What are the guidelines for arthritis treatment?

Guidelines for Arthritis Treatment

Treatment Approach by Arthritis Type

Rheumatoid Arthritis (Adult)

Methotrexate is the first-line DMARD for most patients with rheumatoid arthritis, rapidly escalated to 20-25 mg weekly (or maximum tolerated dose), combined with short-term low-dose glucocorticoids as bridging therapy. 1

Initial Treatment Strategy

• Start methotrexate at 7.5-10 mg weekly and rapidly escalate to 20-25 mg weekly within 4-6 weeks, as this represents the optimal therapeutic dose 1
• Add low-dose glucocorticoids (≤10 mg/day prednisone equivalent) when starting DMARDs in patients with moderate or high disease activity 1, 2
• Limit glucocorticoid duration to less than 3 months and taper as rapidly as clinically feasible to minimize long-term adverse effects including cataracts, osteoporosis, and cardiovascular disease 1

Monitoring and Treatment Escalation

• Monitor disease activity every 1-3 months using validated measures (SDAI, CDAI, or DAS28) with a treatment target of remission or low disease activity 1
• If methotrexate monotherapy fails after 3 months in patients with moderate-to-high disease activity, add a biologic DMARD (preferably a TNF inhibitor) or targeted synthetic DMARD in combination with methotrexate 1
• TNF inhibitors (adalimumab, etanercept, infliximab, golimumab, certolizumab pegol) are the preferred first biologic agents 1

Adjunctive Therapy

• Intra-articular corticosteroids serve as adjunctive therapy for mono- or oligoarthritis, not primary treatment 2
• Use intra-articular corticosteroids as bridging therapy while awaiting DMARD efficacy 2
• Consider intra-articular corticosteroids for persistent synovitis in specific joints despite adequate systemic therapy 2

Special Population Considerations

• For patients with heart failure (NYHA class III or IV), use non-TNF inhibitor biologics or targeted synthetic DMARDs instead of TNF inhibitors, as TNF inhibitors can worsen heart failure 1
• Perform tuberculosis screening (TST or IGRA) before initiating biologics or JAK inhibitors 1
• Perform hepatitis B and C screening before initiating biologics 1
• For patients with hepatitis B infection, prophylactic antiviral therapy is strongly recommended for those initiating rituximab who are hepatitis B core antibody positive 1

Juvenile Idiopathic Arthritis

Oligoarticular JIA

A trial of scheduled NSAIDs combined with intra-articular glucocorticoids is recommended as initial therapy, with triamcinolone hexacetonide as the preferred steroid agent. 3

• Scheduled NSAIDs are conditionally recommended as part of initial therapy 3
• Intra-articular glucocorticoids (IAGCs) are strongly recommended as part of initial therapy 3
• Triamcinolone hexacetonide is strongly recommended as the preferred agent for intra-articular injection 3
• Oral glucocorticoids are conditionally recommended against as part of initial therapy 3

Conventional synthetic DMARDs are strongly recommended if there is inadequate response to scheduled NSAIDs and/or IAGCs, with methotrexate as the preferred agent. 3

• Methotrexate is conditionally recommended as preferred over leflunomide, sulfasalazine, and hydroxychloroquine (in that order) 3
• Biologic DMARDs are strongly recommended if there is inadequate response to or intolerance of NSAIDs and/or IAGCs and at least 1 conventional synthetic DMARD 3
• There is no preferred biologic DMARD among available options 3

Polyarthritis, Sacroiliitis, and Enthesitis

• Prompt initiation of appropriate therapy is critical in preventing permanent damage and improving outcomes 3
• Treatment options include NSAIDs, systemic and intra-articular glucocorticoids, and non-biologic and biologic DMARDs 3
• Consider risk factors for poor outcome (involvement of ankle, wrist, hip, sacroiliac joint, and/or TMJ, presence of erosive disease or enthesitis, delay in diagnosis, elevated inflammation markers, symmetric disease) to guide treatment decisions 3

Temporomandibular Joint (TMJ) Arthritis

• A trial of scheduled NSAIDs is conditionally recommended as part of initial therapy 3
• Intra-articular glucocorticoids are conditionally recommended as part of initial therapy 3
• Oral glucocorticoids are conditionally recommended against as part of initial therapy 3
• Conventional synthetic DMARDs are strongly recommended for inadequate response to or intolerance of NSAIDs and/or IAGCs 3
• Biologic DMARDs are conditionally recommended for inadequate response to or intolerance of NSAIDs and/or IAGCs and at least 1 conventional synthetic DMARD 3

Systemic JIA

• Treatment approach depends on presence or absence of macrophage activation syndrome (MAS) 3
• IL-1 or IL-6 inhibitors are recommended, with no preferred agent 3
• Brief trial of scheduled NSAIDs may be considered 3
• For residual arthritis, add conventional synthetic DMARD or switch to different biologic DMARD 3

Osteoarthritis

• Current approaches focus on reducing pain and improving or maintaining mobility 4
• Pharmacological treatments include analgesics (acetaminophen, opiates), NSAIDs, COX-2 inhibitors, corticosteroids, viscosupplementation, and symptomatic slow-acting drugs 4
• For patients aged ≥75 years, topical NSAIDs are strongly recommended over oral NSAIDs due to reduced gastrointestinal risk 5
• Injectable corticosteroids and viscosupplementation have shown favorable short-term response but no long-term structural modification 4

NSAID Use Considerations

• Both selective (etoricoxib) and nonselective (piroxicam) NSAIDs carry cardiovascular risks proportional to COX-2 selectivity and the patient's underlying cardiovascular risk 5
• Use NSAIDs at the minimum effective dose for the shortest time possible after evaluation of gastrointestinal, renal, and cardiovascular risks 5
• For patients with history of symptomatic or complicated upper GI ulcer, a COX-2 selective inhibitor is strongly recommended over nonselective NSAIDs 5
• Neither etoricoxib nor piroxicam should be used in patients with chronic kidney disease stage IV or V (eGFR <30 ml/min) 5
• Regular monitoring of blood pressure, renal function, and liver function is recommended for patients on long-term NSAID therapy 5

Treatment De-escalation

• For patients in sustained remission (at least 6 months of low disease activity or remission), consider cautious de-escalation of therapy through shared decision-making 1
• Approximately 15-25% of patients may achieve sustained drug-free remission, particularly those with shorter symptom duration, absence of rheumatoid factor or anti-CCP antibodies, lower disease activity before remission, and less baseline disability 1

Common Pitfalls to Avoid

• Do not delay DMARD initiation in rheumatoid arthritis; early aggressive therapy improves outcomes 1, 6
• Do not use inadequate methotrexate doses; escalate to 20-25 mg weekly for optimal efficacy 1
• Do not continue glucocorticoids beyond 3 months without reassessment due to cumulative toxicity 1
• Do not use TNF inhibitors in patients with NYHA class III or IV heart failure 1
• Do not initiate biologics without tuberculosis and hepatitis screening 1