Purpose and audience
This concise review is written for clinicians managing patients with inflammatory arthritis (rheumatoid arthritis, psoriatic arthritis, axial spondyloarthritis, and similar immune‑mediated conditions). It summarizes treatment goals, a stepwise pharmacologic approach, safety monitoring, and practical considerations for special populations.
Treatment objectives
- Rapid control of pain and inflammation to restore function
- Prevention of structural joint damage and long‑term disability
- Minimization of medication‑related adverse effects
- Integration of pharmacologic and non‑pharmacologic strategies to improve quality of life
Stepwise pharmacologic strategy
1) Symptomatic control: NSAIDs and analgesics
NSAIDs reduce prostaglandin‑mediated inflammation and pain (eg, naproxen, ibuprofen, diclofenac, celecoxib). They are effective for symptom relief but do not alter disease progression. Select agents considering GI, renal, and cardiovascular risk; use lowest effective dose and consider gastroprotection for high‑risk patients.
2) Short‑term control: Glucocorticoids
Glucocorticoids rapidly suppress inflammation and are valuable as bridging therapy while DMARDs take effect or for severe flares. Aim for the shortest effective duration and a planned taper. For oligoarthritis, intra‑articular corticosteroid injection provides potent local control with fewer systemic effects.
3) Disease modification: Conventional synthetic DMARDs (csDMARDs)
Begin csDMARD therapy promptly to prevent joint damage. Common choices:
- Methotrexate (first‑line): weekly dosing with folic acid; monitor CBC, LFTs, and renal function.
- Leflunomide: alternative to methotrexate; monitor hepatic function and consider cholestyramine washout if needed.
- Sulfasalazine and hydroxychloroquine: useful in combination regimens; hydroxychloroquine is pregnancy‑safe and has favorable metabolic effects.
4) Targeted therapies: Biologic and targeted synthetic DMARDs
Escalate to targeted therapy for inadequate response to csDMARDs or aggressive disease phenotype.
- TNF inhibitors (eg, etanercept, adalimumab): broad efficacy across inflammatory arthritides; screen for latent TB and hepatitis B prior to initiation.
- IL‑6 receptor antagonists (eg, tocilizumab): effective in refractory RA; monitor lipids and LFTs.
- B‑cell depletion (rituximab): option for seropositive or refractory disease.
- Costimulation inhibitors (abatacept) and other biologics for specific indications.
- JAK inhibitors (tofacitinib, baricitinib, upadacitinib): oral agents with rapid efficacy; assess thromboembolic and infection risks according to patient profile and regulatory guidance.
Targeted agents substantially reduce disease activity and structural progression but require prescriber awareness of infection risk and rare adverse events.
Safety, baseline screening, and vaccination
- Baseline tests: CBC, renal and liver panels, hepatitis B/C serologies, TB screening (IGRA or chest x‑ray), and assessment of vaccination status.
- Monitoring schedule: periodic CBC, LFTs, creatinine, and lipid profile (especially with JAK or IL‑6 therapies).
- Vaccination: Update inactivated vaccines (influenza, pneumococcal, hepatitis B) ideally before initiating biologic therapy. Avoid live vaccines during significant immunosuppression.
- Infection vigilance: Educate patients to report fever or infection signs promptly. Temporarily suspend immunosuppression during severe infections and coordinate reinitiation with specialists.
Special populations and practical considerations
- Reproductive health: Methotrexate and leflunomide are teratogenic—discontinue before conception; hydroxychloroquine and certain TNF inhibitors may be continued in pregnancy with specialist oversight.
- Comorbid conditions: Select agents compatible with cardiovascular disease, chronic lung disease, or prior malignancy.
- Perioperative management: Coordinate timing of biologics around elective surgery to minimize infection risk and manage wound healing.
Non‑pharmacologic measures
Incorporate physical therapy, occupational therapy, weight management, smoking cessation, and psychosocial support. Rehabilitation and early functional interventions improve outcomes and reduce disability.
Practical prescribing tips
- Adopt a “treat‑to‑target” approach (eg, remission or low disease activity), reassessing response at defined intervals (eg, 3 months).
- Consider combination csDMARD therapy or early targeted therapy in high‑risk phenotypes.
- Minimize long‑term systemic steroid use and employ steroid‑sparing strategies.
Conclusion
Effective management of inflammatory arthritis balances rapid symptom control with early, sustained disease‑modifying therapy and vigilant safety monitoring. Personalized regimens, multidisciplinary care, and patient engagement are central to preventing joint damage and preserving function.