Immunomodulatory drugs for arthralgias, myalgias and arthritis

If arthralgias, myalgias and symptoms of arthritis are difficult to control, the specialist may choose to initiate immunomodulatory drugs, such as conventional synthetic disease-modifying antirheumatic drugs (csDMARDs). It may take weeks to months for immunomodulatory drugs to become effective. Drugs commonly used include hydroxychloroquine or, for severe arthritis, methotrexate. Dosages are adjusted depending on clinical response and adverse effects. For considerations for use of immunomodulatory drugs (including monitoring, screening for infection, and vaccination), see Principles of immunomodulatory drug use.

For a patient with inflammatory connective tissue disease and severe arthralgias, myalgias or symptoms of arthritis, the usual dosage of hydroxychloroquine is:

For additional considerations specific to hydroxychloroquine use, see Specific considerations for use of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs).

For a patient with inflammatory connective tissue disease and severe arthritis, the usual dosage of methotrexate is:

For additional considerations specific to methotrexate use, see Specific considerations for use of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs).

For people with inflammatory connective tissue disease and severe arthritis, low-dose oral corticosteroids may be required. After communication between the general practitioner and specialist (or hospital specialty registrar), it is reasonable for the general practitioner to start an oral corticosteroid to control arthritis symptoms while awaiting specialist review; however, starting an oral corticosteroid before specialist review may delay subsequent diagnosis. If oral corticosteroids are started, use the lowest dose possible to control symptoms. Ideally, wean the dose to less than 10 mg daily prior to specialist review, as corticosteroids can mask clinical signs.

People with inflammatory connective tissue disease are usually highly steroid sensitive. For people with systemic sclerosis, if possible avoid oral corticosteroids, or use the lowest dose for the shortest duration possible. Avoid prednisolone (or prednisone) doses of more than 10 mg daily in patients with systemic sclerosis because there is a risk of precipitating scleroderma renal crisis. See Management overview for systemic sclerosis for more details.

If oral corticosteroids are considered essential for rapid symptom relief in inflammatory connective tissue diseases (other than systemic sclerosis), use:

Doses higher than the recommendations are rarely necessary and are associated with more adverse effects.