Arthritis is a common condition seen frequently by family practitioners, and there are many types of arthritis. Management of arthritis depends largely on the specific type of arthritis that the patient suffers from. In this article, we will provide the primary care doctor with practical information for managing arthritis, focussing on the management of osteoarthritis and rheumatoid arthritis.
The term ‘arthritis’ refers to the swelling of a joint or joints with associated limitation of movement, heat, pain or tenderness, which is caused by inflammation or degeneration of one or more joints.
In the United States, the prevalence rate of self-reported arthritis is estimated to be about 59.4 million people,
There is a paucity of prevalence data in Africa. In South Africa, osteoarthritis is the most prevalent form of arthritis, with a prevalence rate of 55.1% in urban settings, and between 29.5% and 82.7% in adults over 65 years of age in rural settings.
Arthritis is the pathological feature in over 100 different chronic diseases involving the joints and connective tissues, with the most common forms being osteoarthritis, rheumatoid arthritis (RA) and ankylosing spondylitis. Less common forms of arthritis include systemic lupus erythematosus, scleroderma, psoriatic arthritis and gout.
The three major physiological categories of arthritis include
Although arthritis may be monoarticular or polyarticular, all types may be monoarticular early in the pathological course.
Classification of arthritis, clinical characteristics, lab and radiological features.
Subtype | Arthritis | F:M | Age of onset (in years) | Target joints | Distribution | Radiographic features | Lab investigations |
---|---|---|---|---|---|---|---|
OA | 1:1 to 2:1 | ↑elderly | Lower extremity joints, PIP, DIP, first MCP joint | Asymmetrical or symmetrical | Narrow joint space; osteophytes; subchondral sclerosis | None indicated | |
RA | 3:1 | 40–70 | MTP, MCP, PIP, knees, hips, cervical spine | Bilateral, symmetric | Narrow joint space – symmetrical; thickened capsule; periarticular osteoporosis; marginal erosions; joint deformity | Rheumatoid factor, anti-cyclic citrullinated peptide (anti-CCP) | |
SLE | 9:1 | 30–50 | MCP; PIP of the hands primarily | Bilateral, symmetric | No erosions; joint deformity; osteonecrosis | ANA, anti-ds DNA, anti-Smith antibodies, proteinuria and haematuria, serum C3/C4 | |
Ankylosing spondylitis | 1:10 | 15–35 | SI; spine: vertebral bodies and apophyseal articulations; hip; shoulder | Bilateral, symmetric | Erosions; periostitis; ankylosis; thin, marginal syndesmophytes | Human leukocyte antigen (HLA) B27, ESR, CRP | |
Psoriatic arthritis | 1:1 | 30–50 | Predominantly upper extremity; DIP and PIP; SI; spine | Bilateral, symmetric; asymmetric in SI joints and extremities | Marginal or central erosions with periostitis; early joint space widening with eventual narrowing; non-marginal syndesmophytes; SI erosions | - | |
Reiter’s syndrome | 1:5 | 15–35 | Predominantly lower extremity; MTP; calcaneus; SI; spine | Asymmetric in foot; bilateral, symmetric or asymmetric in SI joints | Similar to psoriatic in the spine and extremities; calcaneal enthesopathy | Testing for |
|
Gout | 1:20 | 40–50 | MTP of first digit; other MTP joints, DIP, midfoot, ankle, DIP joints of hand | Asymmetric; often monoarticular | Soft-tissue nodules (tophi) with calcification; para-articular erosions; intact joint space; no osteopenia | Serum uric acid, uric acid crystals in joint fluid | |
Bacterial | Not known | ↑children, elderly | Large joints – elbows, hips, knees, spine, fever | Asymmetric; often monoarticular | Effusions | Lyme disease testing, joint/blood culture | |
Viral | 3:1 to 4:1 | ↑children | Wrists, MCP, PIP, ankle, MTP | Symmetric, polyarticular, associated fever and rash | Normal | HIV, Hepatitis B surface antigen, Hepatitis C virus antibody, Parvovirus B19 |
ANA, anti-nuclear antibody; CRP, C-reactive protein; DIP, distal interphalangeal joint; ESR, erythrocyte sedimentation rate; F, female; HIV, human immunodeficiency virus; M, male; MCP, metacarpophalangeal joint; MTP, metatarsophalangeal joint; OA, osteoarthritis; PIP, proximal interphalangeal joint; RA, rheumatoid arthritis; SI, sacroiliac joint; SLE, systemic lupus erythematosus; CCP, cyclic citrullinated peptide.
When approaching musculoskeletal pain, differentiating between articular and non-articular or diffuse pain narrows the differential, and this is based on history and examination (
Approach to musculoskeletal pain.
Osteoarthritis is a clinical syndrome of joint pain that is accompanied by varying degrees of functional restriction, reduced quality of life and lack of psychosocial well-being.
Damage to the cartilage causes the tissues within the joint to become active, altering its structure, resulting in pain, stiffness and restricted range of movement. Osteophytes develop at the edge of the joint while the synovium thickens and fluid accumulation causes swelling (
Osteoarthritis pathological findings.
The main symptoms of osteoarthritis are pain and sometimes stiffness in the affected joints. The pain tends to be worse when the joint is moved or at the end of the day. Stiffness occurs at rest and usually improves with activity.
The swelling may be hard and knobbly, which is caused by the growth of extra bone, or it may be soft, which may be caused by the thickening of the synovium and extra fluid inside the joint capsule.
Crepitus is a common sign of osteoarthritis. Muscle wasting around a joint is a late feature.
The diagnosis of osteoarthritis is predominantly clinical based on a good history and physical examination. Plain radiological procedures may confirm diagnosis or rule out other medical conditions.
The management of osteoarthritis encompasses both pharmacological and non-pharmacological options involving the patient in decision-making that incorporates adherence and self-management.
Key non-pharmacological interventions include arthritis education, land-based exercise programmes and weight reduction. Optional non-pharmacological interventions include heat therapy, manipulation and massage, transelectrical nerve stimulation (TENS) and water-based exercises. These can be tried according to patient preferences and stopped if found to be ineffective.
The popularity of paracetamol has decreased with new studies questioning the safety profile in comparison to the minimal efficacy it produces.
Topical and oral non-steroidal anti-inflammatory drugs (NSAIDS) form the backbone of pharmacological interventions for osteoarthritis. While all NSAIDS share similar efficacy, individual sensitivities may differ. In principle, the lowest dose should be used for the shortest period of time to achieve a clinical response to balance the risk of long-term use. Comorbid conditions should be factored in when prescribing NSAIDS as they are cardiotoxic, nephrotoxic and cause peptic ulceration.
Non-steroidal anti-inflammatory drugs for knee osteoarthritis.
Opioids provide marginal efficacy for joint pain but carry a serious risk of abuse, tramadol can be used in certain instances, while other opioids in general should be avoided. Intra-articular steroids are of significant benefit during an acute flare for short-term pain relief. However, repeated injections may result in rapid cartilage loss with no long-term benefit and hence judicious use is warranted.
Summary of international recommendations for knee osteoarthritis management.
Rheumatoid arthritis is a systemic autoimmune condition, which causes pain, swelling and stiffness of multiple joints of the body.
Autoimmunity and overall systemic and articular inflammation are responsible for the destructive progression of the disease.
Pathological features of rheumatoid arthritis.
Assessment of the patient is based on clinical history and physical examination. The pain of arthritis is the factor that causes patients to frequently seek healthcare. Characteristics such as location, quantity, intensity, nature and the course of pain can assist diagnosis. Other symptoms of arthritis include stiffness, limited motion, fatigue, weakness and swollen joints. The latter can be assessed by inspection or by direct palpation of the joint. A count of the number of swollen joints provides an indication of the amount of inflamed tissue. Use of diaries could prove a useful adjunct to traditional methods of pain assessment (e.g. visual analogue scales) and can incorporate ratings of stiffness, fatigue and mood.
Early diagnosis and initiation of treatment or referral to a physician is key in the prevention of severe disability and the loss of quality of life.
A joint working group of the ACR and the European League against Rheumatism (EULAR) developed updated criteria to assist in making diagnoses earlier (
The 2010 American College of Rheumatology/European League against Rheumatism classification criteria for rheumatoid arthritis.
Criteria | Score |
---|---|
1 large joint | 0 |
2−10 large joints | 1 |
1−3 small joints (with or without involvement of large joints) | 2 |
4−10 small joints (with or without involvement of large joints) | 3 |
> 10 joints (at least 1 small joint) | 5 |
Negative RF |
0 |
Low-positive RF |
2 |
High-positive RF |
3 |
Normal CRP |
0 |
Abnormal CRP |
1 |
< 6 weeks | 0 |
≥ 6 weeks | 1 |
Note: Add score of A to D, a score of ≥ 6/10 needed for classification of RA.
ACR, American College of Rheumatology; CCP, cyclic citrullinated peptide; ACPA, anti-cyclic citrullinated peptide antibody; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; RF, rheumatoid factor.
General laboratory tests can help determine whether arthritis and its treatment have affected major body systems. A full blood count may reveal the presence of anaemia of chronic disease, a common feature of arthritis. Neutropenia is often associated with severe RA. Liver function tests and viral serology are essential prior to commencement of treatment.
In RA, 80% of patients will test positive for rheumatoid factor. Positive rheumatoid factor and anti-citrullinated peptide antibody tests are associated with increased disease severity, the development of erosions, extra-articular manifestation and greater disability. Levels of acute phase reactants (e.g. C-reactive protein and erythrocyte sedimentation rate) are used to monitor disease activity.
The management of RA has changed dramatically over the past 30 years.
The 2016 update of the EULAR recommendations is based on recent evidence in the area of RA management.
The recommended target is to reach a state of sustained remission or low disease activity using standardised scoring systems like the disease activity 28 joint score (DAS28). Methotrexate (MTX) is the initial drug of choice if not contraindicated. It is a conventional synthetic disease-modifying antirheumatic drug (csDMARD). A trial period of 3 to 6 months is the goal before treatment is adjusted according to the degree of improvement.
A second-line drug like another csDMARD (e.g. leflunomide or sulphasalazine) may be added in the presence of poor prognostic factors. Biological drugs (e.g. etanercept) may be added to csDMARDS until remission before the former is weaned off and then the latter.
Biologicals should be co-prescribed with a csDMARD in most cases. It is not advisable to combine two biologicals. Once remission is obtained, first wean off the biological and then the csDMARD.
A multidisciplinary approach through networking with allied health disciplines like physiotherapy, occupational therapy, podiatry and dietetics is essential to reach goal-orientated targets.
The basic management for some of the other common arthritis is detailed in
Management of other arthritides.
Arthritis | Therapeutic Options |
---|---|
Hydroxychloroquine, glucocorticoids; if they fail, MTX or AZA; biological – Belimumab |
|
NSAIDS | |
TNF Inhibitors, for example, infliximab, etanercept, adalimumab | |
IL17 inhibitors – secukinumab, ixekizumab |
|
TNF inhibitor biologics | |
Oral small molecules – MTX, SSZ, CYC | |
IL12/23i – ustekinumab | |
IL17 inhibitors | |
Smoking cessation |
|
Acute – NSAIDS | |
Chronic stage – DMARDS (SSZ, MTX) | |
Biologics – etanercept, adalimumab | |
Acute attack – NSAIDS, systemic steroids if cannot tolerate, or no response use colchicine | |
Recurrent attacks (2 or more/year), tophi, urate arthropathy or kidney failure – urate-lowering therapy with allopurinol (caution – nephrotoxic) use probenecid |
|
Drainage of infected fluid | |
Antibiotics | |
Joint immobilisation | |
Treat the cause | |
NSAIDS |
AZA, azathioprine; CYC, cyclosporine; DMARDs, disease-modifying antirheumatic drug; IL, interleukin; MTX, methotrexate; NSAIDs, non steroidal anti-inflammatory drugs; SSZ, salazopyrin; TNF, tumour necrosis factor; SLE, systemic lupus erythematosus.
While arthritis is common and the differential diagnosis is broad, having a well-rounded approach and holistically managing a patient, including timely referral for the inflammatory forms of arthritis, will result in better patient outcomes, better quality of life and decreased morbidity.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
All authors contributed equally to this work.
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Data sharing is not applicable to this article as no new data were created or analysed in this study.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.