What is the best treatment approach for a patient experiencing an arthritis flare, considering their medical history and potential comorbid conditions such as hypertension, diabetes, or impaired renal function?

Treatment of Arthritis Flare

For an acute arthritis flare, initiate NSAIDs at the minimum effective dose after evaluating gastrointestinal, renal, and cardiovascular contraindications, and strongly consider intra-articular glucocorticoid injection for localized joint inflammation. 1

Immediate Symptomatic Management

NSAIDs as First-Line Therapy

• NSAIDs are the cornerstone of flare management, providing rapid relief of pain and inflammation 1
• Use the minimum effective dose for the shortest duration possible to minimize toxicity 1
• No specific NSAID is superior—selection should be based on the patient's prior NSAID response, comorbidities, and contraindications 1
• Critical risk assessment required before prescribing: evaluate gastrointestinal bleeding risk (history of ulcers, concurrent anticoagulation), renal function (creatinine clearance, baseline kidney disease), and cardiovascular risk (hypertension, heart failure, prior MI) 1, 2

Glucocorticoid Options

• Intra-articular glucocorticoid injection is strongly recommended for relief of localized joint inflammation during a flare 1
• Systemic glucocorticoids reduce pain and swelling but should only be used as temporary adjunctive treatment (less than 6 months) at the lowest effective dose 1
• Avoid glucocorticoid monotherapy before establishing a definitive diagnosis, as it can mask disease activity and delay appropriate DMARD initiation 1

Comorbidity-Specific Modifications

Hypertension

• NSAIDs can elevate blood pressure and reduce antihypertensive efficacy 1, 2
• Monitor blood pressure closely during NSAID use 2
• Consider intra-articular glucocorticoids as an alternative to minimize systemic NSAID exposure 1

Diabetes

• Systemic glucocorticoids worsen glycemic control and increase diabetes risk 1
• If systemic steroids are necessary, use the lowest dose for the shortest duration and intensify glucose monitoring 1
• Intra-articular injections are preferred over systemic administration 1

Impaired Renal Function

• NSAIDs must be avoided or used with extreme caution in patients with chronic kidney disease, as they can precipitate acute kidney injury and worsen renal function 1, 3
• Methotrexate requires dose adjustment or avoidance in renal dysfunction 3
• Intra-articular glucocorticoids become the preferred option when NSAIDs are contraindicated 1

Beyond Acute Flare Management

When to Escalate to DMARDs

• If the patient has recurrent flares, multiple swollen joints, elevated acute phase reactants (ESR/CRP), or positive rheumatoid factor/anti-CCP antibodies, they are at risk for persistent erosive disease 1
• Methotrexate should be initiated within 3 months in patients at risk of persistent arthritis, even if classification criteria are not yet met 1
• Methotrexate is the anchor drug and should be part of the first treatment strategy unless contraindicated 1

Monitoring During Flare Treatment

• Assess disease activity at 1-3 month intervals using tender/swollen joint counts, patient and physician global assessments, and ESR/CRP 1
• The treatment goal is clinical remission (SDAI ≤3.3 or CDAI ≤2.8) or low disease activity (SDAI ≤11 or CDAI ≤10) 1, 4

Critical Pitfalls to Avoid

• Do not continue NSAIDs indefinitely—prolonged use increases gastrointestinal bleeding, cardiovascular events, and renal toxicity 1, 2
• Do not use systemic glucocorticoids beyond 1-2 years, as risks (cataracts, osteoporosis, fractures, cardiovascular disease, infections) outweigh benefits 1, 5
• Do not prescribe NSAIDs without assessing contraindications—failure to evaluate GI, renal, and CV risk is a common and dangerous error 1, 2
• Do not delay rheumatology referral—patients with polyarticular arthritis should be seen by a rheumatologist within 6 weeks of symptom onset 1
• Do not use glucocorticoid monotherapy before diagnosis is established, as it obscures the clinical picture and delays definitive treatment 1

Non-Pharmacological Adjuncts

• Dynamic exercises, occupational therapy, and patient education should be incorporated as adjuncts to pharmacologic treatment 1, 6
• Address modifiable risk factors: smoking cessation, weight control, dental care, and vaccination status 1