How do you approach treatment for arthritis associated with multicentric reticulohistiocytosis?

There are no systematic treatment studies of multicentric reticulohistiocytosis due to its rarity. There are, however, numerous case reports of TNF inhibitors used with success, frequently requiring higher doses than used for rheumatoid arthritis. As this condition is based on proliferation of osteoclasts in the dermis and synovium, anti-osteoclast medications such as bisphosphonates have also been used, occasionally with success. Given the severity of bone damage that MRH can cause rapidly, it would be reasonable to treat with both high dose TNF inhibition and intravenous bisphosphonates up front.