What is the initial treatment for arthritis in an urgent care setting?

Initial Treatment for Arthritis in an Urgent Care Setting

NSAIDs should be considered as the first-line treatment for arthritis in an urgent care setting after careful evaluation of gastrointestinal, renal, and cardiovascular risks. 1, 2

Initial Assessment and Treatment Algorithm

• Arthritis is characterized by joint swelling associated with pain or stiffness 1
• In the urgent care setting, clinical examination is the primary method for detecting synovitis 1
• Initial laboratory tests should include complete blood count, urinary analysis, transaminases, and antinuclear antibodies to exclude other conditions 1

First-Line Treatment Options

• NSAIDs are the recommended initial therapy for symptomatic relief of arthritis in the urgent care setting 1, 2
• Use NSAIDs at the minimum effective dose for the shortest time possible to minimize adverse effects 1, 2
• For juvenile idiopathic arthritis with 4 or fewer affected joints and low disease activity, NSAID monotherapy is appropriate as initial treatment 1
• Intra-articular glucocorticoid injections should be considered for relief of local symptoms of inflammation, particularly for oligoarticular involvement 1, 2

Glucocorticoid Considerations

• Systemic glucocorticoids (e.g., prednisone) can be considered as a temporary adjunctive treatment to reduce pain and swelling 1, 3
• Intra-articular injections with triamcinolone hexacetonide are recommended and can provide clinical improvement for at least 4 months 1
• Limit systemic glucocorticoids to the lowest effective dose for the shortest duration possible (less than 6 months) to avoid cumulative side effects 1, 3

Treatment Based on Disease Activity and Prognosis

Moderate to High Disease Activity

• For patients with high disease activity and features of poor prognosis, consider initiating methotrexate without prior therapy 1, 4, 5
• Following initial glucocorticoid joint injections, methotrexate should be considered for patients with high disease activity without poor prognostic features 1, 5
• For enthesitis-related arthritis with moderate or high disease activity, sulfasalazine is recommended following glucocorticoid joint injection or an adequate NSAID trial 1

Monitoring and Follow-up

• Disease activity should be assessed at 1-3 month intervals until treatment target is reached 1, 4
• Monitoring should include tender and swollen joint counts, patient and physician global assessments, ESR, and CRP 1
• Non-pharmacological interventions such as dynamic exercises and occupational therapy should be considered as adjuncts to drug treatment 1, 2

Common Pitfalls to Avoid

• Continuing NSAID monotherapy for longer than 2 months in patients with active arthritis is inappropriate 1
• Using acetaminophen as first-line therapy may be less effective than NSAIDs for inflammatory arthritis, as studies show limited efficacy compared to NSAIDs 6, 7, 8
• Delaying referral to a rheumatologist for patients with persistent symptoms beyond 4-6 weeks 2, 4
• Failing to consider cardiovascular, renal, and gastrointestinal risks when prescribing NSAIDs 1

In the urgent care setting, the goal is to provide symptomatic relief while establishing a diagnosis and treatment plan. Early recognition and appropriate initial management are critical to prevent potential progression to chronic arthritis 2.