Refer to Rheumatology Services for further advice regarding the assessment and management of patients with inflammatory arthritis and in cases where there are diagnostic difficulties. This should be done as soon as possible after presentation.
This section does not address the management of septic arthritis. All cases of suspected septic arthritis should be referred to Rheumatology or Orthopaedics depending on local protocol.
Treatment options
A. Pain control
1. Non-opioid and weak opioid analgesics
Paracetamol oral 1g 4–6 hourly (maximum 4g in 24 hours)
- Paracetamol is as effective as non-steroidal anti-inflammatory drugs (NSAIDs) in many patients with osteoarthritis. Consider dose reduction of paracetamol in patients with low body weight (≤50kg), renal / hepatic impairment or glutathione deficiency (chronic malnourishment, chronic alcoholism) to 15mg/kg/dose up to four times daily (max 60mg/kg/day). An example is: dose reducing to paracetamol oral 500mg four times daily. N.B. Patients with chronic liver failure may require a further dose adjustment (7.5mg/kg/dose, max 30mg/kg/day).
- If response is inadequate to simple analgesia try using regularly for 3-4 days at maximum prescribed dose, or NSAIDs may be tried but should be stopped if ineffective.
2. NSAIDs
(Also see 'Acute Pain Guidelines' (NSAIDs sub-section) on AthenA / Guidelines - Prescribing (link only active if accessing via NHS network)).
- Ibuprofen oral 400–600mg three times daily after food or
- Naproxen oral 250–500mg twice daily after food
NSAIDs are associated with risk of significant toxicity. Brief cautions and contraindications which should be noted (see NHSAAA 'Acute Pain Guidelines' (NSAIDs sub-section) for further prescribing notes) include:
- Assess each patient's individual risk factors, including any history of cardiovascular and gastrointestinal (GI) illness before prescribing. Avoid or minimise use of NSAIDs in patients with ischaemic heart disease and hypertension.
- Always use the lowest possible dose of NSAID for the shortest possible duration.
- Avoid combinations of NSAIDs and, where possible, concomitant use of NSAIDs and nephrotoxic drugs.
- Use with caution in mild renal impairment and hepatic impairment
- NSAIDs are contraindicated in moderate to severe renal failure, severe cardiac failure, severe hepatic failure and active peptic ulcer disease.
- Consider gastroprotection in those patients at increased GI risk (see table 1 below). Remember patients remain at risk of perforation and bleeds despite gastroprotection.
- Avoid, if possible, the co-administration of low dose aspirin with NSAIDs due to increased GI risk. Non-selective NSAIDs may also antagonise the antiplatelet effects of low dose aspirin.
| Table 1 – People at high risk of serious NSAID induced GI adverse effects |
- Age ≥65 years
- History of gastroduodenal ulcer, perforation or GI bleeding.
- Concomitant use of medication known to increase risk of upper GI adverse events e.g. aspirin, anticoagulants, corticosteroids, selective serotonin re-uptake inhibitors.
- Serious co-morbidity e.g. cardiovascular disease, renal or hepatic impairment (including dehydration), diabetes, hypertension.
- Requirement for prolonged duration of NSAID use.
- High dose NSAID use (ibuprofen 2400mg per day or naproxen 1g per day).
- Heavy smoking
- Excessive alcohol consumption
- Previous side effects from NSAIDs.
|
Gastroprotection
- Proton pump inhibitors e.g.:
- Omeprazole oral 20mg each day or
- Lansoprazole oral 15–30mg each day.
- Gastroprotection is only required for the duration of the NSAID course.
COX-2 selective NSAIDs (Coxibs)
Choice:
- Celecoxib oral 100mg twice daily or
- Meloxicam 7.5-15mg once daily (consider 7.5mg once daily in elderly).
Coxibs are associated with less GI toxicity than NSAIDs but with increased cardiovascular risk. The following should be noted:
- Coxibs should only be prescribed for patients with high risk of GI toxicity and low cardiac risk.
- Coxibs should not be prescribed for patients taking concomitant aspirin.
- For patients requiring a PPI, the combination of a Coxib and a PPI should be prescribed if the anti-inflammatory is essential.
B. Disease Modifying Anti-Rheumatic Drugs (DMARDs) and immunosuppressant therapies
Many patients with inflammatory arthritides or connective tissue diseases will be receiving one or more DMARDs or immunosuppressants including biologic agents such as tumour necrosis factor alpha (TNFα) inhibitors. These medicines are usually initiated on the advice of rheumatology. N.B. Some rheumatology patients may be on regular oral steroids- please confirm and manage on admission as per Assessing Medicines on Admission in Acute Patients guidance.
DMARDs include:
- Methotrexate (once weekly preparation, orally or subcutaneously)
- Sulfasalazine EC
- Hydroxychloroquine
- Leflunomide
- Azathioprine
- Ciclosporin
Guidelines on DMARD monitoring (BSR / BHPR) are available on NHSAAA AthenA / Guidelines - Prescribing / Musculoskeletal and Joint Diseases or the British Society for Rheumatology website.
Biologics include:
- Etanercept SC
- Adalimumab SC
- Infliximab IV
- Rituximab IV
- Tocilizumab IV/SC
- Sarilumab SC
- Abatacept IV/SC
- Certolizumab Pegol SC
- Golimumab SC
JAK inhibitors include:
- Baricitinib oral
- Filgotinib oral
- Tofacitinib oral
- Upadacitinib oral
Biosimilar agents are available e.g. Benepali (etanercept), Amgevita (adalimumab) and various brands of rituximab and infliximab.
Important points to note
Biologics and JAK inhibitors are hospital prescribed medications and therefore may not be listed on a patient's Emergency Care Summary (ECS). Be aware that the dose frequency for these medicines can be variable e.g. daily, weekly, 4 weekly or longer. Check carefully before prescribing.
Biosimilar agents are available for several biologics. It is good practice to prescribe biological medicines by brand name.
DMARDs, biologics and immunosuppressant therapies may increase the patient's risk of infection and/or mask the typical signs of sepsis. For example, tocilizumab and sarilumab suppress CRP and ESR, and therefore these markers are not reliable to measure in intercurrent illness in patients on these drugs.
Discuss with rheumatology if:
- Infection is suspected on treatment with DMARD, biologic or immunosuppressant therapy - withhold drug until it has been discussed (N.B. sulfasalazine and hydroxychloroquine can be safely continued in most circumstances).
- There are any abnormalities in blood monitoring thought to be related to DMARD, biologic or immunosuppressant therapy.
- Changes to DMARD, biologic or immunosuppressant therapy doses are planned when a patient is admitted for other reasons e.g. patient going for surgery.
- Long-term DMARD, biologic or immunosuppressant therapy is stopped e.g. due to side effects.
- A DMARD, biologic or immunosuppressant therapy prescription is unclear – withhold drug until it has been discussed.
Medication supply
Patients who are admitted on a SC biologic or JAK inhibitor, should have a supply at home via their Home Care provider. Medication should be brought in from home if needed during an admission to avoid missed doses. Ensure that nursing staff, who may try and order via pharmacy, are aware of this. Please make sure that medications are added to discharge prescriptions for information only.
