Fig. 13

The algorithm summarizes the proposed treatment algorithm. For mild cases NSAIDs can be started but the disease is aggressive in most cases requiring steroids in varying doses and DMARDs. The Methotrexate can be used once the diagnosis is secured with biopsy. Given the erosive nature of the disease with possibility of joint mutilation and good response to biologic agents seen in multiple case reports especially the anti TNF agents, step up therapy should be considered in patients with suboptimal response to DMARDs