What is the recommended oral treatment for joint inflammation?

Oral Treatment for Joint Inflammation

For adults with degenerative joint inflammation (osteoarthritis), start with paracetamol (acetaminophen), and if inadequate, use ibuprofen at the lowest effective dose (1.2 g daily) as the most cost-effective NSAID option. 1

Initial Treatment Approach

• Paracetamol should be the first-line oral therapy for joint pain from degenerative arthritis, as it is cheaper, has less gastrointestinal toxicity, and similar withdrawal rates compared to NSAIDs. 1

• If paracetamol provides insufficient relief, ibuprofen is the preferred NSAID because it is safer than diclofenac or naproxen, three to four times cheaper, and the most cost-effective alternative. 1

• NSAIDs are conditionally recommended as adjunct therapy in juvenile idiopathic arthritis (JIA) with polyarthritis, though they should not be used as monotherapy when disease-modifying therapy is indicated. 1

NSAID Selection and Dosing Strategy

• Low-dose ibuprofen (1.2 g daily) is specifically recommended when transitioning from paracetamol or co-codamol for degenerative arthritis. 1

• Naproxen demonstrates neutral cardiovascular risk relative to placebo, while ibuprofen and diclofenac are associated with increased cardiovascular risk. 2

• Modified-release NSAID preparations should not be used as they are relatively expensive with no evidence of superior effectiveness compared to standard formulations. 1

Safety Monitoring and Risk Mitigation

• Discuss potential NSAID side effects with patients before initiating treatment, and review requirements at least every six months, encouraging "as required" rather than continuous use. 1

• For patients under 65 years without cardiovascular or renal contraindications, NSAIDs should be combined with gastroprotection (proton pump inhibitor or H2 blocker). 3

• Assess renal function, cardiovascular risk, and gastrointestinal bleeding risk before prescribing NSAIDs, especially in elderly patients. 3

Management of NSAID-Related Dyspepsia

If upper gastrointestinal symptoms occur with NSAIDs, follow this stepwise approach: 1

1. Confirm the diagnosis of NSAID-associated dyspepsia
2. Review and confirm the need for any drug treatment
3. Consider substituting paracetamol for the NSAID
4. If paracetamol is insufficient, try co-codamol (paracetamol with codeine)
5. Consider low-dose ibuprofen (1.2 g daily) if co-codamol is inadequate
6. Lower the dose of the current NSAID if still required
7. Add acid suppression therapy if sufficient analgesia requires continued NSAID use

Topical NSAIDs

• Topical NSAIDs cannot be recommended as evidence-based treatment for osteoarthritis due to lack of well-designed trials directly comparing topical versus oral formulations. 1

• While topical NSAIDs may reduce gastrointestinal side effects, there is insufficient evidence to support their routine use over oral formulations for joint inflammation. 1, 4

Disease-Modifying Therapy Considerations

• For inflammatory arthritis (JRA/JIA), initial therapy with a DMARD is strongly recommended over NSAID monotherapy, with methotrexate as the preferred agent. 1

• Methotrexate dosing for adult rheumatoid arthritis starts at 7.5 mg once weekly orally, with gradual adjustment to achieve optimal response, not ordinarily exceeding 20 mg/week due to increased toxicity risk. 5

• Subcutaneous methotrexate is conditionally recommended over oral methotrexate in pediatric polyarticular JIA. 1

Critical Pitfalls to Avoid

• Routine prophylaxis with misoprostol or proton pump inhibitors is not cost-effective for reducing serious gastric events in all patients, though may be appropriate in higher-risk individuals. 1

• Avoid chronic low-dose glucocorticoid therapy irrespective of risk factors or disease activity in JIA. 1

• Do not use intravenous colchicine due to high risk of serious toxicity. 3

• Ibuprofen, but not naproxen, attenuates the antiplatelet effects of aspirin, which is clinically significant for patients on cardiovascular prophylaxis. 2