From the Guidelines
Polyarthritis in the emergency room requires prompt evaluation and management by a rheumatologist within 6 weeks after the onset of symptoms. The initial assessment should focus on distinguishing between infectious, crystal-induced, and autoimmune etiologies. Start with a thorough history, physical examination, and basic laboratory tests including complete blood count, inflammatory markers (ESR, CRP), renal and liver function tests, and joint fluid analysis when possible 1.
For acute severe polyarthritis, begin with NSAIDs such as naproxen 500mg twice daily or ibuprofen 600-800mg three times daily for pain control, but use them at the minimum effective dose for the shortest time possible after evaluation of gastrointestinal, renal, and cardiovascular risks 1. If septic arthritis is suspected, obtain joint fluid for culture and initiate empiric antibiotics like vancomycin 15-20mg/kg IV plus ceftriaxone 2g IV while awaiting culture results. For crystal arthropathies like gout, colchicine 0.6mg twice daily can be started if not contraindicated. Severe autoimmune flares may require prednisone 20-40mg daily, but systemic glucocorticoids should be used at the lowest dose necessary as temporary (<6 months) adjunctive treatment 1.
Key considerations in management include:
- Starting DMARDs, such as methotrexate, as early as possible (ideally within 3 months) in patients at risk of persistent disease 1
- Using intra-articular glucocorticoid injections for the relief of local symptoms of inflammation 1
- Monitoring disease activity regularly, including tender and swollen joint counts, patient and physician global assessments, ESR, and CRP 1
- Considering non-pharmacological interventions, such as dynamic exercises and occupational therapy, as adjuncts to drug treatment 1
- Ensuring patient education and addressing comorbidities, such as smoking cessation, dental care, weight control, and vaccination status 1.
Arranging prompt rheumatology follow-up within 1-2 weeks is crucial, as polyarthritis often requires ongoing specialized care beyond the emergency setting. The main goal of treatment is to achieve clinical remission, and regular monitoring of disease activity, adverse events, and comorbidities should guide decisions on choice and changes in treatment strategies 1.
From the FDA Drug Label
Methotrexate is indicated in the management of selected adults with severe, active rheumatoid arthritis (ACR criteria), or children with active polyarticular-course juvenile rheumatoid arthritis, who have had an insufficient therapeutic response to, or are intolerant of, an adequate trial of first-line therapy including full dose non- steroidal anti-inflammatory agents (NSAIDs). Aspirin, (NSAIDs), and/or low dose steroids may be continued, although the possibility of increased toxicity with concomitant use of NSAIDs including salicylates has not been fully explored. Steroids may be reduced gradually in patients who respond to methotrexate.
Methotrexate is used to treat polyarthritis in the context of rheumatoid arthritis, including polyarticular-course juvenile rheumatoid arthritis. The treatment may be used in combination with other medications such as NSAIDs and steroids. However, the possibility of increased toxicity with concomitant use of NSAIDs has not been fully explored 2.
- Key points:
- Methotrexate is indicated for severe, active rheumatoid arthritis.
- It may be used in combination with NSAIDs and steroids.
- The treatment is also used for polyarticular-course juvenile rheumatoid arthritis.
- Prednisone may be used as an adjunctive therapy for short-term administration in rheumatoid arthritis, including juvenile rheumatoid arthritis 3.
From the Research
Definition and Causes of Polyarthritis
- Polyarthritis is defined by the palpable synovitic swelling of more than 4 joints 4
- It is always due to a systemic disease and not a local process
- Causes include a broad spectrum of rheumatic and infectious diseases with clearly different therapeutic options
Septic Polyarthritis
- Septic polyarthritis is rarer than septic monoarthritis, but associated with higher mortality 5
- It may be difficult to distinguish clinically from noninfectious inflammatory arthritis
- Patients with septic polyarthritis are more likely to have rheumatoid arthritis, sepsis, and higher peripheral and synovial white blood cell counts compared to those with septic monoarthritis 5
Diagnosis and Treatment of Septic Arthritis
- Septic arthritis must be considered and promptly diagnosed in any patient presenting with acute atraumatic joint pain, swelling, and fever 6
- Risk factors for septic arthritis include age older than 80 years, diabetes mellitus, rheumatoid arthritis, recent joint surgery, hip or knee prosthesis, skin infection, and immunosuppressive medication use 6
- Synovial fluid studies are required to confirm the diagnosis, and empiric antibiotic therapy should be initiated if there is clinical concern for septic arthritis 6
Management of Septic Arthritis
- Total duration of therapy ranges from two to six weeks, but certain infections require longer courses 6
- Consideration for microorganisms such as Neisseria gonorrhoeae, Borrelia burgdorferi, and fungal infections should be based on history findings and laboratory results 6
- Early diagnostic arthrocentesis of the joint for Gram stain microscopy, culture and antibiotic sensitivity testing is recommended to guide the appropriate use of antibiotics 7