What medication can I give to a patient with acute arthritis, considering their medical history, including any history of gastrointestinal problems or kidney disease?

Treatment of Acute Arthritis

For acute arthritis, start with NSAIDs at high doses (such as ibuprofen 800 mg three times daily or naproxen 500 mg twice daily) combined with gastroprotection if the patient has GI risk factors, or use intra-articular corticosteroid injections for monoarticular involvement. 1, 2

First-Line Pharmacological Approach

NSAIDs as Primary Therapy

• High-dose NSAIDs are the cornerstone of acute arthritis management, providing both analgesic and anti-inflammatory effects needed for acute flares 1, 2
• For acute crystal arthritis (gout, pseudogout), NSAIDs with short half-lives like indomethacin provide excellent control 1
• Use the lowest effective dose for the shortest duration, but in acute settings, full anti-inflammatory doses are necessary (e.g., ibuprofen 2400 mg/day, naproxen 1000 mg/day) 1, 3, 4

Mandatory Risk Stratification Before Prescribing NSAIDs

Gastrointestinal Risk Assessment:

• High GI risk includes: age ≥60 years, history of peptic ulcer or GI bleeding, concurrent corticosteroids, anticoagulants, or aspirin use 1, 3
• If high GI risk exists, you must add a proton pump inhibitor to any NSAID or consider a COX-2 inhibitor plus PPI 1
• Ibuprofen has superior GI safety at analgesic doses compared to other non-selective NSAIDs, but at full anti-inflammatory doses (≥2400 mg/day) the GI bleeding risk equals other NSAIDs 1

Cardiovascular and Renal Risk Assessment:

• Evaluate for hypertension, heart failure, established cardiovascular disease, or cardiovascular risk factors before prescribing 3
• NSAIDs should be used with extreme caution in patients with these conditions 3
• Monitor blood pressure, renal function (BUN, creatinine), and fluid retention 3

Renal Function Considerations:

• NSAIDs are contraindicated in severe renal impairment 3
• The combination of NSAIDs with other nephrotoxic drugs (like methotrexate in chronic arthritis patients) significantly increases acute kidney injury risk 5

Alternative and Adjunctive Therapies

Intra-articular Corticosteroid Injections

• For monoarticular or oligoarticular acute arthritis, intra-articular corticosteroid injection is highly effective and may be sufficient as monotherapy 1
• Provides rapid pain relief within 1-2 weeks with clinically meaningful benefit 1
• Particularly useful when NSAIDs are contraindicated due to GI, renal, or cardiovascular comorbidities 1

Oral or Parenteral Corticosteroids

• Short tapering courses of oral corticosteroids or parenteral corticosteroids (e.g., single IM injection of 7 mg betamethasone or 125 mg IV methylprednisolone) are effective alternatives when NSAIDs are contraindicated 1
• Particularly useful for polyarticular acute flares 1
• Corticosteroids provide faster pain control than NSAIDs in the first 24 hours 1

Colchicine

• Low-dose oral colchicine (0.5 mg up to 3-4 times daily, with or without 1 mg loading dose) is effective for acute crystal arthritis 1
• However, colchicine use is often limited by toxicity and comorbidities, especially in elderly patients 1
• Consider colchicine primarily for acute gout or pseudogout when NSAIDs and corticosteroids are contraindicated 1

Non-Pharmacological Adjuncts

• Application of ice or cool packs to affected joints 1
• Temporary rest of the affected joint 1
• Joint aspiration for diagnostic confirmation and symptomatic relief in monoarticular presentations 1

Critical Pitfalls to Avoid

Do Not Use Acetaminophen Alone for Acute Inflammatory Arthritis:

• While acetaminophen (up to 4 g/day) is appropriate for osteoarthritis pain, it lacks anti-inflammatory properties needed for acute inflammatory arthritis 1, 3
• Acetaminophen is equipotent to aspirin for analgesia but does not address inflammation 6
• NSAIDs are significantly more effective than acetaminophen for inflammatory conditions 7

Avoid Combining Multiple NSAIDs:

• Never combine NSAIDs with each other, including low-dose aspirin when possible, as this increases GI bleeding risk more than 10-fold 8

Monitor for Drug Interactions:

• If the patient is on methotrexate for chronic arthritis, adding NSAIDs significantly increases methotrexate toxicity risk through reduced renal clearance 5

Duration Matters:

• All NSAID risks (GI, cardiovascular, renal) are both dose-dependent and time-dependent 3, 4
• For acute arthritis, plan to taper and discontinue NSAIDs as soon as the acute flare resolves 3

Practical Treatment Algorithm

1. Assess patient risk factors (GI history, cardiovascular disease, renal function, age, concurrent medications) 1, 3

2. For monoarticular acute arthritis: Consider intra-articular corticosteroid injection as first-line 1

3. For polyarticular acute arthritis without high-risk features: Start high-dose NSAID (ibuprofen 800 mg TID or naproxen 500 mg BID) 1, 2

4. For polyarticular acute arthritis with GI risk factors: Use NSAID + PPI or consider short-course oral corticosteroids 1

5. For polyarticular acute arthritis with cardiovascular/renal contraindications to NSAIDs: Use short tapering course of oral corticosteroids or parenteral corticosteroids 1

6. Monitor: Blood pressure, renal function, GI symptoms, and cardiovascular status during NSAID therapy 3

7. Taper and discontinue NSAIDs as soon as acute inflammation resolves 3