We suggest treatment of arthritis in most patients initially with nonsteroidal antiinflammatory drugs (NSAIDs) in antiinflammatory doses (eg, naproxen 500 mg two to three times daily, diclofenac 50 mg three times daily, or indomethacin 50 mg three times daily), rather than starting a disease-modifying antirheumatic drugs (DMARD) upon diagnosis.
•Inadequate response to initial NSAID therapy
In patients who do not respond adequately to NSAIDs, we suggest intraarticular glucocorticoids, rather than initiating therapy with daily oral glucocorticoids or a DMARD.
•Inadequate response to NSAIDs and intraarticular glucocorticoids
In patients who do not respond adequately to NSAIDs and intraarticular glucocorticoid injections, we suggest low to moderate doses of systemic glucocorticoids, rather than initiating treatment with a DMARD. A typical dose would be prednisone, 20 mg daily, titrated to the lowest dose required to control symptoms
•Inadequate NSAID response and glucocorticoid dependence
In patients who have not responded adequately to NSAIDs over at least four weeks and who require ongoing therapy with more than 7.5 mg of prednisone or equivalent for more than three to six months we suggest a trial of a conventional synthetic (cs) DMARD, rather than continuing moderate to high dose glucocorticoids without a DMARD. We usually prescribe sulfasalazine (SSZ, beginning with 500 to 1000 mg daily and titrating the dose to a maximum of 3 g daily). Methotrexate (MTX, up to 25 mg one day weekly) is an alternative to SSZ. Treatment with a tumor necrosis factor (TNF) blocker may be used in the rare patients who are resistant to NSAIDs and csDMARD therapy.
●Prognosis
The prognosis is good in the majority of patients, with spontaneous remission within 6 to 12 months of onset of arthritis. However, some patients have persistent but mild musculoskeletal symptoms, and others develop radiologic evidence of joint injury and evolve to a more chronic form of SpA.
