What are the treatment options for managing inflammation?

Managing Inflammation: Evidence-Based Treatment Approach

NSAIDs are the first-line treatment for acute inflammation, with continuous dosing preferred over intermittent use for optimal control, while corticosteroids serve as rapid-acting second-line agents for moderate-to-severe inflammation or when NSAIDs are insufficient. 1

Initial Treatment Strategy

First-Line: NSAIDs

• Start with full-dose NSAIDs for acute inflammation, as 75% of patients achieve good or very good response within 48 hours 1
• Continuous NSAID treatment is superior to intermittent "on-demand" dosing and may retard disease progression in chronic inflammatory conditions 2
• Choose NSAIDs based on the patient's gastrointestinal and cardiovascular risk profile, as all NSAIDs carry dose-dependent risks 2, 3, 4

Key NSAID Selection Considerations:

• For patients with low GI risk and no cardiovascular disease: any traditional NSAID at the lowest effective dose 1, 3
• For patients with GI risk factors (age >65, history of ulcers, concurrent corticosteroids): consider COX-2 selective agents with gastroprotection 2, 5
• Avoid NSAIDs in patients with recent myocardial infarction, heart failure, or immediately before/after coronary artery bypass surgery 3, 4

Monitoring Requirements

• Monitor for GI complications (bleeding, ulceration), cardiovascular events (hypertension, thrombosis), and renal dysfunction with any NSAID use 3, 4
• The risk of serious GI bleeding increases with longer duration, higher doses, advanced age, alcohol use, smoking, and concurrent anticoagulants or corticosteroids 2, 3

Second-Line: Corticosteroids

When to Escalate to Corticosteroids

Add corticosteroids when NSAIDs provide inadequate control or for rapid symptom relief in moderate-to-severe inflammation 1

Local Corticosteroid Administration (Preferred for Localized Inflammation):

• Intra-articular or periarticular injection for monoarticular or oligoarticular inflammation 2, 6
• Triamcinolone hexacetonide is the preferred agent for intra-articular injection due to lower rates of systemic absorption 2, 6
• Dosing: 5-40 mg depending on joint size for intra-articular use; 60 mg for intramuscular administration 6
• Application of ice/cool packs and temporary rest enhance effectiveness 2

Systemic Corticosteroid Administration:

• Use short tapering courses (not long-term therapy) for polyarticular or widespread inflammation 2
• Options include oral prednisone, parenteral methylprednisolone, or ACTH 2
• Systemic corticosteroids should only serve as a bridge to steroid-free maintenance therapies, never as long-term treatment due to significant adverse effects 2, 1

Critical Safety Precautions:

• Rule out infection before administering any corticosteroid 6
• Warn diabetic patients about transient hyperglycemia following injection 6
• Coagulopathy or anticoagulation is not an absolute contraindication unless bleeding risk is very high 6

Third-Line: Disease-Modifying and Biologic Agents

For Chronic Inflammatory Conditions

When NSAIDs and corticosteroids are insufficient or contraindication exists, advance to DMARDs or biologics 1

DMARD Options (for specific conditions):

• Methotrexate: preferred for peripheral arthritis in Crohn's disease and as first-line DMARD for juvenile idiopathic arthritis 2, 1
• Sulfasalazine: effective for peripheral arthritis but not axial disease in spondyloarthropathies 2, 1
• Low-dose colchicine (0.5-1 mg daily): for prophylaxis of recurrent acute crystal arthropathy 2

Biologic Therapy:

• TNF inhibitors (infliximab, adalimumab, golimumab): first-line biologics for moderate-to-severe inflammatory arthritis unresponsive to conventional DMARDs 2, 1
• JAK inhibitors and IL-6 inhibitors: alternative options for refractory cases 2, 1
• IL-1 inhibitors: specifically for systemic juvenile idiopathic arthritis with macrophage activation syndrome 2

Special Considerations for Ocular Inflammation

For neuropathic corneal pain and ocular surface inflammation:

• Loteprednol 0.5% gel or suspension is the preferred topical corticosteroid due to minimal intraocular penetration and lower neurotoxic preservative concentration (0.003% benzalkonium chloride vs 0.05-0.01% in other preparations) 2
• Dosing schedule: four times daily for 2 weeks, then twice daily for 2 weeks, then once daily for 6-12 weeks with slow taper 2
• Steroid-sparing alternatives include cyclosporine A 0.05%, tacrolimus 0.03%, or lifitegrast 5% 2

Common Pitfalls to Avoid

• Never use intermittent NSAID dosing for chronic inflammation—continuous scheduled dosing is more effective 2, 1
• Avoid long-term systemic corticosteroids—they cause significant morbidity and should only bridge to definitive therapy 2, 1
• Do not ignore cardiovascular risk when selecting NSAIDs—emerging evidence suggests both COX-2 selective and non-selective NSAIDs may increase cardiovascular events 2
• Do not use NSAIDs in pregnancy after 30 weeks gestation—risk of fetal harm including oligohydramnios and premature ductus arteriosus closure 4
• Screen for infection before any corticosteroid administration—corticosteroids can mask and worsen underlying infections 6