Monarthritis/Polyarthritis: Differential Diagnosis (2023)

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Monarthritis/Polyarthritis: Differential Diagnosis



Stephen Ray Mitchell


John F. Beary III






Monarthritis/Polyarthritis: Differential Diagnosis (1)KEY POINTS




  • The number of joints involved and the time course of their involvement enable the physician to classify joint problems and to construct the appropriate differential diagnosis.



  • “Chronic” refers to joint symptoms that persist beyond 2 months. Oligoarthritis refers to the involvement of 2 to 4 joints, and polyarthritis is defined as the involvement of more than four joints.



  • Acute monarthritis can be due to infection, and septic arthritis is a rheumatologic emergency.



  • Gout is a classic example of acute monarthritis, but approximately 25% of gout cases present as polyarthritis, mainly in the lower extremity.



  • Rheumatoid arthritis (RA) is the classic example of chronic polyarthritis, but it is important to carefully confirm the diagnosis, as one occasionally encounters a patient with gout who has hand deformities that look like RA and has a relatively normal uric acid. Such a patient may even receive disease-modifying antirheumatic drugs (DMARDs) for a time, which are stopped when it is discovered that it is actually gouty tophi that are involved in the destructive hand lesions.



  • The importance of identifying the pauciarticular pattern in children with juvenile idiopathic arthritis (JIA) is that it is an important clue to seek, identify, and treat iridocyclitis, which is asymptomatic but can destroy the sight of children.

    (Video) Polyarthritis Differential diagnosis and Management

(Video) Differential Diagnosis for Rheumatic Diseases


Monarthritis/Polyarthritis: Differential Diagnosis (2)INTRODUCTION




  • The number of joints and the time course during which a joint disorder develops guide the approach to differential diagnosis. Acute and severe monarthritis, especially one that presents along with fever, may represent septic arthritis, which is a rheumatologic emergency. The promptness of the diagnosis and treatment of a potentially septic process is likely to profoundly alter the outcome.



  • Alternatively, a single abnormal inflamed joint that persists beyond 2 months presents a different diagnostic challenge, with infection being a much less likely
    disease process. In each case, one must view the overall clinical presentation, including factors such as extra-articular visceral involvement, constitutional signs and symptoms, severity of illness, limitation of function, potential foci of infection, skin lesions, hyperuricemia, and history of trauma or bleeding disorders.









    Table 14-1 Differential Diagnosis of Monarthritis by Presentation












































    MonarthritisCommonLess common
    AcuteBacterial arthritisLeukemia
    Gout (CPPD)Rheumatoid arthritis
    SpondyloarthropathiesSarcoid arthritis
    Reactive arthritisHemarthrosis
    Psoriatic arthritisCoagulopathy
    Inflammatory bowel diseaseDialysis/apatite crystals
    JIAOsteochondromatosis
    Hemarthrosis
    Trauma
    Anticoagulant therapy
    PVNS
    ChronicOsteoarthritisFungal arthritis
    SpondyloarthropathiesTuberculous arthritis
    Lyme disease (recurring)Bacterial arthritis
    Monarticular RA
    CPPD
    Sarcoid arthritis
    PVNS
    Osteochondromatosis
    CPPD, calcium pyrophosphate dihydrate; JIA, juvenile idiopathic arthritis; PVNS, pigmented villonodular synovitis; RA, rheumatoid arthritis.


  • Often, an aggressive initial approach is indicated, including joint aspiration with synovial fluid analysis and occasionally, in more refractory or unexplained situations, referral for synovial biopsy or arthroscopy. Therapy will vary significantly depending on the presumptive diagnosis. Specific therapy for each disease is discussed in later chapters. Tables 14-1 and 14-2 summarize the diagnostic approach to this group of disorders.



Monarthritis/Polyarthritis: Differential Diagnosis (3)ACUTE MONARTHRITIS




  • Infectious arthritis has an abrupt onset and a marked systemic inflammatory response. Because prompt therapy is required to prevent irretrievable joint damage, it is important to diagnose bacterial infection promptly. One may be deceived, however, in a partially treated patient on oral antibiotics or in an immunosuppressed patient in whom the inflammatory response is dampened by steroid therapy. A prudent approach includes careful examination for associated infectious foci and clinical clues (e.g., cutaneous pustules with neisserial infection), prompt joint aspiration and synovial fluid analysis, synovial fluid culture and Gram stain, and empiric antibiotics (depending on age and epidemiology). A viral process is typically polyarticular and may be accompanied by rash or other viral signs and symptoms. Lyme arthritis, caused by a Borrelia spirochete in endemic areas, can present acutely in recurring episodes of knee monarthritis; but more often it presents early in the course of the disease as migratory polyarthralgias, is associated with a characteristic rash or tick bite, and has a less “toxic” presentation (see Chapter 47).

    (Video) Rheumatoid arthritis - causes, symptoms, diagnosis, treatment, pathology



  • Crystal-induced disease




    • Gout classically presents as “podagra” with the abrupt and intense onset of pain and inflammation in the first metatarsophalangeal joint; it often affects the midfoot and ankle, but can involve any joint or bursa. Typically, a man in his fifties with
      hypertension, obesity, diabetes, and coronary artery disease presents with monarthritis of the lower extremity. However, approximately 25% present with polyarticular synovitis. Between episodes, the joints return to normal unless chronic disease develops. A careful check for tophi on the ears, elbows, hands, or feet is required. At a younger age of onset of gout, one must think of lymphoma or other disorders associated with rapid cell turnover. The finding of negatively birefringent, needle-shaped crystals within the white blood cells in the synovial fluid is diagnostic. Note that gout can coexist with pseudogout, and both can coexist with infection (see Chapter 43).









      Table 14-2 Differential Diagnosis of Polyarthritis by Presentation





















      PolyarthritisCommonLess common
      Acute
      Migratory

      Neisseria infection
      Acute rheumatic fever
      Lyme disease (early)

      Viral
      NonmigratoryRheumatoid arthritis
      Serum sickness
      Systemic lupus
      Polyarticular JIA
      Hematologic disorders
      Polyarticular gout
      Chronic
      Rheumatoid arthritis
      Polyarticular JIA
      Systemic lupus
      Polyarticular gout
      Oligoarticular OA
      Sarcoid arthritis
      CTD and overlap syndromes
      Spondyloarthropathy
      CTD, connective tissue disease; JIA, juvenile idiopathic arthritis; OA, osteoarthritis.


    • Calcium pyrophosphate dihydrate (CPPD) deposition disease (pseudogout) is an acute or subacute process in the elderly with involvement of large or small joints (including the second and third metacarpophalangeal joints). Chondrocalcinosis can often be defined radiographically in the knee, symphysis pubis, or triangular cartilage of the wrist. Crystals found within synovial fluid white blood cells are rhomboid-shaped and positively birefringent. In those patients who present at a younger age, other diagnostically important, treatable medical conditions, such as hemochromatosis or hyperparathyroidism must be considered (see Chapter 44).



  • Hemarthrosis is defined through the aspiration of bloody joint fluid.




    • Trauma usually is associated with a relevant history of injury. A layer of fat (from the bone marrow) seen on top of bloody fluid implies intra-articular fracture even in the presence of negative radiographs.



    • Internal derangement. Meniscal tears involving avascular portions of knee fibrocartilage may not be bloody but can cause intermittent locking, giving way, and a positive MacMurray’s maneuver (a painful click produced by extending the knee when the foot is internally or externally rotated). Instability of the collateral and cruciate ligaments is also a clue to this condition (see Chapter 24).



    • Nontraumatic hemarthrosis may be seen in the setting of anticoagulation, after the use of heparin during dialysis, or with benign neoplasms such as pigmented villonodular synovitis, synovial osteochondromatosis, or hemangioma of the synovium. Diagnosis of the latter three disorders is confirmed with synovial biopsy, arthroscopy, or magnetic resonance imaging (MRI).



  • Periarticular syndromes. Any of the tissues surrounding the joint can be involved in an inflammatory or traumatic process. A careful musculoskeletal examination can distinguish between tendinitis, bursitis, overuse syndromes, and surrounding cellulitis. Erythema nodosum is often seen with drug reaction, inflammatory bowel disease, or acute sarcoidosis. It often causes a periarthritis about the ankles and can result in an associated joint effusion. Osteomyelitis or neoplasia should be considered
    with focal bone pain. Severe nighttime periarticular pain in a child is uncommon with juvenile arthritis and should always suggest leukemia.

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  • Noninfectious inflammatory conditions




    • Spondyloarthropathies. Because of the highly inflammatory, monarticular nature of some episodes of joint inflammation associated with reactive arthritis (ReA) or psoriatic arthritis, the clinical presentation may be indistinguishable from that of infection. The diagnosis may be supported by the presence of characteristic extra-articular features, such as a psoriasiform rash, eye inflammation, or urethritis. A history of low-back symptoms or tenderness over the sacroiliac joints suggests the diagnosis of spondyloarthritis and is an indication for radiographic study of the sacroiliac joints (see Chapter 39).



    • Juvenile idiopathic arthritis (JIA). The child who presents with monarthritis, often subacute in character, and a negative infectious workup may well have pauciarticular (fewer than four joints) JIA (see Chapter 36). Transient synovitis of the hip characteristically presents as a monarthritis of the hip in a child following a viral illness. The child is nontoxic in appearance and has a culture-negative joint effusion. This self-limited disorder is felt to be mediated by a virus or immune complexes and responds to bed rest and anti-inflammatory medications.

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      You may also need

      • Arthrocentesis, Intra-Articular Injection, and Synovial Fluid Analysis
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      • Rheumatoid Arthritis
      • Gout
      • Infectious Arthritis

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      Jul 29, 2016 | Posted by drzezo in RHEUMATOLOGY | Comments Off on Monarthritis/Polyarthritis: Differential Diagnosis

FAQs

What is the difference between polyarthritis and Monoarthritis? ›

The involvement of only 1 joint is referred to as monoarthritis. Oligoarthritis is the involvement of 2-4 joints. Polyarthritis is the involvement of 5 or more joints.

What is the differential diagnosis for arthritis? ›

The following disorders should also be considered in the differential diagnosis: Crystalline arthropathies (ie, gout and pseudogout) Inflammatory arthritis (eg, rheumatoid arthritis) Seronegative spondyloarthropathies (eg, psoriatic arthritis and reactive arthritis)

What is the difference between polyarthritis and arthritis? ›

If you have arthritis in more than one joint, your provider will classify it based on how many joints are affected. Oligoarticular arthritis is the term for having arthritis in two to four joints. Polyarthritis is the medical definition of arthritis that affects five or more of your joints.

How can you differentiate between inflammatory and noninflammatory arthritis? ›

The location and pattern of joint pain, the presence or absence of joint swelling, the rapidity of its onset, as well as the presence of signs and symptoms outside the joint (such as rash), can help to distinguish between inflammatory and noninflammatory arthritis.

What is the most common cause of Monoarthritis? ›

The most common causes of monoarthritis are crystals (i.e., gout and pseudogout), trauma, and infection. A careful history and physical examination are important because diagnostic studies frequently are only supportive. Examination of joint fluid often is essential in making a definitive diagnosis.

What are the types of polyarthritis? ›

Types
  • Ankylosing spondylitis.
  • Gout.
  • Juvenile idiopathic arthritis.
  • Osteoarthritis.
  • Psoriatic arthritis.
  • Reactive arthritis.
  • Rheumatoid arthritis.
  • Septic arthritis.
15 Sept 2021

What are the causes of polyarthritis? ›

Polyarthritis may be caused by an autoimmune disorder or an acute illness. It occurs when the inflammation affects joints in the body.
...
Illness
  • Rheumatic fever.
  • Alphaviral infections, including the Ross River virus, chikungunya virus, and Mayaro virus.
  • Dengue.
  • Zika.
  • Hepatitis.
  • Epstein-Barr virus (EBV)
  • Cytomegalovirus (CMV)
26 Oct 2022

How do you test for polyarthritis? ›

Your doctor will ask about your medical history and perform a physical exam. They may also order blood tests and X-rays or an ultrasound of the joints. Your doctor will look for inflamed joints, tenderness, and swelling. They will also look for symmetric or asymmetric patterns of pain.

How serious is polyarthritis? ›

Share on Pinterest Polyarthritis may cause scarring on the lungs, leading to shortness of breath and coughing. A heightened risk of heart attacks is also a potential complication. If polyarthritis is not treated or controlled well, other organs and parts of the body can be severely affected.

How do you deal with polyarthritis? ›

Lifestyle and home remedies
  1. Weight loss. Excess weight puts extra stress on weight-bearing joints. ...
  2. Exercise. Regular exercise can help keep joints flexible. ...
  3. Heat and cold. Heating pads or ice packs may help relieve arthritis pain.
  4. Assistive devices.
15 Sept 2021

Can polyarthritis cause back pain? ›

Many forms of arthritis and related conditions can cause back pain, stiffness and swelling. About 80% of back pain is acute and usually lasts one to seven days. Otherwise, it's considered chronic and may be caused by arthritis. The lower back is the most common site of arthritis back pain.

What are the five classical signs of inflammation? ›

Based on visual observation, the ancients characterised inflammation by five cardinal signs, namely redness (rubor), swelling (tumour), heat (calor; only applicable to the body' extremities), pain (dolor) and loss of function (functio laesa).

What are the four classical signs of inflammation? ›

This type of stimulation–response activity generates some of the most dramatic aspects of inflammation, with large amounts of cytokine production, the activation of many cell types, and in fact the four cardinal signs of inflammation: heat, pain, redness, and swelling (1).

What are the 4 indicators of inflammation? ›

Signs of an inflammation
  • Redness.
  • Heat.
  • Swelling.
  • Pain.
  • Loss of function.
23 Nov 2010

What can cause Monoarticular arthritis? ›

The major causes of acute monoarticular symptoms include trauma, infection, crystal-induced arthritis, osteoarthritis, systemic rheumatic diseases, and mechanical derangement (table 1) [1-3].

How is monoarthritis treated? ›

Intra-articular or systemic steroids and anti-inflammatory drugs may be used to suppress the immune system in crystal-induced arthritis, urate-lowering or uricosuric drugs are used to prevent future recurrence of the disease.

What is the main protein that causes arthritis? ›

SPOKANE, Wash. – Scientists have identified a protein known as sulfatase‑2 that plays a critical role in the damage caused by rheumatoid arthritis. A chronic disease in which the immune system attacks the body's own joint tissues, rheumatoid arthritis affects an estimated 1.5 million Americans.

Which arthritis is the most serious type of arthritis? ›

Rheumatoid arthritis (RA) is recognized as the most disabling type of arthritis. While they both fall under the "arthritis" umbrella and share certain similarities, these diseases have significant differences.

What are the 3 main types of arthritis? ›

Arthritis Types
  • Osteoarthritis.
  • Rheumatoid Arthritis (RA)
  • Childhood Arthritis.

What are 2 types of inflammatory arthritis? ›

The most common forms of inflammatory arthritis are: rheumatoid arthritis (RA), ankylosing spondylitis and psoriatic arthritis.

What does inflammatory polyarthritis mean? ›

Inflammatory polyarthropathy/polyarthritis is defined as arthritis that affects four or more joints. 1 It's not a type of arthritis and can be applied to many types of arthritis in which the disease process is driven by inflammation. Conditions that can cause polyarthropathy include:1. Rheumatoid arthritis.

What is the differential diagnosis of joint pain? ›

Indeed, the differential diagnosis can be narrowed through investigation of six clinical factors: disease chronology, inflammation, distribution, extra-articular manifestations, disease course, and patient demographics (Table 2). More common causes of polyarticular joint pain should be considered first.

What are the 4 types of arthritis? ›

The most common types include osteoarthritis (OA), rheumatoid arthritis (RA), psoriatic arthritis (PsA), fibromyalgia and gout. Arthritis and related diseases can cause debilitating, life-changing pain in different ways.

Can a differential diagnosis be wrong? ›

If any step of the diagnostic process is incomplete, there is a risk that the differential diagnosis will lead to an inaccurate diagnosis. With the help of additional testing, the likelihood of error after following the diagnostic process significantly reduces.

How do you identify a differential diagnosis? ›

Steps involved in a differential diagnosis
  1. What're your symptoms?
  2. How long you have been experiencing these symptoms?
  3. Is there anything that triggers your symptoms?
  4. Is there anything that makes your symptoms worse or better?
  5. Do you have a family history of specific symptoms, conditions, or diseases?

How do doctors do differential diagnosis? ›

Most differential diagnoses include a physical exam and a health history. During a health history, you'll be asked about your symptoms, lifestyle, and previous health problems. You'll also be asked about your family's health problems. Your provider may also order lab tests for different diseases.

What blood tests confirm arthritis? ›

Some of the main blood tests used include: erythrocyte sedimentation rate (ESR) – which can help assess levels of inflammation in the body. C-reactive protein (CRP) – another test that can help measure inflammation levels.

Is polyarthritis the same as fibromyalgia? ›

The difference between fibromyalgia and Polyarthralgia is polyarthritis causes inflammation to the joints, whereas there is no inflammation with polyarthralgia. Polyarthralgia and Polymyalgia: Polyarthralgia also shares some similarities with Polymyalgia, and both of those conditions cause similar pain levels.

Do you need a blood test to confirm arthritis? ›

Blood tests are not needed to diagnose all types of arthritis, but they help to confirm or exclude some forms of inflammatory arthritis. Your doctor may also draw joint fluid or do a skin or muscle biopsy to help diagnose certain forms of arthritis. Making an arthritis diagnosis may take some time.

What infection causes polyarthritis? ›

Causes of polyarthritis. Systemic vasculitis, sarcoidosis, Behcet's disease etc. I-Viral infections (Chikungunya, HIV, HCV, HBV, human parvovirus B19 etc.)

Can you work with polyarthritis? ›

If you have arthritis or joint pain, your condition may pose some challenges which could make your working life harder. However, work is certainly feasible for most people with arthritis or a related condition.

Is polyarthritis a disability? ›

Many people may wonder is arthritis a disability. Yes. Arthritis can prompt incapacity, as can numerous other mental and physical conditions. If your arthritis confines your daily movements, or activities you may qualify for disability benefits.

Which is the best tablet for joint pain? ›

Besides ibuprofen and naproxen, other examples of prescription NSAIDs include diclofenac (Cambia, Cataflam, Voltaren), etodolac (Lodine), meloxicam (Mobic), oxaprozin (Daypro), and piroxicam (Feldene).

How can polyarthritis be prevented? ›

How to reduce your risk of arthritis
  1. Stay at a healthy weight. Extra pounds put pressure on weight-bearing joints like hips and knees. ...
  2. Control your blood sugar. ...
  3. Exercise. ...
  4. Stretch. ...
  5. Avoid injury. ...
  6. Quit smoking. ...
  7. Eat fish twice a week. ...
  8. Get routine preventive care.

What is the best anti-inflammatory drug for arthritis? ›

NSAIDs. NSAIDs are considered one of the most effective OTC drugs for pain stemming from osteoarthritis, which causes inflammation. These drugs reduce pain, stiffness, and swelling from arthritis. A common examples of NSAIDs include ibuprofen (Advil, Motrin).

Which organ is affected due to arthritis? ›

Normally, your immune system helps protect your body from infection and disease. In rheumatoid arthritis, your immune system attacks healthy tissue in your joints. It can also cause medical problems with your heart, lungs, nerves, eyes and skin.

What is degenerative polyarthritis? ›

Degenerative arthritis is a term synonymous with osteoarthritis, a chronic disorder that damages the cartilage and tissues surrounding a joint. It is sometimes called “degenerative joint disease” or “wear and tear” arthritis. Osteoarthritis is the most common type of arthritis, affecting 27 million Americans 1.

Is polyarthritis the same as polymyalgia? ›

The relationship between polymyalgia rheumatica (PMR) and inflammatory polyarthritis (IP) remains a source of debate in rheumatology: although both conditions have been classified separately as distinct entities, they share many clinical features.

What are the three hallmark signs of inflammation? ›

The four cardinal signs of inflammation are redness (Latin rubor), heat (calor), swelling (tumor), and pain (dolor). Redness is caused by the dilation of small blood vessels in the area of injury.

What are the 3 warning signs of inflammation? ›

What are the symptoms of acute and chronic inflammation?
  • Flushed skin at the site of the injury.
  • Pain or tenderness.
  • Swelling.
  • Heat.
28 Jul 2021

What are the 3 major events in inflammation? ›

Important microcirculatory events that occur during the inflammatory process include vascular permeability changes, leukocyte recruitment and accumulation, and inflammatory mediator release [2, 6].

Is there a blood test that shows inflammation? ›

Blood tests known as 'inflammatory markers' can detect inflammation in the body, caused by many diseases including infections, auto-immune conditions and cancers. The tests don't identify what's causing the inflammation: it might be as simple as a viral infection, or as serious as cancer.

What is the main cause of inflammation in the body? ›

When inflammation happens, chemicals from your body's white blood cells enter your blood or tissues to protect your body from invaders. This raises the blood flow to the area of injury or infection. It can cause redness and warmth. Some of the chemicals cause fluid to leak into your tissues, resulting in swelling.

Does coffee cause inflammation? ›

Research suggests that coffee does not cause inflammation in most people—even if your norm is more than one or two caffeinated cups. In fact, it's quite the opposite. Coffee may have anti-inflammatory effects in the body.

Does inflammation make you tired? ›

Indeed, it is well-known from experimental studies that acute severe inflammation, such as induced by lipopolysaccharide (LPS), causes acute sickness behavior, including fatigue.

What does chronic inflammation feel like? ›

Classic signs of inflammation include fatigue, fever, and joint and muscle pain. Inflammation is also known for causing symptoms that are considered atypical. This can include things like balance issues, insulin resistance, muscle weakness, eye problems, skin issues, and more.

What does inflammation in your body feel like? ›

Acute inflammation is the short-term form of inflammation that occurs when you get an injury or contract an infection. It often shows up as redness, swelling, warmth, and pain in the affected area.

What does monoarthritis mean? ›

Monoarthritis is inflammation of one joint characterized by joint swelling, pain, warmth, and sometimes fever and periarticular erythema.

What is the worse form of arthritis? ›

Rheumatoid arthritis can be one of the most painful types of arthritis; it affects joints as well as other surrounding tissues, including organs. This inflammatory, autoimmune disease attacks healthy cells by mistake, causing painful swelling in the joints, like hands, wrists and knees.

Can mononucleosis cause joint pain? ›

Infectious mononucleosis (say: in-feck-shuss mon-oh-new-clee-oh-siss), or mono, often is caused by the Epstein-Barr virus. Mono usually is not serious, but some people with mono feel very tired and have pain in their joints that lasts for several weeks.

What causes polyarthritis? ›

Rheumatic diseases, which prototype is rheumatoid arthritis, cause polyarthritis as well as non-rheumatic diseases such as infectious diseases, malignancies and even some medications.

What is the first stage of arthritis called? ›

Stage I: Synovitis

During stage I, you may start having mild symptoms, including joint pain and joint stiffness. Most commonly, this affects the hands and fingers, as well as the ankles and knees. The immune system has begun attacking the joint tissue, causing the synovial membrane to swell and become inflamed.

What is the most common inflammatory arthritis? ›

The most common forms of inflammatory arthritis are: rheumatoid arthritis (RA), ankylosing spondylitis and psoriatic arthritis. Inflammatory arthritis also affects children.

What types of arthritis are autoimmune? ›

Rheumatoid arthritis is an autoimmune and inflammatory disease, which means your immune system attacks healthy cells in your body by mistake.

Which arthritis is worse in the morning? ›

The joint pain associated with rheumatoid arthritis is usually a throbbing and aching pain. It is often worse in the mornings and after a period of inactivity.

What is end stage arthritis? ›

End-stage rheumatoid arthritis (RA) is an advanced stage of disease in which there is severe joint damage and destruction in the absence of ongoing inflammation.

What is acute polyarthritis? ›

Polyarthritis is a term used when five or more joints are affected with joint pain. There are many potential causes, so symptoms can vary widely from person to person. Polyarthritis can present as acute episodes or it may become chronic, lasting for more than six weeks. Polyarthritis can follow many viral infections.

Is there a blood test for arthritis? ›

No blood test can definitively prove or rule out a diagnosis of rheumatoid arthritis, but several tests can show indications of the condition. Some of the main blood tests used include: erythrocyte sedimentation rate (ESR) – which can help assess levels of inflammation in the body.

What is the safest treatment for arthritis? ›

NSAIDs. NSAIDs are considered one of the most effective OTC drugs for pain stemming from osteoarthritis, which causes inflammation. These drugs reduce pain, stiffness, and swelling from arthritis. A common examples of NSAIDs include ibuprofen (Advil, Motrin).

How do you know if your arthritis is severe? ›

The more joints that are painful and swollen, the more severe the disease may be, says Dr. Cush. Joint pain and swelling are characteristic signs and symptoms of rheumatoid arthritis. Rheumatologists consider this a very important way to measure disease severity.

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