What are the initial treatment recommendations for arthritis?

Initial Treatment Recommendations for Arthritis

For patients with early arthritis, methotrexate is considered the anchor drug and should be the first-line disease-modifying antirheumatic drug (DMARD) treatment in patients at risk of persistent disease, unless contraindicated. 1

Diagnosis and Initial Assessment

• Arthritis is characterized by joint swelling associated with pain or stiffness. Patients presenting with arthritis of more than one joint should be referred to a rheumatologist, ideally within 6 weeks after symptom onset 1
• Clinical examination is the primary method for detecting synovitis, with ultrasonography as a confirmatory tool in doubtful cases 1
• Initial laboratory assessment should include complete blood count, urinary analysis, transaminases, antinuclear antibodies, ESR, and CRP 1
• Risk factors for persistent and/or erosive disease should be evaluated, including number of swollen/tender joints, acute phase reactants, rheumatoid factor, anti-CCP antibodies, and radiographic findings 1

Pharmacological Treatment Algorithm

First-line Treatment:

• DMARDs should be started as early as possible (ideally within 3 months) in patients at risk of persistent arthritis, even if they don't yet fulfill classification criteria for inflammatory rheumatological diseases 1
• Methotrexate is the anchor drug of choice with recommended starting doses:
  • For adult rheumatoid arthritis: 7.5 mg once weekly orally, or 2.5 mg at 12-hour intervals for 3 doses given once weekly 2
  • For juvenile rheumatoid arthritis: 10 mg/m² once weekly 2
  • Dosage may be gradually adjusted to achieve optimal response, generally not exceeding 20 mg/week in adults 2

Symptomatic Treatment:

• NSAIDs should be used at the minimum effective dose for the shortest time possible after evaluating gastrointestinal, renal, and cardiovascular risks 1
• Systemic glucocorticoids can be used as temporary (<6 months) adjunctive treatment at the lowest effective dose to reduce pain and swelling 1
• Intra-articular glucocorticoid injections should be considered for relief of localized inflammation 1

Monitoring and Treatment Targets

• The main goal of DMARD treatment is to achieve clinical remission 1
• Disease activity should be monitored using:
  • Tender and swollen joint counts
  • Patient and physician global assessments
  • ESR and CRP measurements
  • Composite disease activity measures 1
• Assessment frequency should be every 1-3 months until treatment target is reached 1
• Structural damage should be assessed by radiographs of hands and feet every 6-12 months during the first few years 1

Non-pharmacological Interventions

• Dynamic exercises and occupational therapy should be considered as adjuncts to drug treatment 1
• Patient education programs focused on coping with pain, disability, and maintaining work ability are important 1, 3
• Lifestyle modifications including smoking cessation, dental care, weight control, and management of comorbidities should be part of overall patient care 1

Important Considerations and Pitfalls

• Regular monitoring of potential methotrexate toxicity is essential, including complete blood count, liver function, and renal function tests 2
• NSAIDs can interact with methotrexate by reducing its tubular secretion, potentially enhancing toxicity, especially at higher doses 2
• Initial intensive treatment with combination DMARDs may provide better outcomes than monotherapy in patients with severe disease, but the benefit-to-risk ratio favors starting with methotrexate monotherapy in most cases 1
• Non-pharmaceutical interventions alone have not been shown to improve long-term outcomes such as radiographic progression and should be used as adjuncts to pharmaceutical treatment 1, 3

By following this structured approach to early arthritis treatment with prompt DMARD initiation (particularly methotrexate), appropriate symptomatic management, regular monitoring, and complementary non-pharmacological interventions, patients have the best chance for optimal outcomes in terms of disease control, joint preservation, and quality of life.