What is the recommended treatment for reactive arthritis?

Treatment of Reactive Arthritis

The recommended treatment for reactive arthritis begins with nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapy, followed by disease-modifying antirheumatic drugs (DMARDs) such as sulfasalazine for persistent cases lasting longer than 6 months.

Initial Treatment Approach

First-Line Therapy

• NSAIDs: Should be used at the minimum effective dose for the shortest time possible after evaluation of gastrointestinal, renal, and cardiovascular risks 1
  • Options include ibuprofen, naproxen, diclofenac, and others
  • Typically treat for weeks to several months depending on symptom persistence

Local Measures

• Arthrocentesis for symptomatic relief of affected joints
• Cold pads for pain and inflammation
• Rest of affected joints during acute flares

Management of Underlying Infection

For Urogenital Reactive Arthritis

• If Chlamydia is isolated, treat with:
  • Doxycycline 100mg twice daily for 10-14 days, OR
  • Erythromycin 500mg 4 times daily for 10-14 days, OR
  • Single dose of azithromycin 1g 2
• Sexual partners should be treated concurrently to prevent reinfection

For Enteric Reactive Arthritis

• Antibiotics have not shown benefit over placebo for reactive arthritis following Salmonella, Shigella, Yersinia, or Campylobacter infections 2
• Treatment focuses on managing symptoms rather than the triggering infection

Treatment for Persistent Disease

For Reactive Arthritis Lasting >6 Months

• Add sulfasalazine 2g/day in addition to continued NSAIDs 2
  • Shown to be moderately superior to placebo in controlled studies
  • Well-tolerated in most patients

For Inadequate Response to Sulfasalazine

• Consider other DMARDs such as methotrexate, which is considered the anchor drug for persistent inflammatory arthritis 1
• If a definite diagnosis cannot be reached and the patient has early undifferentiated arthritis with risk factors for persistent disease, DMARDs should be started as early as possible (ideally within 3 months) 1

Severe or Refractory Cases

Biologic Therapy

• For patients with inadequate response to conventional DMARDs, consider biologic DMARDs 1
• TNF inhibitors may be considered in cases with poor prognostic factors and inadequate response to conventional DMARDs

Intra-articular Therapy

• Intra-articular glucocorticoid injections should be considered for relief of local symptoms of inflammation 1
• Particularly useful for large joint involvement 3

Monitoring and Follow-up

• Monitor disease activity at 1-3 month intervals until treatment target has been reached 1
• Assessment should include:
  • Tender and swollen joint counts
  • Patient and physician global assessments
  • ESR and CRP
  • Functional assessments

Non-pharmacological Interventions

• Dynamic exercises and occupational therapy should be considered as adjuncts to drug treatment 1
• Patient education about the disease, its outcome, and treatment is important
• Smoking cessation, dental care, weight control, and management of comorbidities should be part of overall patient care 1

Common Pitfalls and Caveats

1. Reactive arthritis can become chronic in up to 20% of patients, requiring long-term therapy
2. Antibiotics are only beneficial in Chlamydia-induced reactive arthritis when the organism is isolated; they show no benefit in enteric forms
3. Long-term high-dose NSAIDs can lead to significant gastrointestinal, renal, and cardiovascular side effects
4. Failure to recognize and treat persistent disease can lead to joint damage and disability

Remember that reactive arthritis typically affects one knee or ankle for weeks to several months, but early and appropriate treatment can significantly improve outcomes and prevent progression to chronic destructive arthritis.