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OPD Management of Polyarthralgia: A Comprehensive Reference Guide

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1. Definition and Initial Framing

• Arthralgia only (pain, no swelling/warmth) vs. True arthritis (swelling + warmth + tenderness = synovitis)
• Articular vs. Periarticular (bursitis, tendinitis, enthesitis - these mimic joint disease but do not involve the synovium)

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2. OPD Diagnostic Algorithm

• Articular? → proceed to effusion check → arthrocentesis if effusion present
• Periarticular/soft tissue? → Bursitis/Tendinitis → symptomatic treatment, consider viral testing

• Arthrocentesis → Is it suggestive of septic arthritis?
  • Yes → cultures, IV antibiotics, orthopedic input
  • No → workup for gout, pseudogout, rheumatologic illness, OA, seronegative spondyloarthropathy, viral causes

• Viral arthritis, OA, early rheumatologic illness → outpatient viral/rheumatologic testing as indicated

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3. History Taking: The Seven Dimensions

• Skin rash (psoriasis → PsA; butterfly rash → SLE; keratoderma blennorrhagica → reactive arthritis)
• Mucosal ulcers (SLE, Behçet's, reactive arthritis)
• Uveitis/iritis (SpA, JIA)
• Urogenital symptoms (reactive arthritis)
• GI symptoms / diarrhea (enteropathic arthritis, reactive arthritis)
• Fever + weight loss (septic arthritis, adult-onset Still's, malignancy-associated)
• Raynaud's, dry eyes/mouth (connective tissue disease, Sjögren's)

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4. Physical Examination

• Synovial swelling = soft, doughy, fluctuant around the joint line (finger sinks in)
• Bony swelling = hard, fixed (e.g., Heberden's nodes in OA)
• Redness/warmth = highly active inflammation (septic arthritis, gout, reactive arthritis)
• Use the "squeeze test" (lateral compression of MCP/MTP joints) as a screening sign for inflammatory arthritis

• RA follow-up: DAS28 (28 joints: MCP 1-5, PIP 1-5 bilateral; wrists, elbows, shoulders, knees)
• Full initial exam: 66/68-joint count at first presentation

Pattern Recognition Table (Firestein & Kelley's Rheumatology)

• Skin: psoriasis, tophi (gout), nodules (RA), malar rash (SLE), keratoderma blennorrhagica (reactive)
• Eyes: uveitis/iritis (SpA, JIA), scleritis (RA)
• Lymphadenopathy: viral arthritis, lymphoma, Still's
• Salivary glands: Sjögren's
• Entheses: SpA (Achilles, plantar fascia, iliac crest)
• Dactylitis: "sausage digit" in PsA, reactive arthritis, rarely sarcoidosis
• Spine: restricted lumbar flexion, Schober's test (AS/axial SpA)

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5. Investigations in OPD

Tier 1 - Order in ALL patients with polyarthralgia

Tier 2 - Targeted by clinical picture

Tier 3 - Imaging beyond plain X-ray

Synovial Fluid Analysis (Arthrocentesis) - Whenever a joint effusion is present

• Crystals: Monosodium urate (gout) = negatively birefringent, needle-shaped; CPPD (pseudogout) = positively birefringent, rhomboid
• Gram stain + culture: mandatory if infection suspected (precede antibiotics)
• Glucose: low in septic arthritis (<60% of serum glucose)
• Lactate: rising evidence; point-of-care synovial lactate >10 mmol/L supports septic arthritis

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6. Differential Diagnosis and Disease-Specific OPD Management

6.1 Rheumatoid Arthritis (RA)

• Joint involvement (score 0-5)
• Serology: RF/anti-CCP positive (score 0-3)
• Acute phase reactants: abnormal CRP/ESR (score 0-1)
• Duration ≥6 weeks (score 0-1)

1. NSAIDs - short-term symptom relief in early disease; use lowest effective dose
2. Low-dose corticosteroids (prednisolone ≤10 mg/day) - bridge therapy while waiting for DMARD effect; taper as DMARDs take hold
3. DMARDs (start within 3 months of diagnosis - treat-to-target strategy):
   • Methotrexate is the anchor DMARD (7.5-25 mg/week oral or SC); supplement with folic acid 5 mg/week
   • Hydroxychloroquine (200-400 mg/day) - milder disease; requires annual ophthalmology review
   • Sulfasalazine (500 mg titrated to 2-3 g/day)
   • Leflunomide (10-20 mg/day) - alternative to MTX
4. Biologic DMARDs (if inadequate response to 2 csDMARDs):
   • TNF-alpha inhibitors (etanercept, adalimumab, infliximab)
   • IL-6 inhibitors (tocilizumab, sarilumab)
   • T-cell co-stimulation inhibitor (abatacept)
   • Rituximab (anti-CD20)
5. Treat-to-target: Target = remission or low disease activity by DAS28; reassess every 1-3 months
6. OPD monitoring: CBC, LFT, RFT every 3 months on MTX; screen for TB before biologics

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6.2 Osteoarthritis (OA)

• Weight loss (if BMI >25) - most effective single intervention for knee OA
• Aerobic exercise + resistance training (does not worsen cartilage)
• Physiotherapy - range of motion + muscle strengthening
• Occupational therapy - joint protection, assistive devices
• Footwear modification, knee bracing for medial compartment OA

1. Topical NSAIDs (diclofenac gel) - preferred over oral in patients >65 years (less systemic toxicity)
2. Oral NSAIDs (ibuprofen, naproxen, celecoxib) - short courses; use with PPI if GI risk
3. Paracetamol (acetaminophen) - limited benefit; useful in mild cases
4. Intra-articular corticosteroids - acute exacerbations; no more than 3-4 injections/year per joint
5. Intra-articular hyaluronic acid - modest evidence; considered if corticosteroids fail
6. Duloxetine - evidence for central sensitization component; FDA approved for OA pain

• Failed 6 months of optimal conservative treatment
• Significant functional impairment
• Unicompartmental (partial) or total knee/hip replacement

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6.3 Crystal Arthropathies

Gout

• NSAIDs (indomethacin 50 mg TID or naproxen 500 mg BD for 5-7 days) - first choice if no contraindication
• Colchicine (1.2 mg loading dose, then 0.6 mg 1 hour later; then 0.6 mg BD) - effective if started within 36-48 hours of attack
• Corticosteroids (prednisolone 30-35 mg/day for 5 days, or intra-articular injection) - when NSAIDs and colchicine are contraindicated (renal failure, elderly)
• Do NOT stop existing allopurinol during an acute attack; do NOT start new urate-lowering therapy during an attack

• Allopurinol - start at 50-100 mg/day; titrate to serum uric acid <6 mg/dL (target <5 mg/dL in tophaceous gout)
• Febuxostat (80-120 mg/day) - alternative xanthine oxidase inhibitor; avoid in cardiovascular disease
• Probenecid - uricosuric; only if underexcretor with normal renal function
• Colchicine 0.6 mg/day prophylaxis for 6 months when starting urate-lowering therapy
• Dietary counseling: avoid organ meats, shellfish, beer, high-fructose corn syrup; increase hydration
• Address contributing medications: thiazides, cyclosporine, low-dose aspirin (if clinically safe to switch)

Pseudogout (CPPD)

• Acute: NSAIDs, colchicine, or intra-articular/systemic corticosteroids
• Asymptomatic CPPD (radiologic chondrocalcinosis without symptoms) - treat underlying cause (hyperparathyroidism, hemochromatosis, hypomagnesemia)
• No proven agents to dissolve CPPD crystals; promising but unproven: methotrexate, IL-1 inhibitors

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6.4 Seronegative Spondyloarthropathies (SpA)

• Psoriform skin/nail changes or GI/urogenital trigger
• Enthesitis
• Asymmetric peripheral arthritis (lower > upper limb)
• Radiation to sacroiliac joints; HLA-B27 positive

Ankylosing Spondylitis / Axial SpA

1. NSAIDs continuously (not on-demand) - cornerstone; reduce inflammation + slow radiographic progression
2. Physiotherapy - daily spinal exercises mandatory; prevent ankylosis
3. Biologic DMARDs if NSAIDs fail (ASsess by ASDAS/BASDAI):
   • TNF inhibitors (etanercept, adalimumab, certolizumab, golimumab)
   • IL-17A inhibitors (secukinumab, ixekizumab) - preferred if also IBD present (caution - may worsen IBD)
4. csDMARDs (sulfasalazine) have NO role in pure axial disease; useful for peripheral SpA
5. Monitor: spine X-ray every 2 years; DEXA for osteoporosis

Psoriatic Arthritis (PsA)

1. NSAIDs - first-line for mild peripheral arthritis
2. Local corticosteroid injections - adjunct (avoid systemic steroids - rebound psoriasis flare risk)
3. csDMARDs (initiated early):
   • Methotrexate - particularly useful when skin psoriasis also needs treatment
   • Sulfasalazine, leflunomide - alternatives
4. Biologic DMARDs (TNF inhibitors, IL-17 inhibitors, IL-23 inhibitors such as guselkumab for skin-predominant) if csDMARDs fail
5. Nail disease: topical treatments; biologic agents treat both nail and joint
6. Referral to dermatology for skin management coordination

Reactive Arthritis (Reiter's Syndrome)

• Triggered by: Chlamydia trachomatis (urogenital), Salmonella, Shigella, Campylobacter, Yersinia (enteric)
• Classic triad: arthritis + urethritis + conjunctivitis ("can't see, can't pee, can't climb a tree")
• NSAIDs are first-line and usually sufficient
• Antibiotics: doxycycline for Chlamydia-triggered (does not alter arthritis course in post-dysenteric)
• DMARDs if refractory: sulfasalazine, methotrexate
• Most resolve within 3-6 months; 20-30% develop chronic arthritis

Enteropathic Arthritis (IBD-associated)

• Affects up to 40% of IBD patients; arthritis often mirrors GI flares
• NSAIDs - first-line for joint pain but may exacerbate IBD (use with caution)
• Sulfasalazine - treats both bowel and joint disease
• Intra-articular corticosteroids - avoid systemic steroids long-term
• Control of underlying IBD (biologics: TNF inhibitors, vedolizumab) - often resolves peripheral arthritis

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6.5 Infectious Arthritis

Septic Arthritis (Bacterial)

• EMERGENCY - irreversible joint destruction possible within 24-48 hours
• OPD role: identify and immediately refer to inpatient management
• Signs: fever + single (usually) hot, swollen joint + WCC in synovial fluid >50,000/mm³
• Treatment: empirical IV antibiotics (cover Staph aureus: oxacillin/nafcillin or vancomycin if MRSA risk) + repeated joint drainage

Gonococcal Arthritis

• Most common septic arthritis in young sexually active adults
• Presents as migratory polyarthralgia + tenosynovitis + skin lesions (pustules) → then settles in 1-4 joints
• Cultures often negative; PCR preferred; test all mucosal sites
• Treatment: ceftriaxone 2g IV/IM daily; transition to oral (cefixime) after improvement; add azithromycin 1g once for Chlamydia co-treatment

Lyme Arthritis

• Borrelia burgdorferi (Ixodes tick); endemic areas (northeast USA, parts of Europe)
• Late-stage: asymmetric large joint (knee) effusion
• Treatment: doxycycline 100 mg BD for 28 days (oral); amoxicillin or cefuroxime alternatives
• Prophylaxis after tick bite >24-36 hours: single dose doxycycline 200 mg PO

Viral Arthritis

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6.6 Connective Tissue Diseases with Polyarthralgia

Systemic Lupus Erythematosus (SLE)

• Arthritis/arthralgia in >90% - typically symmetric, non-erosive, affecting small joints
• Non-deforming Jaccoud's arthropathy may occur
• Key investigations: ANA (screen), anti-dsDNA, anti-Sm, complement (C3/C4 low), urine for casts
• OPD management of arthritis: hydroxychloroquine (200-400 mg/day) - backbone therapy for all SLE; NSAIDs; low-dose steroids; methotrexate for refractory

Sjögren's Syndrome

• Non-erosive polyarthritis + sicca symptoms (dry eyes, dry mouth)
• Anti-Ro (SS-A) and anti-La (SS-B) antibodies
• Treatment: hydroxychloroquine, pilocarpine (sicca); NSAIDs for arthralgia

Systemic Sclerosis

• Arthralgia, morning stiffness; tenosynovitis; rarely true synovitis
• Raynaud's phenomenon is the dominant feature
• NSAIDs; calcium channel blockers for Raynaud's

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6.7 Other Important Causes

Polymyalgia Rheumatica (PMR)

• Age >50 years (almost exclusively); bilateral shoulder/hip girdle stiffness + pain
• ESR consistently >50 mm/hr; CRP elevated
• Dramatic response to prednisolone 15 mg/day (diagnostic + therapeutic)
• Exclude GCA (giant cell arteritis) - temporal artery involvement in 20% of PMR
• Taper steroids very slowly over 12-18 months; DMARDs (tocilizumab, MTX) as steroid-sparing

Adult-Onset Still's Disease (AOSD)

• Classic triad: quotidian fever (spikes to 39°C, resolves within hours) + evanescent salmon-pink rash + polyarthritis
• Ferritin >10,000 ng/mL (highly suggestive); leukocytosis (WCC >15,000)
• Treatment: NSAIDs, systemic corticosteroids, methotrexate; biologics (tocilizumab, anakinra) for refractory

Rheumatic Fever

• Post-streptococcal; migratory large joint polyarthritis; carditis; Sydenham's chorea; subcutaneous nodules; erythema marginatum
• Diagnose by Jones criteria (2 major or 1 major + 2 minor) + evidence of preceding strep infection (positive ASOT)
• Treatment: penicillin (eradicate strep) + aspirin/NSAIDs; steroids for carditis; long-term benzathine penicillin prophylaxis

Fibromyalgia

• Widespread musculoskeletal pain + fatigue + sleep disturbance + cognitive symptoms
• No true arthritis; normal inflammatory markers and imaging
• OPD management: education, aerobic exercise, cognitive behavioral therapy; duloxetine, pregabalin, low-dose amitriptyline

Malignancy-Associated Arthritis (Carcinomatous Polyarthritis)

• Sudden-onset symmetric seronegative polyarthritis in older adults
• Asymmetric large joint involvement, lower limb predominant
• Red flags: no family history, no typical pattern, no response to standard therapy; age >50 with new-onset polyarthritis
• Workup: CT chest/abdomen/pelvis; PSA; mammography; colonoscopy

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7. OPD Referral Criteria

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8. OPD Monitoring Protocol Summary

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9. Quick Reference: Key Autoantibodies and Their Disease Associations

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10. Practical OPD Prescribing Pearls

• NSAIDs: always prescribe with gastroprotection (PPI) in patients >60 years, history of peptic ulcer, or on anticoagulants
• Colchicine: narrow therapeutic window; reduce dose in renal impairment; interactions with statins (myopathy risk)
• Methotrexate: always co-prescribe folic acid 5 mg/week (not on the same day as MTX); check CBC + LFT before each prescription increase
• Hydroxychloroquine: safe in pregnancy; annual ophthalmology review (retinal toxicity at cumulative dose >5 mg/kg/day)
• Biologics: screen for latent TB (IGRA or Mantoux + CXR) before starting; withhold during active infection; live vaccines contraindicated
• Corticosteroids: always counsel on bone protection (calcium + vitamin D); use bisphosphonate if >3 months treatment anticipated
• Allopurinol: start LOW (50-100 mg/day), titrate slowly (risk of drug reaction with eosinophilia and systemic symptoms - DRESS if escalated rapidly); HLA-B*58:01 screening before starting in Han Chinese, Thai, Korean populations

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