What are the treatment options for inflammation?

Treatment for Inflammation

NSAIDs are the first-line treatment for acute inflammation, with naproxen or low-dose ibuprofen preferred due to their lower cardiovascular risk profile compared to other NSAIDs. 1, 2

Initial Treatment Approach

First-Line: NSAIDs

• Start with NSAIDs at the lowest effective dose for the shortest duration necessary to control symptoms 1, 3
• Naproxen and low-dose ibuprofen have the most favorable cardiovascular safety profiles among NSAIDs and should be prioritized, particularly in patients with cardiovascular risk factors 2
• For acute inflammatory conditions, approximately 75% of patients achieve good or very good response within 48 hours of full-dose NSAID therapy 4
• Maximum tolerated doses should be used for at least 2-4 weeks before considering NSAID failure 5

NSAID Selection Based on Risk Profile

• For patients with gastrointestinal risk factors (elderly, history of GI bleeding, concurrent corticosteroid or anticoagulant use): use COX-2 selective inhibitors OR non-selective NSAIDs plus gastroprotective agents 1, 3
• For patients with cardiovascular disease or risk factors: avoid COX-2 selective inhibitors; use naproxen or low-dose ibuprofen instead 2, 6
• All NSAIDs carry risks of GI ulceration, cardiovascular events, and renal complications that increase with dose and duration 3, 7

Second-Line Options

When NSAIDs Are Insufficient or Contraindicated

For rapid control of moderate-to-severe inflammation:

• Corticosteroids provide rapid symptom control through local injection for localized inflammation or systemic administration for widespread inflammation 1
• Intra-articular glucocorticosteroids are particularly effective and safe for monoarticular or oligoarticular inflammatory conditions 8
• Short tapering courses of oral glucocorticosteroids (or parenteral glucocorticosteroids/ACTH) are effective alternatives when intra-articular injection is not feasible 8
• Avoid long-term systemic corticosteroid use due to significant adverse effects including bone loss, infection risk, and metabolic complications 1, 5

For chronic inflammatory conditions when NSAIDs fail:

• Add disease-modifying antirheumatic drugs (DMARDs) such as methotrexate or sulfasalazine for persistent inflammatory arthritis 1
• Methotrexate is preferred over leflunomide, sulfasalazine, and hydroxychloroquine for most chronic inflammatory conditions 8

Third-Line: Biologic Therapies

• TNF inhibitors, IL-17 inhibitors, or JAK inhibitors are indicated for moderate-to-severe inflammation unresponsive to NSAIDs and DMARDs 1
• IL-1 or IL-6 inhibitors are specifically recommended for autoinflammatory diseases with the goal of achieving complete remission (absence of clinical symptoms and normal inflammatory markers) 8
• Biologic therapies should be administered continuously with dose adjustments based on disease activity and inflammatory marker normalization 8

Critical Safety Monitoring

NSAID-Related Risks

• Monitor for gastrointestinal complications including ulceration and bleeding, which can occur without warning symptoms and may be fatal 3, 9
• Cardiovascular risks increase within weeks of COX-2 selective inhibitor use and with higher doses of traditional NSAIDs 2
• Assess renal function regularly, particularly in elderly patients and those with pre-existing kidney disease 3, 10

High-Risk Populations Requiring Extra Caution

• Elderly patients (increased GI and renal risk) 3
• Patients with history of GI bleeding or ulcers 3
• Those taking corticosteroids, anticoagulants, SSRIs, or SNRIs concurrently 3
• Patients with cardiovascular disease, heart failure, or hypertension 2
• Individuals with poor health, advanced liver disease, or bleeding disorders 3

Treatment Algorithm Summary

1. Start with NSAIDs (naproxen or low-dose ibuprofen preferred) at lowest effective dose 1, 2
2. If inadequate response after 2-4 weeks at maximum tolerated dose: consider rotating to different NSAID or adding short-term corticosteroids 5
3. For localized inflammation: add intra-articular glucocorticosteroids (triamcinolone hexacetonide preferred) 8
4. For persistent symptoms beyond 3-6 months: add DMARDs (methotrexate first-line) 1
5. For severe or refractory inflammation: escalate to biologic therapies (TNF inhibitors, IL-17 inhibitors, or IL-1/IL-6 inhibitors depending on condition) 8, 1

Critical Contraindications

• Never use NSAIDs in patients with history of NSAID-induced asthma, hives, or allergic reactions 3, 9
• Avoid NSAIDs immediately before or after coronary artery bypass graft surgery 3, 9
• Do not use NSAIDs after 30 weeks of pregnancy due to risk of harm to the fetus 3
• Between 20-30 weeks of pregnancy, limit NSAID use to less than 2 days and monitor amniotic fluid if longer duration needed 3