What is the role of Iguratimod in the treatment of osteoarthritis?

Iguratimod Has No Established Role in Osteoarthritis Treatment

Iguratimod is not recommended for osteoarthritis as it is not mentioned in any major osteoarthritis treatment guidelines and lacks clinical trial evidence demonstrating efficacy for this indication.

Current Evidence Status

The available evidence reveals a critical gap:

• No guideline support: Major osteoarthritis guidelines from NICE 1, the American College of Rheumatology 1, AAOS 1, and EULAR 1 make no mention of iguratimod as a treatment option for osteoarthritis 1

• Wrong disease indication: All available research on iguratimod focuses exclusively on rheumatoid arthritis (RA) and related inflammatory conditions, not osteoarthritis 2, 3, 4, 5, 6

• Mechanistic mismatch: Iguratimod's mechanism targets inflammatory pathways (RANKL, TNF-α, NF-κB) relevant to RA and inflammatory bone loss 2, 3, which differs fundamentally from the predominantly mechanical and degenerative pathology of osteoarthritis

Established Osteoarthritis Treatment Algorithm

Instead of iguratimod, follow this evidence-based approach:

Core Treatments (Start Here for Every Patient)

• Exercise therapy focusing on strengthening and aerobic fitness 1
• Weight loss if overweight or obese 1
• Patient education about the condition and self-management strategies 1

First-Line Pharmacological Treatment

• Acetaminophen (paracetamol) up to 4 grams daily for pain relief 1
• Topical NSAIDs before considering oral NSAIDs, particularly for knee and hand osteoarthritis 1

Second-Line Pharmacological Treatment

If acetaminophen and topical NSAIDs provide insufficient relief:

• Oral NSAIDs or COX-2 inhibitors at the lowest effective dose for the shortest duration 1
• Always prescribe with a proton pump inhibitor for gastroprotection 1
• Assess cardiovascular, gastrointestinal, and renal risk factors before prescribing, especially in elderly patients 1

Third-Line Options

• Duloxetine for patients with contraindications to NSAIDs or inadequate response 1
• Intra-articular corticosteroid injections for moderate to severe pain, particularly with effusion 1
• Tramadol only when other options exhausted, recognizing modest benefits and addiction potential 1

Adjunctive Non-Pharmacological Treatments

• Local heat or cold applications for temporary symptom relief 1
• Manual therapy (manipulation and stretching) combined with exercise 1
• Assistive devices and braces for specific functional limitations 1

Treatments Explicitly NOT Recommended

• Glucosamine and chondroitin are strongly recommended against for knee and hip OA 1
• Hyaluronic acid injections are conditionally or strongly recommended against depending on the joint 1
• Opioids (non-tramadol) are conditionally recommended against due to minimal benefit and high toxicity risk 1
• Hydroxychloroquine and methotrexate have no efficacy in osteoarthritis 1

Critical Distinction: Rheumatoid Arthritis vs. Osteoarthritis

Iguratimod is approved and effective for rheumatoid arthritis, particularly in combination with methotrexate 5, 6. However, RA is an autoimmune inflammatory disease requiring immunomodulation, while osteoarthritis is a degenerative joint disease requiring pain management, mechanical support, and functional optimization. These are fundamentally different conditions requiring different therapeutic approaches 1, 2.

Surgical Referral Considerations

Consider joint replacement surgery when:

• Joint symptoms substantially affect quality of life 1
• Symptoms are refractory to non-surgical treatment 1
• Referral should occur before prolonged functional limitation develops 1
• Age, sex, smoking, obesity, and comorbidities should not be barriers to referral 1