What are the treatment options for arthropathy?

Treatment of Arthropathy

For IBD-associated arthropathy, control of intestinal inflammation through optimized IBD therapy is the primary treatment, supplemented by physiotherapy and simple analgesia, with progression to DMARDs or biologics only for persistent symptoms. 1

Initial Assessment and Classification

The approach to arthropathy treatment depends critically on the underlying type:

• IBD-associated arthropathy requires distinguishing between Type 1 (fewer than 5 joints, asymmetric, lower limb predominant) and Type 2 (more than 5 joints, symmetric, upper limb predominant), as treatment strategies differ significantly 1
• Osteoarthritis requires holistic assessment of impact on function, quality of life, occupation, mood, relationships, and leisure activities before formulating a management plan 1
• Early inflammatory arthritis (any joint swelling with pain or stiffness) should prompt referral to rheumatology within 6 weeks of symptom onset 1

Treatment Algorithm for IBD-Associated Arthropathy

Type 1 Peripheral Arthropathy (≤5 joints, asymmetric)

First-line approach:

• Optimize treatment of underlying IBD, as joint inflammation typically parallels intestinal disease activity 1
• Initiate physiotherapy immediately 1
• Use simple analgesia (acetaminophen preferred over NSAIDs due to IBD considerations) 1

Second-line for non-responders:

• Local corticosteroid injections for persistent joint symptoms 1
• Consider sulfasalazine, methotrexate, or anti-TNF therapy for the small proportion with persistent problems 1

Type 2 Peripheral Arthropathy (>5 joints, symmetric)

• This pattern is typically independent of gut inflammation and requires more aggressive management 1
• Refer to rheumatology for consideration of immunomodulator or biological therapy 1
• Rule out other causes: non-specific arthralgia, osteonecrosis, lupus-like syndrome from anti-TNF therapy, corticosteroid withdrawal arthralgia, or azathioprine-related arthralgia 1

Axial Spondyloarthropathy

Red flags requiring immediate investigation:

• Low back pain in patients under 45 years 1
• Duration >3 months 1
• Pain improved with exercise but not relieved by rest 1
• Pain worse in latter part of night 1
• Morning stiffness >30 minutes 1

Diagnostic workup:

• MRI scanning (sagittal cervicothoracic and thoracolumbar regions with T1 and STIR images, coronal/oblique sacroiliac joints with T1 and STIR) 1
• Note: Plain radiography will miss most early disease 1
• HLA-B27 testing (though less often positive in IBD-associated cases) 1

Treatment:

• NSAIDs are more effective than simple analgesia, but use cautiously in IBD patients 1
• Sulfasalazine and methotrexate are NOT effective for axial disease 1
• Early progression to anti-TNF agents is often necessary 1
• Specialist physiotherapy is essential to prevent long-term disability 1

Treatment Algorithm for Osteoarthritis

Core Treatments (Universal for All OA Patients)

These must be provided to every patient before or alongside other interventions: 1, 2

• Patient education: Provide written and oral information countering the misconception that OA is inevitably progressive and untreatable 1, 2
• Exercise programs: Local muscle strengthening and general aerobic fitness, including walking, aquatic exercise, and strengthening exercises 1, 2
• Weight loss: Strongly recommended for overweight/obese patients with knee or hip OA to reduce joint load 1, 2
• Self-management strategies: Emphasize behavioral changes including appropriate footwear with shock-absorbing properties and activity pacing 1

Non-Pharmacological Adjuncts (Add Based on Joint Involvement)

For knee OA:

• Tibiofemoral bracing (strongly recommended) 2
• Patellofemoral bracing (conditionally recommended) 2
• Local heat or cold applications 1, 2
• TENS for pain relief 1

For hip OA:

• Cane use (strongly recommended) 2
• Manipulation and stretching (particularly beneficial) 1
• Balance exercises 2

For hand OA:

• First carpometacarpal (CMC) joint orthoses (strongly recommended) 2
• Orthoses for other hand joints (conditionally recommended) 2

Assistive devices:

• Walking sticks, tap turners for activities of daily living 1
• Consider occupational therapy consultation 1

Pharmacological Treatment Ladder for OA

Step 1: Topical therapy (for accessible joints, especially knee)

• Topical NSAIDs are strongly recommended as first-line pharmacological treatment for knee OA due to effective pain relief with minimal systemic exposure 2, 1
• Topical capsaicin can be considered 1

Step 2: Oral acetaminophen

• Offer regular dosing up to 4g/day for pain relief 1, 3
• Note: Recent guidelines have downgraded acetaminophen's importance due to limited efficacy, making it conditionally recommended 2, 3

Step 3: Oral NSAIDs/COX-2 inhibitors

• Use at the lowest effective dose for the shortest possible period 1, 2, 3
• First choice should be either a COX-2 inhibitor (other than etoricoxib 60mg) or standard NSAID 1
• Always prescribe with a proton pump inhibitor for gastroprotection, choosing the one with lowest acquisition cost 1, 3
• Assess cardiovascular, gastrointestinal, renal, and liver risk factors before prescribing, especially in elderly patients 1, 3

Step 4: Duloxetine

• Conditionally recommended for patients with inadequate response to first-line treatments or with comorbid depression 2, 3

Step 5: Tramadol (reserve for refractory cases)

• Conditionally recommended only when other options have failed 2, 3
• Carries significant risks of dependence and side effects 2

Step 6: Intra-articular corticosteroid injections

• Strongly recommended for knee and hip OA for short-term pain relief during flares 2, 3
• Can be used at any stage for persistent symptoms 2

Treatments NOT Recommended for OA

• Electroacupuncture should not be used 1
• Glucosamine and chondroitin products are not recommended despite popular use 1, 2, 3
• Opioids (other than tramadol as last resort) are not recommended for initial management 3

Treatment Algorithm for Early Inflammatory Arthritis

Initial Management (Within 3 Months of Symptom Onset)

For patients at risk of persistent arthritis (based on number of swollen joints, acute phase reactants, RF, ACPA, imaging findings):

• Start DMARDs as early as possible, ideally within 3 months, even if classification criteria for inflammatory rheumatologic disease are not fulfilled 1
• Methotrexate is the anchor drug and should be part of first treatment strategy unless contraindicated 1

Adjunctive therapies:

• NSAIDs at minimum effective dose for shortest time after evaluating GI, renal, and cardiovascular risks 1
• Systemic glucocorticoids reduce pain, swelling, and structural progression but should be used at lowest dose as temporary (<6 months) adjunctive treatment 1
• Intra-articular glucocorticoid injections for local symptom relief 1

Monitoring and Treatment Targets

• Goal: Achieve clinical remission 1
• Monitor disease activity at 1-3 month intervals using tender/swollen joint counts, patient and physician global assessments, ESR, CRP, typically via composite measure 1
• Regular monitoring should guide decisions on treatment strategy changes 1

Critical Pitfalls to Avoid

• Do not delay rheumatology referral for early inflammatory arthritis beyond 6 weeks of symptom onset 1
• Do not use NSAIDs without gastroprotection in at-risk patients 1, 3
• Do not treat IBD-associated Type 1 arthropathy with aggressive immunosuppression before optimizing IBD therapy 1
• Do not miss axial spondyloarthropathy by relying on plain radiography; use MRI for early detection 1
• Do not prescribe glucosamine/chondroitin despite patient requests, as evidence does not support use 1, 2, 3
• Do not use sulfasalazine or methotrexate for axial spondyloarthropathy, as they are ineffective 1
• Do not forget core non-pharmacological treatments for OA, as they form the foundation of management 1, 2