What is the best treatment approach for a patient with arthritis experiencing pain and inflammation?

Treatment for Arthritis Pain and Inflammation

For arthritis with active pain and inflammation, initiate physical activity/exercise as first-line therapy combined with patient education, then add NSAIDs at the lowest effective dose for the shortest duration if needed, while ensuring adequate control of underlying inflammatory disease. 1

Assessment Framework

Before initiating treatment, assess the following specific elements 1:

• Pain characteristics: severity (0-10 scale), type (sharp, dull, burning), spread (localized vs. widespread), and quality (constant vs. intermittent) 1
• Inflammation markers: presence of joint swelling, warmth, morning stiffness duration, and systemic symptoms (fever, fatigue) 2
• Current disease control: whether underlying inflammatory arthritis is adequately treated with disease-modifying agents 1
• Functional impact: specific activities the patient cannot perform, mobility limitations, and sleep disruption 1, 2
• Previous treatments: what has been tried, at what doses, for how long, and perceived efficacy 1

Treatment Algorithm

Step 1: Universal First-Line Interventions (All Patients)

Physical activity and exercise have the most uniformly positive evidence across all arthritis types (Level 1A, Grade A) 1. This should include:

• Supervised graded physical exercise or strength training if the patient cannot initiate activity independently 1
• Referral to physiotherapy for individually tailored programs 1
• If fear of movement or catastrophizing prevents activity, combine with cognitive-behavioral therapy 1

Patient education should be provided to all patients 1:

• Educational materials encouraging staying active 1
• Sleep hygiene guidelines 1
• Online or face-to-face self-management interventions 1

Step 2: Pharmacological Management

For inflammatory arthritis (RA, PsA, SpA):

• NSAIDs are recommended at the lowest effective dose for the shortest duration to control symptoms 3
• Ibuprofen 400-800 mg or naproxen 500 mg twice daily are standard options 4, 3
• Monitor for gastrointestinal, cardiovascular, and renal adverse effects, particularly in elderly patients 4, 3
• Critical: Ensure underlying inflammatory disease is adequately controlled with DMARDs or biologics; NSAIDs alone are insufficient 2

For osteoarthritis:

• Topical NSAIDs are recommended first for mild OA, particularly for knee or hand involvement 3
• Oral NSAIDs at the lowest effective dose for moderate to severe OA when topical therapy is inadequate 3
• Topical capsaicin can be used when other treatments are ineffective or contraindicated 1, 5
• Acetaminophen has limited efficacy but may be considered for patients who cannot tolerate NSAIDs 6, 7

Step 3: Additional Interventions for Specific Situations

Orthotics should be considered if pain occurs during activities of daily living 1:

• Knee braces, foot orthoses, or assistive devices for affected joints 1
• Occupational therapy for joint protection techniques and ergonomic adaptations 2

Psychological interventions have Level 1A evidence for pain reduction 1:

• Cognitive-behavioral therapy for patients with inadequate response to initial treatment 8
• Particularly beneficial when pain-related beliefs, catastrophizing, or fear of movement are present 1

Weight management for patients with obesity and lower extremity arthritis 1, 2

Sleep interventions when sleep disturbance is identified 1, 2

Step 4: Multidisciplinary Pain Management

If Steps 1-3 are insufficient, refer for interdisciplinary pain management 1:

• Combines multiple modalities including physical therapy, psychological support, and medication optimization 1
• Reserved for complex cases with persistent pain despite adequate treatment 1

Critical Pitfalls to Avoid

• Do not use NSAIDs as monotherapy for inflammatory arthritis without ensuring adequate disease-modifying treatment is in place 2
• Avoid long-term oral corticosteroids due to significant long-term harm 2
• Do not use opioids routinely for arthritis pain; evidence is uncertain and adverse events are significant 3
• Monitor NSAID use carefully in elderly patients and those with cardiovascular, renal, or gastrointestinal comorbidities 4, 3
• Do not delay referral to rheumatology if inflammatory markers are elevated and synovitis is present 2

Special Considerations

For patients with 1-2 affected joints only, intra-articular corticosteroid injections can provide short-term pain relief 2, 3:

• Use triamcinone hexacetonide for inflammatory arthritis 2
• Provides temporary relief while optimizing systemic therapy 3

For patients with contraindications to NSAIDs, duloxetine can be considered for multiple-joint OA 3