What is the recommended treatment approach for a patient with arthritis?

Treatment of Arthritis

Distinguishing Arthritis Type is Critical

The treatment approach fundamentally differs between inflammatory arthritis (IA) and osteoarthritis (OA), making accurate diagnosis the essential first step before initiating therapy. 1

For Inflammatory Arthritis (Rheumatoid Arthritis)

Start methotrexate 15-25 mg weekly immediately upon diagnosis, combined with short-term low-dose glucocorticoids (≤10 mg/day prednisone equivalent) for rapid symptom control. 2

Initial Treatment Strategy

• Rapidly escalate methotrexate to 25-30 mg weekly within the first few weeks and maintain this maximal dose for at least 3 months before declaring treatment failure. 2
• Add folic acid supplementation to reduce side effects. 2, 3
• Use glucocorticoids at the lowest possible dose for the shortest duration (less than 3 months), then taper and discontinue once remission is achieved. 2
• Undertreating with suboptimal methotrexate doses (<25 mg weekly) prevents achieving treatment targets. 2

Disease Activity Monitoring

• Assess disease activity every 1-3 months during active disease using composite measures (SDAI or CDAI). 2, 4
• Primary target: Clinical remission (SDAI ≤3.3 or CDAI ≤2.8). 2, 4
• Acceptable alternative: Low disease activity (SDAI ≤11 or CDAI ≤10). 2, 4

Treatment Escalation Algorithm

• If less than 50% improvement at 3 months or target not reached at 6 months, escalate therapy immediately. 2
• For patients with poor prognostic factors (high rheumatoid factor, erosive disease), add hydroxychloroquine 400 mg daily to methotrexate. 2, 4
• Consider adding sulfasalazine for complete triple therapy (methotrexate + hydroxychloroquine + sulfasalazine). 2, 4
• If triple therapy fails, add a biologic agent (TNF inhibitor, tocilizumab, or abatacept) or JAK inhibitor. 2, 4
• Switch to a biologic with a different mechanism of action rather than trying a second TNF inhibitor. 2

Critical Monitoring Requirements

• Baseline assessment should include complete blood count with differential and platelet counts, hepatic enzymes, renal function tests, and chest X-ray. 3
• During therapy, monitor hematology at least monthly, renal function and liver function every 1-2 months. 3
• NSAIDs should be used cautiously with methotrexate as they may reduce tubular secretion and enhance toxicity. 3

For Osteoarthritis

Initiate a regular exercise program focusing on both aerobic activity and strengthening exercises as the primary intervention, as this represents the most uniformly effective treatment for OA pain with the strongest evidence. 1

Core Non-Pharmacological Treatments (Mandatory for All Patients)

• Provide at least 12 supervised exercise sessions, 2 sessions per week initially, incorporating local muscle strengthening, general aerobic fitness, and joint-specific exercises. 1, 5
• Structured patient education concerning OA pathophysiology, self-management strategies, and treatment options to maintain long-term adherence. 1, 5
• Weight loss interventions if the patient is overweight or obese. 1
• Exercise therapy provides pain relief equivalent to pharmacological medications without serious adverse effects, regardless of baseline pain intensity or radiographic severity. 5, 6

Adjunct Non-Pharmacological Interventions

• Local heat or cold applications for symptomatic relief. 1
• Manipulation and stretching, particularly for hip OA. 1
• Assessment for bracing, joint supports, or insoles in those with biomechanical joint pain or instability. 1
• Assistive devices (walking sticks, tap turners) for those with specific problems in activities of daily living. 1
• TENS (transcutaneous electrical nerve stimulation) may be considered. 1
• Do not use glucosamine or chondroitin products—these are not recommended. 1

Pharmacological Treatment Algorithm for OA

For knee and hand OA, start with paracetamol (acetaminophen) at regular dosing and/or topical NSAIDs before considering oral NSAIDs, COX-2 inhibitors, or opioids. 1

• If paracetamol or topical NSAIDs are insufficient, add opioid analgesics or substitute with (or add to paracetamol) an oral NSAID or COX-2 inhibitor. 1
• Use oral NSAIDs or COX-2 inhibitors at the lowest effective dose for the shortest possible period. 1
• Prescribe oral NSAIDs or COX-2 inhibitors alongside a proton pump inhibitor, choosing the one with the lowest acquisition cost. 1
• Consider topical capsaicin for additional pain relief. 1
• Consider risks and benefits of pharmacological treatments, particularly in elderly people and those with comorbidities, evaluating gastrointestinal, renal, and cardiovascular status. 1

Joint-Specific Interventions

• Intra-articular corticosteroid injections for relief of local symptoms of inflammation. 1, 7
• Tibiofemoral brace for tibiofemoral OA (strongly recommended). 1
• Patellofemoral brace for patellofemoral OA (conditionally recommended). 1
• First carpometacarpal joint neoprene or rigid orthoses for first CMC joint OA (strongly recommended). 1

Universal Recommendations Across All Arthritis Types

• Smoking cessation is critical as tobacco use predicts worse outcomes. 1, 4
• Dental care, weight control, assessment of vaccination status, and management of comorbidities should be part of overall patient care. 1
• Psychological interventions show uniformly positive effects on pain across both IA and OA. 1
• Sleep hygiene education should be incorporated into the treatment plan. 1

Common Pitfalls to Avoid

• Do not delay DMARD initiation in inflammatory arthritis—early aggressive treatment prevents irreversible joint damage. 1, 2
• Do not undertreate with suboptimal methotrexate doses in rheumatoid arthritis. 2
• Do not prescribe methotrexate on a PRN basis—mistaken daily use has led to fatal toxicity. 3
• Do not use arthroscopic surgery for knee OA—it has been shown to have no benefit. 7
• Do not rely solely on passive modalities in physical therapy—active supervised interventions are superior. 1, 5