What medications are used to treat arthritis?

Medications for Treating Arthritis

For patients with arthritis, the first-line medication treatment should be NSAIDs for symptom management, with progression to disease-modifying antirheumatic drugs (DMARDs) like methotrexate for persistent inflammatory arthritis, followed by biologic agents for refractory cases. 1, 2

Initial Treatment Options

• NSAIDs (such as naproxen) are conditionally recommended as adjunct therapy for symptom management in arthritis, particularly during initiation or escalation of therapy with DMARDs or biologics 2, 1
• NSAIDs have been shown to decrease joint swelling, reduce morning stiffness, and improve mobility in patients with rheumatoid arthritis, osteoarthritis, and other forms of arthritis 3
• NSAIDs are not appropriate as monotherapy for chronic, persistent inflammatory arthritis 1, 2
• Topical NSAIDs are strongly recommended for knee osteoarthritis as they provide effective pain relief with minimal systemic exposure 4

Second-Line Treatment Options

• DMARDs are strongly recommended over NSAID monotherapy for persistent inflammatory arthritis 2, 1
• Methotrexate is conditionally recommended over other DMARDs such as leflunomide or sulfasalazine due to greater evidence supporting its effectiveness 2, 1
• Subcutaneous methotrexate is conditionally recommended over oral administration for better bioavailability 2, 1
• For patients with psoriatic arthritis, methotrexate is recommended when significant skin involvement exists 5
• Intraarticular glucocorticoid injections are conditionally recommended as adjunct therapy for localized joint inflammation 2, 1
• Triamcinolone hexacetonide is strongly recommended over triamcinolone acetonide for intraarticular injections 2, 1

Advanced Treatment Options

• For patients with persistent moderate/high disease activity despite DMARD therapy, adding a biologic agent (TNF inhibitors, IL-17 inhibitors, etc.) to the original DMARD is conditionally recommended 1, 2
• Combination therapy with a DMARD is conditionally recommended for most biologics and strongly recommended for infliximab 2, 1
• For patients who fail a first TNF inhibitor, switching to a non-TNF biologic, such as tocilizumab or abatacept, is conditionally recommended 1, 6
• JAK inhibitors may be considered in patients with peripheral arthritis and inadequate response to at least one bDMARD, taking safety considerations into account 2

Special Considerations for Different Types of Arthritis

Rheumatoid Arthritis

• Early aggressive therapy with DMARDs is recommended for newly diagnosed cases 6, 7
• Methotrexate is the preferred first-line DMARD 2, 6
• Short-term oral glucocorticoids may be used as bridging therapy during initiation or escalation of treatment in patients with moderate to high disease activity 2

Osteoarthritis

• Topical NSAIDs are strongly recommended for knee OA 4, 8
• Oral NSAIDs are strongly recommended for hand, knee, and hip OA, but should be used at the lowest effective dose for the shortest duration due to gastrointestinal and cardiovascular risks 4, 8
• Acetaminophen is conditionally recommended for mild to moderate pain, though recent guidelines have downgraded its importance due to limited efficacy 4, 8
• Intra-articular corticosteroid injections are strongly recommended for knee and hip OA for short-term pain relief during flares 4, 8

Psoriatic Arthritis

• For mild peripheral arthritis, NSAIDs are recommended as first-line therapy 5, 2
• For moderate to severe peripheral arthritis, DMARDs should be initiated rapidly, with methotrexate preferred when significant skin involvement exists 5, 2
• TNF inhibitors, IL-17 inhibitors, or IL-12/23 inhibitors are recommended for inadequate response to at least one DMARD 2, 5

Monitoring and Safety Considerations

• Regular assessment of disease activity using validated tools is recommended for inflammatory arthritis 1
• Monitor for medication side effects, particularly hepatotoxicity with methotrexate and gastrointestinal effects with NSAIDs 1, 3
• NSAIDs can cause ulcers and bleeding in the stomach and intestines, with increased risk in older adults and those taking corticosteroids 3
• Chronic low-dose glucocorticoids are strongly recommended against, regardless of risk factors or disease activity 2, 1

Adjunctive Therapies

• Physical therapy and/or occupational therapy are conditionally recommended for patients who have or are at risk for functional limitations 2, 1
• Regular exercise programs, weight loss for overweight patients, and self-management education are strongly recommended as core treatments for osteoarthritis 4