From the Guidelines
Reactive arthritis is diagnosed based on clinical presentation of joint inflammation following a gastrointestinal or genitourinary infection, typically 1-4 weeks after the triggering infection, and management begins with NSAIDs like naproxen or indomethacin for symptom relief, with disease-modifying antirheumatic drugs (DMARDs) such as sulfasalazine or methotrexate considered for persistent symptoms. The diagnosis relies on the classic triad of arthritis, conjunctivitis, and urethritis, though not all features need to be present. For persistent symptoms, DMARDs such as sulfasalazine (starting at 500mg daily, increasing to 1000mg twice daily) or methotrexate (7.5-25mg weekly with folic acid supplementation) may be necessary 1. Corticosteroids can be used for severe symptoms, either as intra-articular injections or oral prednisone (10-20mg daily with tapering). Any underlying infection should be treated with appropriate antibiotics - doxycycline 100mg twice daily for 7-10 days for chlamydial infections or ciprofloxacin 500mg twice daily for 5-7 days for enteric infections. Physical therapy helps maintain joint function and prevent stiffness. Most cases resolve within 3-12 months, but about 15-20% of patients develop chronic symptoms requiring long-term management. The pathophysiology involves genetic susceptibility (particularly HLA-B27 positivity) and an abnormal immune response to bacterial antigens, resulting in inflammation of joints and other tissues.
Some key points to consider in the management of reactive arthritis include:
- Early diagnosis and treatment to prevent long-term joint damage and disability
- Use of NSAIDs and DMARDs to control symptoms and modify disease progression
- Treatment of underlying infections with appropriate antibiotics
- Physical therapy to maintain joint function and prevent stiffness
- Consideration of genetic susceptibility and abnormal immune response in the pathophysiology of the disease.
It's worth noting that the provided evidence is mostly related to rheumatoid arthritis, and not specifically to reactive arthritis. However, some general principles of management, such as the use of NSAIDs and DMARDs, may still be applicable. The most recent and highest quality study on reactive arthritis management is not available in the provided evidence, and therefore, the recommendations are based on general principles of management and expert opinion 1.
From the Research
Diagnosis of Reactive Arthritis
- The diagnosis of reactive arthritis is mainly clinical, based on acute oligoarticular arthritis of larger joints developing within 2-4 weeks of the preceding infection 2.
- The diagnosis relies on the diagnosis of the triggering infection, and human leucocyte antigen (HLA)-B27 should not be used as a diagnostic tool for a diagnosis of acute ReA 2.
- Diagnostic criteria are based on the ACR guidelines and include rheumatological signs along with a proof of infection 3.
Management Options for Reactive Arthritis
- The acute arthritis is treated nonspecifically with nonsteroidal anti-inflammatory drugs (NSAIDs), local measures such as arthrocentesis, cold pads, and rest of the affected joint 4.
- If the triggering bacterium can be isolated in Chlamydia-induced urogenital reactive arthritis, the infection should be treated specifically with antibacterials such as doxycycline or erythromycin 4.
- For reactive arthritis lasting longer than 6 months, patients may benefit from sulfasalazine 2 g/day in addition to continued use of NSAIDs 4.
- Other disease-modifying antirheumatic drugs (DMARDs) can be tried in individual patients who do not respond to sulfasalazine, and infliximab has been used successfully in some cases 4, 5.
- In chronic destructive cases, antirheumatic treatment, similar to that used in rheumatoid arthritis, is recommended 6.
Treatment of Chlamydia-Induced Reactive Arthritis
- Prolonged treatment of Chlamydia-induced ReA may be of benefit, not only in the case of acute ReA but also in those with chronic ReA or spondylarthropathy with evidence of persisting chlamydia antigens in the body 2.
- Antibacterials given for 3 months in the absence of positive cultures from the urogenital tract may provide some benefit, however, further studies are needed before such treatment is recommended 4.