoid factor and anti-CCP antibodies 1
  • Radiographic erosions 1

• For patients at risk of persistent inflammatory arthritis:

  • Start methotrexate at 10-15 mg/week, increasing to 15-25 mg/week as tolerated 1
  • Add folic acid supplementation to reduce MTX side effects 2, 3
  • Consider short-term systemic glucocorticoids (prednisone) at low doses for temporary (<6 months) symptom relief 1, 4
  • Consider intra-articular glucocorticoid injections for localized inflammation 1, 4

Symptomatic Relief While Awaiting DMARD Effect

• NSAIDs at minimum effective dose for shortest time possible after evaluating GI, renal, and cardiovascular risks 1, 4
• Temporary systemic glucocorticoids to bridge until DMARDs take effect 1, 4

Treatment Monitoring

• Assess disease activity every 1-3 months until treatment target is reached 1
• Monitor using:
  • Tender and swollen joint counts 1
  • Patient and physician global assessments 1
  • ESR and CRP 1
  • Composite measures like SDAI or CDAI 1
• Target should be remission (SDAI ≤3.3, CDAI ≤2.8) or at least low disease activity (SDAI ≤11, CDAI ≤10) 1

Treatment Escalation (If Target Not Reached at 3-6 Months)

• For patients with moderate disease activity (SDAI >11 to ≤26 or CDAI >10 to ≤22) after 3-6 months on MTX:

  • Add sulfasalazine and hydroxychloroquine for triple DMARD therapy 1
  • OR switch to subcutaneous MTX if oral absorption may be an issue 1

• For patients with high disease activity (SDAI >26 or CDAI >22) at 3 months despite MTX:

  • Add a biologic agent (TNF inhibitor or abatacept) 1
  • Continue MTX in combination with the biologic for optimal efficacy 3, 5

Special Considerations

• In patients with cirrhosis, hydroxychloroquine may be used as first-line therapy due to minimal hepatotoxicity 6
• For reactive arthritis, NSAIDs may be sufficient initially, but persistent cases should follow the same MTX-based approach 4
• Non-pharmacological interventions should be incorporated:
  • Dynamic exercises and occupational therapy 1, 4
  • Patient education about disease management 1
  • Programs for coping with pain and maintaining work ability 1

Common Pitfalls to Avoid

• Delaying DMARD therapy beyond 3 months of symptom onset can lead to irreversible joint damage 1, 3
• Using suboptimal doses of MTX (optimal dose range is 15-25 mg/week) 1, 3
• Failing to monitor disease activity regularly and adjust therapy accordingly 1
• Not considering triple DMARD therapy (MTX + sulfasalazine + hydroxychloroquine) before biologics in moderate disease 1
• Discontinuing MTX when adding biologics rather than continuing it for combination therapy 3, 5