Management of Chikungunya Arthritis
NSAIDs remain the first-line treatment for acute chikungunya arthritis, used at the minimum effective dose for the shortest duration after evaluating gastrointestinal, renal, and cardiovascular risks, with low-dose corticosteroids (prednisone 7.5-10 mg/day) added for inadequate response or severe inflammation. 1, 2
Acute Phase Management (First 3 Months)
Initial Symptomatic Treatment
Start with NSAIDs as first-line therapy for acute chikungunya arthritis, selecting agents like naproxen (1000 mg/day) or etoricoxib (120 mg/day) based on individual risk factors. 1, 2, 3
Evaluate cardiovascular, gastrointestinal, and renal status before initiating NSAIDs, as these agents carry dose-dependent risks that increase with age and comorbidities. 4
Add gastroprotection with proton pump inhibitors in patients with increased gastrointestinal risk, or consider selective COX-2 inhibitors as alternatives. 4
Most patients (89-92%) respond well to NSAIDs alone within the first weeks of treatment, making this an appropriate initial strategy. 5
When to Add Corticosteroids
Add low-dose systemic corticosteroids (prednisone 7.5-10 mg/day) when NSAIDs provide inadequate pain relief or when significant joint swelling persists. 1, 2
Approximately 47-75% of patients require low-dose steroids as adjunctive therapy during the acute inflammatory phase. 5
Use intra-articular corticosteroid injections for severely affected individual joints, particularly effective in oligoarticular involvement. 1, 2
Limit systemic corticosteroid duration to less than 2 months in the acute phase without concurrent DMARD therapy to avoid cumulative side effects including weight gain, hypertension, diabetes, and increased infection risk. 4, 1
Chronic/Persistent Arthritis (Beyond 3 Months)
Identifying Patients Requiring DMARD Therapy
Consider DMARD therapy when arthritis persists beyond 3 months despite NSAIDs and corticosteroids, as up to 80% of chikungunya patients may develop chronic musculoskeletal manifestations. 6
Methotrexate is the anchor DMARD and should be initiated in patients with persistent inflammatory polyarthritis affecting multiple joints (≥3 tender or swollen joints by 28-joint count). 2, 7
Sulfasalazine alone or combined with methotrexate produces good response in 71-84% of patients with chronic chikungunya arthritis. 7
Hydroxychloroquine in combination with corticosteroids or other DMARDs has shown success in treating chronic rheumatic manifestations. 6
Monitoring Disease Activity
Assess disease activity at 1-3 month intervals using tender and swollen joint counts, ESR, CRP, and patient global assessment until remission is achieved. 1, 2
Remission is defined as no tender or swollen joints by 28-joint count, which is achievable in 86-93% of patients with protocol-based treatment. 3
Patients who fail to achieve remission typically have higher baseline disease activity, indicating need for earlier DMARD escalation. 3
Non-Pharmacological Interventions
- Dynamic exercises and occupational therapy should complement pharmaceutical treatment as adjunctive interventions throughout the disease course. 1, 2
Critical Pitfalls to Avoid
Never use prolonged NSAID monotherapy without gastroprotection in elderly patients or those with cardiovascular/gastrointestinal risk factors, as serious complications increase with duration of use. 1
Do not continue corticosteroids as monotherapy beyond 2 months without initiating DMARD therapy in patients with persistent arthritis, as cumulative steroid toxicity outweighs benefits. 1
Avoid delaying DMARD initiation beyond 3 months in patients with persistent inflammatory arthritis, as chronic chikungunya arthritis can be erosive and deforming in 5.6% of cases. 7
Do not assume all post-chikungunya arthritis is self-limited—patients with rheumatoid factor-negative but anti-CCP positive polyarthritis require rheumatologic evaluation and DMARD therapy. 7