What is the treatment for Chikungunya arthritis?

Chikungunya Arthritis Treatment

For acute chikungunya arthritis, use NSAIDs as first-line therapy for pain and inflammation control; for chronic chikungunya arthritis lasting beyond 3 months, initiate methotrexate as disease-modifying therapy.

Acute Phase Management (First 3 Months)

Symptomatic Treatment

• NSAIDs are the primary treatment for acute chikungunya arthritis to control joint pain and inflammation 1, 2, 3.
• Analgesics and antipyretics provide symptomatic relief during the acute viremic phase 1, 3.
• Consider short-term oral corticosteroids (prednisolone 30-35 mg/day for 3-5 days) for severe multi-joint involvement, though this is extrapolated from other inflammatory arthritis management 4.
• Avoid intra-articular corticosteroid injections during the acute phase 5.

Important Caveats

• Use NSAIDs with caution in patients with renal impairment, and consider adding a proton pump inhibitor for gastrointestinal protection 4.
• NSAIDs may increase cardiovascular risk with prolonged use 4.
• No antiviral drugs are currently available for chikungunya virus infection 1, 6, 7.

Chronic Phase Management (Beyond 3 Months)

Disease-Modifying Therapy

• Methotrexate is the anchor drug for chronic chikungunya arthritis that persists beyond the acute phase 2, 7.
• The rationale for methotrexate use stems from pathogenetic similarities with rheumatoid arthritis, including elevated proinflammatory cytokines and chemokines in chronic disease 2.
• Attempts to isolate chikungunya virus from synovial fluid in chronic arthritis have been unsuccessful, suggesting a postinfectious inflammatory process rather than persistent viral infection 2.

Adjunctive Therapies

• Continue NSAIDs as needed for breakthrough pain 2, 3.
• Apply heat therapy to affected joints to improve pain and physical function 8.
• Implement regular exercise programs including aerobic and resistance training to improve muscle strength and reduce pain 8.
• Hand therapy exercises are important for patients with hand involvement 8.
• Consider massage therapy delivered by experienced providers 8.

Monitoring and Escalation

• If methotrexate monotherapy fails to achieve adequate disease control, consider other disease-modifying antirheumatic drugs (DMARDs) such as hydroxychloroquine 5, 2.
• Intra-articular corticosteroid injections may be used for persistent single-joint inflammation in the chronic phase 5.
• Refer to rheumatology for patients with severe, refractory chronic arthritis 5.

Key Pathophysiologic Considerations

The treatment approach differs between acute and chronic phases because:

• Acute phase represents active viral infection with viremia, requiring symptomatic management 1, 3.
• Chronic phase represents a postinfectious inflammatory arthritis driven by cytokines and chemokines, justifying DMARD therapy 2, 7.
• Multiple proinflammatory mediators have been identified in chronic chikungunya arthritis, supporting the use of immunomodulatory therapy 2.

Common Pitfalls to Avoid

• Do not delay DMARD initiation in patients with persistent arthritis beyond 3 months, as chronic chikungunya arthritis can be painful and disabling 2, 7.
• Do not use long-term corticosteroids as monotherapy due to risks of cataracts, osteoporosis, and cardiovascular disease 4.
• Do not expect antiviral drugs to treat chronic arthritis, as no commercially available antivirals exist and chronic disease is postinfectious 1, 6, 7.
• Ensure tobacco cessation, as smoking can worsen inflammatory arthritis symptoms 8.