What is the difference in treatment approach between arthritis and arthrosis in patients presenting with joint pain or stiffness?

Arthritis vs Arthrosis: Key Differences in Treatment Approach

Arthritis requires aggressive disease-modifying treatment to prevent joint destruction, while arthrosis (osteoarthritis) is managed primarily with symptom control and joint preservation strategies.

Fundamental Distinction

Arthritis is characterized by inflammatory joint disease with synovitis (joint swelling), systemic inflammation, and morning stiffness lasting >30 minutes, requiring immunosuppressive therapy 1, 2. Arthrosis (osteoarthritis) presents with mechanical pain in weight-bearing joints, minimal morning stiffness (<30 minutes), bony enlargement, and normal inflammatory markers 2, 3.

The terminology itself reflects pathophysiology: "arthrosis" emphasizes degenerative cartilage destruction, while "arthritis" (particularly rheumatoid arthritis) indicates quantitatively variable inflammation present in each disease phase 4.

Diagnostic Approach

For Suspected Inflammatory Arthritis

• Clinical features: Joint swelling (not bony enlargement), pain with stiffness, positive "squeeze test" of metacarpophalangeal/metatarsophalangeal joints 1, 5
• Laboratory markers: Elevated CRP/ESR, positive rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) antibodies 6, 5
• Serology scoring: High positive RF or anti-CCP (>3× upper limit normal) = 3 points; low positive = 2 points in ACR/EULAR criteria 6, 5
• Radiographic features: Non-proliferative marginal erosions with periarticular osteopenia 2

For Suspected Arthrosis/Osteoarthritis

• Clinical features: Mechanical pain worsening with weight-bearing, cool bony joints, <30 minutes morning stiffness 2, 3
• Laboratory markers: Normal inflammatory markers (CRP/ESR) 2
• Joint distribution: Distal interphalangeal joints, first carpometacarpal, first metatarsophalangeal joints—areas typically spared in rheumatoid arthritis 6, 2
• Radiographic features: Joint space narrowing, osteophytes, subchondral sclerosis, and cysts 2

Treatment Algorithms

Inflammatory Arthritis Treatment Pathway

Immediate actions (within 6 weeks of symptom onset):

• Refer to rheumatology urgently—patients with arthritis involving >1 joint should be seen within 6 weeks 1
• Initiate methotrexate 15-30 mg/week as first-line disease-modifying antirheumatic drug (DMARD) 6
• Add short-term low-dose prednisone (10-20 mg daily) as bridge therapy while awaiting DMARD effect 1, 6
• Target remission (SDAI ≤3.3) or low disease activity (SDAI ≤11) 6

Escalation strategy (if inadequate response after 3 months):

• Triple DMARD therapy (methotrexate + hydroxychloroquine + sulfasalazine) OR
• Add biologic agent (TNF inhibitor or IL-6 receptor inhibitor preferred) 1, 6

Monitoring requirements:

• Reassess disease activity every 4-6 weeks using composite measures (SDAI, CDAI, or DAS28) 6
• Repeat inflammatory markers (CRP/ESR) at each visit 6
• Baseline and follow-up radiographs at 6 and 12 months to monitor structural damage 6

Arthrosis/Osteoarthritis Treatment Pathway

First-line management:

• Acetaminophen for mild-to-moderate pain without inflammation 7, 3
• Low-dose ibuprofen if acetaminophen insufficient 7
• Physical activity and exercise programs (aerobic exercise, strength/resistance training) 1
• Weight loss for weight-bearing joint involvement 8

Second-line options:

• NSAIDs at lowest effective dose for shortest duration when inflammation present 1, 7
• Intra-articular corticosteroid injections for localized joint inflammation 1
• Orthotics (orthopedic shoes, splints, knee sleeves/elastic bandages) 1
• Education and self-management programs 1

Advanced interventions:

• Opioids for chronic pain refractory to NSAIDs 7
• Joint arthroplasty in severe cases with functional impairment 3

Critical Distinctions in Pharmacotherapy

NSAIDs serve different purposes: In inflammatory arthritis, NSAIDs provide symptomatic relief but do NOT alter disease progression—DMARDs are mandatory 1, 8. In arthrosis, the inflammatory component is debated; some advocate pure analgesics (acetaminophen) while others support anti-inflammatory agents based on synovial inflammation evidence 7, 8, 4.

Corticosteroids: Systemic corticosteroids (oral short-acting) are appropriate for systemic inflammatory arthritis when NSAIDs fail 7. In arthrosis, corticosteroids are reserved for intra-articular injection of individual inflamed joints 7.

Disease-modifying agents: Slow-acting agents (methotrexate, gold, d-penicillamine) decrease radiographic progression in rheumatoid arthritis and should be initiated early to prevent bone/joint erosions 8. These have NO role in primary arthrosis management 3, 8.

Common Pitfalls to Avoid

• Do not delay inflammatory arthritis treatment waiting for positive serology—seronegative rheumatoid arthritis (20-30% of cases) has similar prognosis and requires equally aggressive treatment 6, 2
• Do not dismiss inflammatory arthritis based on normal CRP/ESR—acute phase reactants can be normal even in active disease and are poor predictors 6, 2
• Do not use acetaminophen monotherapy for inflammatory arthritis—this fails to address underlying immune-mediated joint destruction 7, 3
• Do not prescribe DMARDs in primary care without rheumatology consultation—these require specific monitoring protocols and specialist initiation 5
• Do not use continuous NSAIDs in arthrosis without gastroprotection in high-risk patients—employ proton pump inhibitors or COX-2 selective inhibitors 7

Psychological and Functional Interventions

Both conditions benefit from:

• Cognitive-behavioral therapy (uniform positive effect on pain in rheumatoid arthritis and osteoarthritis) 1
• Occupational therapy for joint protection education, assistive devices, and splinting 6
• Patient education programs (positive effect on pain in osteoarthritis) 1

The fundamental difference remains: inflammatory arthritis demands aggressive immunosuppression to prevent irreversible joint destruction, while arthrosis management focuses on symptom control and functional preservation 3, 8.