What is the recommended treatment approach for polyarthralgia?

Treatment of Polyarthralgia

The treatment of polyarthralgia depends entirely on identifying and treating the underlying cause, as polyarthralgia is a symptom rather than a diagnosis—clinical assessment to differentiate inflammatory from mechanical disorders is the critical first step, followed by targeted therapy based on the specific etiology. 1

Initial Diagnostic Approach

The most important clinical task is distinguishing inflammatory from non-inflammatory processes, as this fundamentally determines treatment strategy. 1, 2

Key Clinical Features to Assess

• Pattern of joint involvement: Migratory polyarthralgia moving from joint to joint over hours to days suggests acute rheumatic fever, particularly in patients from moderate- or high-risk populations. 3

• Morning stiffness duration: Prolonged morning stiffness (>45-60 minutes) with bilateral shoulder and hip girdle pain in patients over 50 years suggests polymyalgia rheumatica. 4

• Response to NSAIDs: Dramatic improvement with salicylates or NSAIDs within hours suggests acute rheumatic fever, while lack of response may indicate a non-inflammatory process. 3

• Constitutional symptoms: Fever, weight loss, or systemic symptoms warrant investigation for inflammatory arthritis, infection, or systemic disease. 4, 3

Essential Laboratory Workup

• Inflammatory markers: ESR and CRP confirm inflammatory processes and guide diagnosis. 4, 3

• Autoantibodies: Rheumatoid factor and anti-CCP antibodies exclude rheumatoid arthritis; ANA and ANCA testing is reserved for atypical presentations. 4

• Infection markers: Anti-streptolysin O (ASO) or anti-DNase B titers support recent streptococcal infection in suspected acute rheumatic fever. 3

• Endocrine screening: TSH and cortisol levels should be checked, as hypothyroidism and isolated ACTH deficiency can present with polyarthralgia and elevated inflammatory markers. 5, 6

Treatment Based on Specific Diagnoses

Polymyalgia Rheumatica (Age >50, Bilateral Shoulder/Hip Pain)

Initiate prednisone 15-20 mg daily (within the guideline range of 12.5-25 mg) based on individual risk factors; expect dramatic improvement within 2 weeks. 4

• Initial dosing considerations: Patients with high ESR (>40 mm/hr), female sex, or peripheral arthritis may require 20-25 mg daily. 4

• Tapering protocol:

  • Reduce to 10 mg daily over 4-8 weeks once remission is achieved. 4
  • From 10 mg, decrease by 1 mg every 4 weeks until discontinuation. 4
  • If relapse occurs, return to the last symptom-free dose and re-taper more slowly. 4

• Osteoporosis prophylaxis: Start calcium 1,200-1,500 mg daily, vitamin D 800-1,000 IU daily, and bisphosphonate therapy (alendronate 70 mg weekly) immediately upon glucocorticoid initiation, especially in postmenopausal women. 4

• Monitoring schedule: Every 4-8 weeks in the first year, assessing clinical symptoms, ESR/CRP, and glucocorticoid adverse effects (blood pressure, glucose, weight). 4

• Methotrexate addition: Consider adding methotrexate 7.5-10 mg weekly if relapse occurs, therapy extends beyond 2 years, or significant glucocorticoid toxicity develops. 4, 7

Common pitfall: Do not start doses below 12.5 mg/day, as sub-therapeutic dosing leads to persistent symptoms and diagnostic uncertainty. 4

Acute Rheumatic Fever (Migratory Pattern, Recent Streptococcal Infection)

Do not initiate anti-inflammatory therapy until diagnosis is confirmed, as treatment masks the characteristic migratory pattern and diagnostic features. 3

• Once confirmed: Start salicylates or NSAIDs for arthritis; reserve corticosteroids only for severe carditis. 3

• Antibiotic prophylaxis: Initiate penicillin prophylaxis to prevent recurrent acute rheumatic fever. 3

• Cardiology referral: Mandatory for suspected cardiac involvement or new murmur. 3

Chronic Lymphocytic Thyroiditis with Hypothyroidism

• Thyroxine replacement: In hypothyroid patients with chronic lymphocytic thyroiditis presenting with polyarthralgia, thyroid replacement therapy induces progressive improvement of symptoms, though statistical significance may not be reached until 12 months. 6

• Symptom management: Acetaminophen for pain control during the gradual improvement phase. 6

Isolated ACTH Deficiency

• Glucocorticoid replacement: Polyarthralgia, fever, and elevated inflammatory markers improve rapidly after glucocorticoid replacement in patients with isolated ACTH deficiency. 5

• Diagnostic clue: Consider this diagnosis when polyarthralgia is accompanied by hyponatremia, fasting hypoglycemia, and low plasma/urinary cortisol with inappropriately low ACTH. 5

General Treatment Principles for Inflammatory Polyarthralgia

• Early intervention: Regardless of etiology, early treatment is key to preventing disability and chronic ill-health. 1

• Combined approach: Lifestyle modification, physical therapy, and medication together are most effective in negating long-term disability. 1

• Follow-up strategy: Monitor over several months to a year, as few symptoms are pathognomonic and the diagnosis often evolves with time. 2

Specialist Referral Indications

• Rheumatology: Positive autoantibodies, persistent inflammatory arthritis, diagnostic uncertainty, or atypical features (age <60, peripheral arthritis, inadequate glucocorticoid response). 4, 3

• Cardiology: Suspected acute rheumatic fever with cardiac involvement. 3

• Endocrinology: Suspected endocrine disorders (thyroid disease, adrenal insufficiency) presenting with polyarthralgia. 5, 6

Critical caveat: Polyarthralgia is never a standalone diagnosis—treatment without identifying the underlying cause risks missing serious conditions such as giant cell arteritis (which requires higher glucocorticoid doses to prevent blindness), endocarditis, or malignancy. 4, 3