What is the treatment for an adult with polyarticular joint pain?

Treatment for Polyarticular Joint Pain in Adults

Begin with a structured diagnostic approach to distinguish inflammatory from non-inflammatory causes, then implement core non-pharmacological treatments (exercise, weight loss, patient education) as first-line therapy for all patients, followed by a stepwise pharmacological algorithm starting with acetaminophen or topical NSAIDs. 1, 2

Initial Diagnostic Priorities

Before initiating treatment, rapidly identify dangerous conditions requiring urgent intervention:

• Rule out septic arthritis if patient presents with fever, chills, systemic symptoms, significantly elevated inflammatory markers, or bacteremia 1, 3
• Exclude malignancy if unexplained weight loss, rapidly growing solitary lesions, or cortical destruction on imaging 1
• Assess for inflammatory arthritis patterns: Look for morning stiffness >30 minutes, palpable synovitis (warmth, swelling, redness), symmetrical small joint involvement, and elevated inflammatory markers 4, 5
• Consider rheumatoid arthritis if symmetrical polyarthritis of small joints with anti-CCP or RF positivity 1, 4
• Evaluate for psoriatic arthritis or axial spondyloarthritis if asymmetrical joint involvement, enthesitis, dactylitis, psoriasis, or inflammatory back pain 1

Core First-Line Treatments (Mandatory for All Patients)

These treatments form the foundation and should be initiated immediately, regardless of additional interventions:

• Exercise therapy: Prescribe both local muscle strengthening exercises and general aerobic fitness activities (walking, swimming, cycling) 1, 2, 6

  • Aquatic exercise in warm water (86°F) is particularly beneficial as buoyancy reduces joint loading while providing resistance 1
  • Avoid high-impact activities that involve rapid joint loading 1

• Weight loss interventions: Mandatory if patient is overweight or obese, as this directly reduces mechanical stress on weight-bearing joints 1, 2, 6

• Patient education: Provide both oral and written information to counter the misconception that joint pain is inevitably progressive and untreatable 1, 2, 6

Stepwise Pharmacological Treatment Algorithm

Step 1: First-Line Analgesics

• Acetaminophen (paracetamol): Start with regular dosing up to 4,000 mg/day as the preferred initial pharmacological treatment 1, 2, 6

  • Comparable efficacy to NSAIDs for mild-to-moderate pain with fewer gastrointestinal side effects 1
  • Monitor for hepatotoxicity, especially in elderly patients 2

• Topical NSAIDs: Use before oral NSAIDs, particularly for knee and hand osteoarthritis, as they provide similar efficacy with significantly fewer systemic side effects 2, 6

Step 2: Oral NSAIDs (If Step 1 Insufficient)

• Prescribe at lowest effective dose for shortest duration 1, 2, 6
• Mandatory risk assessment before prescribing: Evaluate cardiovascular risk factors (hypertension, heart failure, prior MI), gastrointestinal risk (history of ulcers, bleeding, age >65), and renal function 1, 2, 6
• Co-prescribe proton pump inhibitor for gastroprotection in all patients receiving oral NSAIDs 7, 6
• Ibuprofen dosing: 400-800 mg three to four times daily (maximum 3,200 mg/day), though doses above 2,400 mg/day rarely provide additional benefit and increase risk 8
• Take with food or milk to minimize gastrointestinal complaints 8

Step 3: Intra-Articular Therapies (For Moderate-to-Severe Pain)

• Intra-articular corticosteroid injections can provide temporary relief for specific inflamed joints 1, 2, 7
• Consider for patients with localized joint involvement who have inadequate response to oral medications 1

Step 4: Opioid Analgesics (If Previous Steps Insufficient)

• Reserve for severe pain unresponsive to other treatments 7
• Use lowest effective dose for shortest duration due to addiction potential and side effects 7

Essential Non-Pharmacological Adjunct Treatments

• Self-management strategies: Emphasize activity pacing (avoiding "peaks and troughs"), appropriate footwear with shock-absorbing properties, and behavioral modifications 1, 7

• Physical modalities for temporary relief:

  • Local heat or cold applications 1, 7
  • Transcutaneous electrical nerve stimulation (TENS) 1
  • Manual therapy (manipulation and stretching), particularly for hip osteoarthritis 1

• Assistive devices: Assess need for walking aids, braces, joint supports, insoles for biomechanical instability, or adaptive equipment for activities of daily living 1, 7

Critical Pitfalls and What NOT to Use

• Do NOT use glucosamine or chondroitin supplements: Not recommended based on lack of evidence showing benefit over placebo 1, 2, 6
• Do NOT use electroacupuncture: Not supported by current evidence 1, 6
• Avoid aspirin interaction with ibuprofen: If patient takes daily aspirin for cardiovascular protection, administer ibuprofen at least 2 hours after aspirin dose to avoid interfering with aspirin's antiplatelet effects 8

Monitoring and Reassessment

• Provide periodic review tailored to individual patient needs, as disease course and treatment requirements change over time 1, 6
• Monitor for NSAID complications: Check hemoglobin/hematocrit if signs of anemia develop, as NSAIDs can cause occult GI bleeding 8
• Assess liver function if patient develops symptoms suggesting hepatic dysfunction while on NSAIDs 8
• Evaluate treatment effectiveness regularly and adjust therapy accordingly 2, 6

When to Consider Specialist Referral

• Refer for rheumatology evaluation if inflammatory arthritis suspected (positive RF, anti-CCP, persistent synovitis, or systemic symptoms) 4, 5
• Consider surgical referral only after patient has been offered core treatment options and continues to have joint symptoms substantially impacting quality of life despite conservative management 2, 7
• Urgent referral if concern for septic arthritis, malignancy, or rapidly progressive inflammatory disease 1, 3