What is the recommended treatment for a patient with post-chikungunya (chikungunya virus) arthritis?

Treatment of Post-Chikungunya Arthritis

For post-chikungunya chronic arthritis, initiate NSAIDs as first-line therapy with gastrointestinal protection, add methotrexate (20 mg/week) for persistent disease beyond 3 months, and incorporate physical therapy including heat application and structured exercise programs. 1

Initial Management Approach

Acute Phase (First 3 Months)

• Use NSAIDs as primary symptomatic treatment, but prescribe proton pump inhibitors for gastrointestinal protection and monitor cardiovascular risk with prolonged use 1
• Consider short-term oral corticosteroids for severe multi-joint involvement, though avoid intra-articular corticosteroid injections during the acute phase 1
• Most patients with acute chikungunya arthritis improve with symptomatic treatment alone; reserve disease-modifying therapy for those with persistent symptoms beyond 3 months 2

Chronic Phase (Beyond 3 Months)

When arthritis persists despite NSAIDs and initial management:

First-Line DMARD Therapy

• Start methotrexate 20 mg weekly as the anchor drug for chronic inflammatory arthritis that has not resolved after 3 months 1, 3, 4
• Methotrexate produced good response in 71-75% of patients with post-chikungunya chronic arthritis in clinical studies 3, 4
• Monitor disease activity at 1-3 month intervals using tender/swollen joint counts and patient-reported pain scores 1

Second-Line Options

• If methotrexate monotherapy fails after 3-6 months, add or switch to hydroxychloroquine or sulfasalazine 1, 3
• Sulfasalazine with or without methotrexate showed effectiveness in 71.4% and 12.5% of patients respectively in one study 3
• Consider intra-articular corticosteroid injections for persistent single-joint inflammation in the chronic phase 1

Refractory Disease

• Refer to rheumatology for patients with severe, refractory chronic arthritis who fail conventional DMARDs 1
• Biologic agents may be considered in select cases, though evidence is limited (12 of 92 patients required biologics in one series) 4

Non-Pharmacological Interventions

Physical therapy is essential and should be initiated early:

• Apply heat therapy to affected joints to improve pain and physical function 1
• Implement regular exercise programs including both aerobic and resistance training to improve muscle strength and reduce pain 1
• Prescribe hand therapy exercises for patients with hand involvement 1
• Consider massage therapy delivered by experienced providers 1
• Multimodal physiotherapy (electrotherapy, thermotherapy, kinesiotherapy) showed improvement in quality of life domains in case reports 5

Lifestyle Modifications

• Ensure tobacco cessation, as smoking worsens inflammatory arthritis symptoms 1
• Address weight control and comorbidities as part of comprehensive care 1

Critical Pitfalls to Avoid

• Do not use long-term corticosteroids as monotherapy due to risks of cataracts, osteoporosis, and cardiovascular disease 1
• Do not expect immediate response to DMARDs; maximal effect may take 3-6 months to manifest 4
• Avoid intra-articular corticosteroids during the acute inflammatory phase 1
• Current evidence does not support chloroquine, hydroxychloroquine as monotherapy, or ribavirin over standard anti-inflammatory treatment 2

Monitoring and Follow-Up

• Assess treatment response at 4-week intervals initially, then every 1-3 months once stable 6
• Use standardized measures including DAS28 scores, tender/swollen joint counts, and visual analog pain scales 6
• Radiographic evaluation may be needed as bone lesions can develop (median time 3.5 years post-infection) 4
• If no improvement after 3 months of DMARD therapy, adjust treatment strategy 1