What is the recommended prescription for treating viral arthritis?

Sample Prescription for Viral Arthritis

For viral arthritis, initiate treatment with NSAIDs at the minimum effective dose for symptomatic relief, as this condition is typically self-limited and resolves without aggressive immunosuppression. 1

First-Line Prescription

Naproxen 500 mg PO twice daily with food

• Duration: 7-14 days initially 1
• Dispense: #28 tablets
• Refills: 1

OR

Ibuprofen 400-600 mg PO three times daily with food

• Duration: 7-14 days initially 1
• Dispense: #42 tablets (if 600 mg) or #84 tablets (if 400 mg)
• Refills: 1

Key Prescribing Considerations

• Before prescribing NSAIDs, assess gastrointestinal, renal, and cardiovascular risk factors 1, 2
• Use the lowest effective dose for the shortest duration possible to minimize adverse effects including gastritis, ulcers, bleeding, renal impairment, and cardiovascular events 1, 2
• NSAIDs should not be used in patients with aspirin-sensitive asthma, active peptic ulcer disease, or immediately post-cardiac surgery 2, 3
• Avoid in late pregnancy 2, 3

Second-Line Option for Oligoarticular Involvement

If 1-4 joints are predominantly affected and NSAIDs provide insufficient relief:

Triamcinolone acetonide 40 mg intra-articular injection (for large joints like knee)

• Can provide clinical improvement for at least 4 months 1
• Particularly effective for localized joint inflammation 1

OR

Triamcinolone acetonide 10-20 mg intra-articular injection (for smaller joints)

Escalation for Persistent Symptoms Beyond 2-4 Weeks

If symptoms persist despite NSAIDs:

Prednisone 10-20 mg PO daily

• Duration: Taper over 2-4 weeks 1
• Dispense: #30 tablets (10 mg)
• Use lowest effective dose for shortest duration (<6 months total) 1

Critical Monitoring Points

• Reassess at 2-4 weeks: If no improvement with NSAIDs alone, consider glucocorticoids or intra-articular injections 1
• Refer to rheumatology if symptoms persist beyond 4-6 weeks, as this may indicate progression to chronic inflammatory arthritis rather than self-limited viral arthritis 1
• Do not continue NSAID monotherapy beyond 2 months in patients with persistent active arthritis 4

Common Pitfalls to Avoid

• Do not prescribe methotrexate or other DMARDs for typical viral arthritis, as it is usually self-limited and does not require immunosuppression 5, 1, 6
• Avoid long-term NSAID use without gastroprotection in patients over 65, those with history of ulcers, or concurrent corticosteroid/anticoagulant use 2
• Do not use hepatotoxic agents like methotrexate in patients with concurrent hepatitis C-related viral arthritis 5
• Failing to distinguish viral arthritis from rheumatoid arthritis: Viral arthritis is typically non-erosive, non-deforming, and self-limited, whereas RA requires aggressive DMARD therapy 5

Special Considerations for HCV-Related Arthritis

If hepatitis C virus is the underlying cause:

• Low-dose glucocorticoids and hydroxychloroquine are preferred over methotrexate 5
• Antiviral therapy targeting HCV should be considered as definitive treatment 5
• Avoid potentially hepatotoxic DMARDs like methotrexate and leflunomide 5