What can be given to a patient with arthritis for swelling?

Treatment for Arthritis-Related Joint Swelling

For arthritis-related swelling, start with NSAIDs (naproxen 500 mg twice daily or ibuprofen 400 mg three times daily) after evaluating gastrointestinal, renal, and cardiovascular risk, and add systemic glucocorticoids (prednisone 10-20 mg daily) if NSAIDs provide insufficient relief. 1

Initial Pharmacologic Approach

First-Line: NSAIDs

• NSAIDs should be considered as first-line therapy for symptomatic relief of joint swelling after careful evaluation of gastrointestinal, renal, and cardiovascular status. 1
• Naproxen 500 mg twice daily is preferred over ibuprofen based on superior efficacy in relieving resting pain, movement pain, night pain, and interference with daily activities in osteoarthritis patients. 2
• Ibuprofen 400 mg three times daily (or 800-1600 mg daily in divided doses) is an alternative option with comparable anti-inflammatory effects but may require higher dosing frequency. 3, 4
• Use the lowest effective dose for the shortest duration possible due to cardiovascular and gastrointestinal risks that extend to all NSAIDs, not just COX-2 selective agents. 1

Critical Safety Considerations:

• Prescribe proton pump inhibitors alongside NSAIDs for patients with gastrointestinal risk factors (age >65, prior ulcer history, concurrent corticosteroid use, anticoagulants, SSRIs/SNRIs). 1
• Contraindicate NSAIDs in patients with recent cardiovascular events or high cardiovascular risk. 1
• Monitor renal function, especially in elderly patients or those with pre-existing kidney disease. 1

Second-Line: Systemic Glucocorticoids

• Systemic glucocorticoids reduce pain and swelling and should be added as adjunctive therapy when NSAIDs alone are insufficient. 1
• Start with prednisone 10-20 mg daily for 2-4 weeks for moderate symptoms (Grade 2 inflammatory arthritis). 1
• This is intended as mainly temporary treatment as part of the overall disease management strategy. 1
• If symptoms improve, taper corticosteroids over 4-8 weeks to the lowest effective dose. 1

Escalation for Inadequate Response

• If no improvement after 2-4 weeks of prednisone 10-20 mg daily, increase to prednisone 1 mg/kg/day (or equivalent). 1
• Consider disease-modifying antirheumatic drugs (DMARDs) if unable to taper corticosteroids below 10 mg/day after 3 months. 1
• Methotrexate is the anchor DMARD and should be used first in patients at risk of developing persistent disease. 1

Local Treatment Options

Intra-articular Corticosteroid Injections

• Intra-articular glucocorticoid injections should be considered for relief of local symptoms of inflammation, particularly when ≤2 joints are affected. 1
• This approach is especially useful for large joint involvement (knee, shoulder, hip) when systemic therapy is insufficient or contraindicated. 1
• Consider early use in oligoarthritis (few joints affected) to avoid systemic corticosteroid exposure. 1

Severity-Based Treatment Algorithm

Grade 1 (Mild): Mild pain with inflammatory symptoms, erythema, or joint swelling

• Continue with NSAIDs: naproxen 500 mg twice daily or ibuprofen 400 mg three times daily. 1
• If NSAIDs ineffective after 4-6 weeks, consider low-dose prednisone 10-20 mg daily for 2-4 weeks. 1
• Consider intra-articular corticosteroid injection if ≤2 joints affected and oral medications not effective. 1

Grade 2 (Moderate): Moderate pain with signs of inflammation, limiting instrumental activities of daily living

• Escalate to higher-dose NSAIDs if inadequately controlled. 1
• Add prednisone 20 mg daily for 2-4 weeks; if no response, increase to 1 mg/kg/day. 1
• Refer to rheumatology to confirm inflammatory arthritis and assess for early bone damage. 1
• Taper corticosteroids over 4-8 weeks if symptoms improve to Grade 1. 1

Grade 3-4 (Severe): Severe pain with irreversible joint damage, disabling, limiting self-care activities

• Initiate prednisone 1 mg/kg/day (or equivalent) for 2-4 weeks or until symptoms improve. 1
• Consider additional immunosuppression with methotrexate (starting dose 15 mg weekly with daily folic acid), sulfasalazine, or leflunomide. 1
• Consider anti-cytokine therapy (TNF-α inhibitors or IL-6 receptor inhibitors) if no improvement after 4-6 weeks. 1
• Mandatory rheumatology referral for severe cases. 1

Important Monitoring and Safety Measures

Before Initiating DMARDs or Biologics

• Screen for hepatitis B and C before starting methotrexate, sulfasalazine, or leflunomide. 1
• Evaluate for latent or active tuberculosis before anti-cytokine therapy. 1

Prophylaxis with Prolonged Corticosteroid Use

• Consider PCP prophylaxis for patients receiving ≥20 mg methylprednisolone equivalent for ≥4 weeks or high-dose corticosteroids for >12 weeks. 1
• Provide calcium and vitamin D supplementation with prolonged steroid use. 1
• Prescribe proton pump inhibitor therapy for GI prophylaxis in all patients with Grade 2-4 inflammation receiving steroids. 1

Monitoring Schedule

• Monitor inflammatory markers (ESR and CRP) every 4-6 weeks after treatment initiation to guide treatment decisions. 5, 6
• Conduct serial rheumatologic examinations at 2 weeks, 4 weeks, then every 4-6 weeks. 1

Common Pitfalls to Avoid

• Do not delay rheumatology referral beyond 6 weeks from symptom onset in patients with polyarticular arthritis, as early treatment improves outcomes. 1
• Do not use NSAIDs without gastroprotection in high-risk patients (elderly, prior GI bleeding, concurrent anticoagulation). 1
• Do not continue corticosteroids long-term without attempting taper or adding steroid-sparing agents like DMARDs. 1
• Do not use acetaminophen alone for inflammatory arthritis with significant swelling, as it is inferior to NSAIDs for pain reduction and functional improvement. 7