What are the best treatment approaches for arthritis?

Best Arthritis Treatments

The optimal treatment for arthritis depends critically on whether you have osteoarthritis or rheumatoid arthritis—these are fundamentally different diseases requiring completely different therapeutic approaches.

For Rheumatoid Arthritis (Inflammatory)

First-Line Pharmacologic Treatment

Initiate methotrexate 15 mg weekly immediately upon diagnosis, escalating to 20-25 mg weekly within the first 3 months, combined with folic acid 1 mg daily. 1 This represents the cornerstone of RA therapy based on the favorable efficacy/toxicity profile compared to other conventional DMARDs. 1

• Add low-dose prednisone 5-10 mg daily as bridging therapy for the first 2 years to provide rapid symptom control and disease-modifying benefits with minimal corticosteroid-related adverse effects. 1
• The TEAR trial demonstrated that initial methotrexate monotherapy with step-up to combination therapy at 6 months produces equivalent clinical and radiographic outcomes at 2 years compared to initial combination therapy with biologics, making this the most cost-effective approach. 1

Critical 3-Month Assessment Point

Reassess disease activity at 3 months using SDAI (Simplified Disease Activity Index) or CDAI (Clinical Disease Activity Index)—this timepoint predicts the probability of achieving remission at 1 year. 1

• Target: SDAI ≤3.3 (remission) or SDAI ≤11 (low disease activity) 1
• Over 75% of patients achieving low disease activity or remission at 3 months will be in remission at 1 year. 1

Escalation Strategy for Inadequate Response

If moderate/high disease activity persists (SDAI >11) at 3 months: 1

• Add sulfasalazine and hydroxychloroquine to methotrexate (triple-DMARD therapy) as the next step before considering biologics. 1
• If triple-DMARD therapy fails, switch to a biologic agent:
  • TNF inhibitors (adalimumab, etanercept) as first-line biologics 1, 2
  • After inadequate response to ≥1 TNF inhibitor, consider abatacept (CTLA4:Ig), tocilizumab (anti-IL-6R), or rituximab (anti-CD20) 1
  • For seronegative patients failing TNF inhibitors, prefer abatacept or tocilizumab over rituximab 1

Essential Non-Pharmacologic Components

Refer to occupational therapy for joint protection instruction, assistive devices, orthotics, and splints—these interventions substantially improve function and reduce pain. 1

• Dynamic exercise programs incorporating both aerobic exercise and progressive resistance training improve fitness, strength, and lean body mass safely. 1
• Patient education about disease pathophysiology and self-management skills leads to improved health and physical function. 1
• Multidisciplinary care team including rheumatologist, nurses, physical/occupational therapists, psychologists, and primary care physician optimizes outcomes. 1

Monitoring Strategy

• Reassess disease activity every 4-6 weeks using composite measures (SDAI/CDAI). 3
• Treatment adjustments should occur every 3 months if target not achieved. 4
• Obtain baseline bilateral hand, wrist, and foot radiographs, then repeat at 6 months and annually to monitor for erosive changes. 3, 4

For Osteoarthritis (Degenerative)

First-Line Non-Pharmacologic Treatment

Exercise is the single most strongly recommended intervention for knee, hip, and hand OA—this should be the foundation of all treatment plans. 1

• Exercise options include walking, strengthening, neuromuscular training, and aquatic exercise with no hierarchy of one over another. 1
• Supervised exercise programs produce better outcomes than unsupervised programs. 1
• Weight management is critical for weight-bearing joint OA (knee and hip). 1

Orthotic Interventions

For hand OA: Use first carpometacarpal (CMC) joint neoprene or rigid orthoses for first CMC joint OA (strongly recommended). 1

For knee OA: Use tibiofemoral braces for tibiofemoral OA (strongly recommended); patellofemoral braces for patellofemoral OA (conditionally recommended). 1

Pharmacologic Treatment

Begin with topical NSAIDs for localized joint involvement, then advance to oral NSAIDs or acetaminophen if needed—prioritize treatments with least systemic exposure. 1

• Oral NSAIDs demonstrate greater symptomatic efficacy than acetaminophen but carry gastrointestinal and cardiovascular risks. 5
• Avoid opioid analgesics—these are overused in OA and represent a key gap in appropriate treatment. 6
• Intraarticular corticosteroid injections provide short-term relief for isolated joint inflammation. 1
• Viscosupplementation (hyaluronic acid injections) may be considered but evidence for long-term structural modification is lacking. 5

Multimodal Approach

Combine physical, psychological, and pharmacologic interventions rather than relying on single medication—OA management requires addressing pain, mood disorders, sleep disturbances, and functional limitations simultaneously. 1

• Cognitive behavioral therapy and self-efficacy training improve overall well-being and treatment success. 1
• Physical and occupational therapy referrals should occur at various times during disease course, not just initially. 1

Surgical Consideration

Joint replacement surgery should be considered when conservative management fails to control symptoms and quality of life is significantly impaired. 1

Critical Distinction

The evidence makes clear that RA and OA require fundamentally different treatment paradigms: RA demands aggressive disease-modifying therapy targeting remission with tight control monitoring 1, 7, while OA focuses on symptom management through exercise, weight management, and judicious use of analgesics with no currently available disease-modifying agents. 1, 5 Misclassifying the arthritis type leads to inappropriate treatment—inflammatory arthritis presenting with morning stiffness ≥60 minutes, symmetric small joint involvement, and elevated inflammatory markers requires immediate DMARD therapy 3, 4, whereas mechanical symptoms worsening with activity suggest OA requiring exercise-based rehabilitation. 1