Iguratimod in Osteoarthritis
Iguratimod should NOT be used for osteoarthritis—it is a disease-modifying antirheumatic drug (DMARD) approved only for rheumatoid arthritis, not osteoarthritis, which has entirely different pathophysiology and treatment paradigms. 1, 2, 3
Why Iguratimod is Not Appropriate for OA
Fundamental Disease Differences
Osteoarthritis is a degenerative joint disease, not an autoimmune inflammatory condition, and therefore does not respond to DMARDs like iguratimod that target B cells, immunoglobulin production, and inflammatory cytokines involved in autoimmune processes 3
Iguratimod's mechanism of action involves inhibiting B cell production of inflammatory cytokines (TNF-α, IL-1β, IL-6, IL-8, IL-17) and suppressing immunoglobulin production—pathways that are not primary drivers of osteoarthritis pathology 3
All clinical evidence for iguratimod comes exclusively from rheumatoid arthritis populations, with no studies evaluating its efficacy or safety in osteoarthritis patients 1, 2, 4, 5
Regulatory Status and Approved Indications
Iguratimod is approved only for active rheumatoid arthritis in China and Japan, with no regulatory approval for osteoarthritis anywhere in the world 4, 3
The Asia Pacific League of Association for Rheumatology (APLAR) recommends iguratimod as a first-line drug specifically for rheumatoid arthritis, not osteoarthritis 1
Evidence-Based Treatment for Osteoarthritis Instead
Core Non-Pharmacological Treatments (First-Line)
Exercise therapy is mandatory and includes isotonic strengthening exercises, static stretching daily when pain is minimal, and aerobic fitness training—these have equivalent analgesic efficacy to oral NSAIDs and paracetamol 6, 7
Weight loss interventions are essential if the patient is overweight or obese, as this reduces mechanical stress on weight-bearing joints 6, 7
Patient education with written and oral information must counter the misconception that osteoarthritis is inevitably progressive and untreatable 6, 7
Pharmacological Treatment Algorithm
Start with acetaminophen (paracetamol) up to 4000 mg daily as first-line pharmacologic treatment, using regular dosing rather than "as needed" for sustained pain control; consider limiting to 3000 mg daily in elderly patients for enhanced safety 8, 7, 9
Apply topical NSAIDs (such as diclofenac gel) before oral NSAIDs, as they have minimal systemic absorption and substantially lower risk of gastrointestinal, renal, and cardiovascular complications 8, 7, 9
Prescribe oral NSAIDs or COX-2 inhibitors only when topical treatments fail, using the lowest effective dose for the shortest duration, and always co-prescribe a proton pump inhibitor for gastroprotection 7, 9
Critical Safety Considerations in Older Adults with Comorbidities
Carefully assess cardiovascular, gastrointestinal, and renal risk factors before prescribing any oral NSAID, particularly in patients over 50 years, as elderly patients face substantially higher risks of GI bleeding, renal insufficiency, and cardiovascular complications 8, 7, 9
Never exceed 4000 mg daily of acetaminophen to prevent hepatotoxicity, and strongly consider lower limits (3000 mg) in elderly patients 9
Never prescribe oral NSAIDs without gastroprotection (proton pump inhibitor co-prescription) 9
Adjunct Non-Pharmacological Options
Local heat or cold applications (ice packs) can be used for temporary pain relief as adjunctive therapy, but should not substitute for core interventions like exercise 8
Self-management strategies emphasizing appropriate footwear with shock-absorbing properties and activity pacing to avoid peaks and troughs 7
Common Pitfalls to Avoid
Do not use glucosamine or chondroitin products, as current evidence does not support their efficacy for osteoarthritis 7, 9
Do not use electroacupuncture based on available evidence 7
Avoid prolonged NSAID use at high doses, particularly in elderly patients who are at highest risk for serious adverse events 9
Never allow medications to substitute for core treatments—exercise, weight loss, and patient education must remain the foundation of osteoarthritis management 6, 7