Initial Treatment for Arthritis
NSAIDs are the recommended first-line treatment for symptomatic relief of arthritis, used at the minimum effective dose for the shortest duration possible after evaluating gastrointestinal, renal, and cardiovascular risks. 1, 2
Immediate Assessment Before Treatment
Before initiating NSAIDs, you must evaluate three critical risk domains 1, 2:
- Gastrointestinal risk: History of peptic ulcer disease, GI bleeding, age >65 years, concurrent corticosteroid or anticoagulant use 2
- Cardiovascular risk: History of myocardial infarction, stroke, heart failure, hypertension, or established cardiovascular disease 2
- Renal risk: Chronic kidney disease, volume depletion, concurrent ACE inhibitor or diuretic use 2
First-Line Pharmacologic Treatment Algorithm
For Oligoarticular Involvement (≤4 joints)
- Intra-articular glucocorticoid injections are the preferred initial approach for localized joint inflammation, particularly with triamcinolone hexacetonide providing clinical improvement for at least 4 months 2, 3
- NSAID monotherapy is appropriate for low disease activity, but should not continue beyond 2 months if active arthritis persists 2
For Polyarticular Involvement (>4 joints)
- Start NSAIDs at minimum effective dose (e.g., ibuprofen 1200-1800 mg/day divided doses) for symptomatic relief 2, 4
- Systemic glucocorticoids can be added as temporary adjunctive therapy (prednisone 10-20 mg/day or equivalent) to reduce pain and swelling, but limit to lowest dose for <6 months to avoid cumulative side effects 1, 2
- Common pitfall: Continuing NSAID monotherapy beyond 2 months in patients with persistent active arthritis is inappropriate and delays definitive treatment 2
When to Escalate to Disease-Modifying Therapy
Patients at risk of persistent arthritis should be started on DMARDs within 3 months of symptom onset, even if they don't fulfill classification criteria for a specific inflammatory rheumatic disease. 1
Risk Factors for Persistent Disease Requiring DMARD Initiation
- High number of swollen joints (typically >4) 1
- Elevated acute phase reactants (ESR, CRP) 1
- Positive rheumatoid factor or anti-citrullinated peptide antibodies (ACPA) 1
- Imaging findings showing synovitis or erosions 1
DMARD Selection
- Methotrexate is the anchor drug and should be part of the first treatment strategy unless contraindicated, typically starting at 7.5-15 mg weekly orally 1, 5, 6
- For patients with high disease activity and poor prognostic features, consider initiating methotrexate without prior NSAID trial 2, 5
- The FDA-approved starting dose for rheumatoid arthritis is 7.5 mg once weekly as a single oral dose, or 2.5 mg at 12-hour intervals for 3 doses given once weekly 6
Essential Non-Pharmacologic Interventions
- Dynamic exercises and occupational therapy should be considered as adjuncts to drug treatment in all patients with early arthritis 1, 2
- Smoking cessation, dental care, weight control, vaccination status assessment, and comorbidity management are integral components of care 1
Monitoring Strategy
Disease activity must be assessed at 1-3 month intervals until treatment target (clinical remission) is reached. 1, 2
Each assessment should include 1, 5:
- Tender and swollen joint counts (28-joint count minimum)
- Patient and physician global assessments
- ESR and CRP measurement
- Composite disease activity measure (SDAI or CDAI)
Critical Timing Considerations
- Patients presenting with joint swelling associated with pain or stiffness should be referred to rheumatology within 6 weeks of symptom onset 1, 5
- Therapeutic response to methotrexate typically begins within 3-6 weeks, with continued improvement for another 12 weeks or more 6
- Common pitfall: Failing to refer promptly to rheumatology delays DMARD initiation and worsens long-term outcomes including joint damage and physical function 1, 5