What is the recommended management for Chikungunya (Chikungunya virus) arthritis?

Management of Chikungunya Arthritis

Initial Symptomatic Treatment

For acute Chikungunya arthritis, start with NSAIDs (at minimum effective dose for shortest duration) after evaluating gastrointestinal, renal, and cardiovascular risk, combined with short-term low-dose corticosteroids (prednisone 10 mg/day for 1-2 months) for symptom relief. 1

• NSAIDs remain first-line for acute phase but should be used cautiously with gastroprotection (proton pump inhibitors or misoprostol) in at-risk patients 2
• Acetaminophen can be added for additional analgesia 1
• Low-dose systemic corticosteroids (prednisone 7.5-10 mg/day) effectively reduce pain and swelling in the acute inflammatory phase 2
• Intra-articular corticosteroid injections provide targeted relief for severely affected joints 2, 3

Chronic/Persistent Arthritis Management (>3 months)

For Chikungunya arthritis persisting beyond 3 months, initiate methotrexate (20 mg/week) as the anchor DMARD, with or without hydroxychloroquine, as this combination has demonstrated sustained clinical improvement. 1, 4

DMARD Therapy Algorithm:

• Methotrexate 20 mg/week is the first-line DMARD for persistent Chikungunya arthritis, showing significant reduction in DAS28 scores (from 6.0 to 2.7) within 4 weeks 4
• Hydroxychloroquine combined with corticosteroids or other DMARDs has proven successful for chronic rheumatic manifestations 1
• Leflunomide 20 mg/day can be used as monotherapy or combined with methotrexate for refractory cases 4
• Sulfasalazine (alone or combined with methotrexate) represents an alternative DMARD option 1

Treatment Duration and Monitoring:

• Initial DMARD trial should be 4 weeks with dexamethasone taper (0-4 mg/day) 4
• Monitor disease activity at 1-3 month intervals using tender/swollen joint counts, ESR, CRP, and patient global assessment 2, 3
• Clinical improvement typically sustains for at least 5 months after 4-week treatment course 4

Evidence Quality Considerations

The strongest evidence comes from a 2023 Brazilian study of 133 patients showing rapid and sustained improvement with methotrexate/leflunomide plus short-term corticosteroids 4. However, a 2022 systematic review found no high-certainty evidence that chloroquine, hydroxychloroquine, or stand-alone methotrexate provides added benefit over NSAIDs alone 5. This apparent contradiction reflects that:

• The systematic review excluded uncontrolled studies and found insufficient controlled trial data 5
• The Brazilian cohort study, while uncontrolled, showed dramatic clinical improvement (DAS28 reduction of 3.3 points) 4
• Real-world clinical experience supports DMARD use despite limited controlled trial evidence 1

Special Populations

Patients with pre-existing rheumatoid arthritis who contract Chikungunya require aggressive management:

• Expect severe disease reactivation even if previously in remission 6
• Double usual corticosteroid doses (average 8.75 mg/day prednisolone) 6
• Consider second-line biologics (anti-TNF, rituximab, tocilizumab) or JAK inhibitors (tofacitinib) for refractory cases 6

Critical Pitfalls to Avoid

• Do not delay DMARD initiation in patients with persistent arthritis beyond 3 months—up to 80% develop chronic disabling symptoms 1
• Avoid prolonged NSAID monotherapy without gastroprotection, given cardiovascular and gastrointestinal risks 2
• Do not use corticosteroids as monotherapy beyond 2 months without concurrent DMARD therapy 2, 1
• Recognize that Chikungunya can trigger true rheumatoid arthritis or spondyloarthropathies in genetically susceptible individuals, requiring long-term rheumatologic management 1

Non-Pharmacological Adjuncts

• Dynamic exercises and occupational therapy should complement pharmaceutical treatment 2, 3
• Current evidence does not support exercise or neuromodulation as stand-alone therapies 5