How is reactive arthritis managed?

Management of Reactive Arthritis

The management of reactive arthritis should begin with NSAIDs as first-line treatment, followed by sulfasalazine for persistent cases, with antibiotics only indicated for confirmed Chlamydia-induced reactive arthritis. 1, 2

Initial Assessment and Diagnosis

• Reactive arthritis typically presents as an inflammatory oligoarthritis affecting larger joints of the lower limbs, occurring 2-4 weeks after a urogenital or gastrointestinal infection 3
• Key diagnostic features:
  • Asymmetric oligoarthritis (primarily knees and ankles)
  • Recent history of urogenital or enteric infection
  • Extra-articular manifestations (enthesitis, tenosynovitis, bursitis, dactylitis) 2
  • HLA-B27 positivity in approximately 70% of cases 4
• Confirm triggering infection through:
  • Stool cultures for enteric pathogens
  • PCR testing for Chlamydia trachomatis
  • Serological tests for evidence of previous infection 3

Treatment Algorithm

1. Acute Phase Management

• First-line therapy: NSAIDs at full anti-inflammatory doses

  • Naproxen has demonstrated efficacy in controlling joint pain, swelling, and morning stiffness 5
  • Target dose: 500mg twice daily until symptoms resolve
  • Continue for 4-6 weeks or until resolution of acute symptoms

• Local measures:

  • Joint rest during acute inflammation
  • Arthrocentesis for symptomatic relief if significant effusion
  • Cold packs for pain and swelling 1

2. Antibiotic Therapy

• For Chlamydia-induced urogenital reactive arthritis only:

  • Doxycycline 100mg twice daily for 10-14 days, OR
  • Azithromycin 1g single dose
  • Treat sexual partners concurrently to prevent reinfection 1

• For enteric forms of reactive arthritis:

  • Antibiotics have not shown benefit over placebo and are not recommended 1, 3

3. Management of Persistent Disease (>6 months)

• Add disease-modifying antirheumatic drugs (DMARDs):

  • Sulfasalazine 2g/day is the preferred DMARD with demonstrated efficacy in placebo-controlled trials 1, 2
  • Start at 500mg daily and gradually increase to 2g/day over 4 weeks
  • Continue for at least 3-6 months to evaluate efficacy

• For sulfasalazine non-responders:

  • Consider other DMARDs such as methotrexate, azathioprine, or cyclosporin for refractory cases 2
  • Carefully evaluate risk-benefit ratio as controlled studies are limited

4. Management of Severe or Refractory Disease

• Corticosteroids:

  • Intra-articular injections for persistent large joint involvement 4
  • Systemic steroids for severe inflammatory symptoms resistant to NSAIDs 2

• Biological therapy:

  • TNF-α inhibitors may be considered in aggressive cases or when disease evolves toward ankylosing spondylitis 2
  • Limited evidence but may be effective in refractory cases

Monitoring and Follow-up

• Assess treatment response every 4-8 weeks during active disease
• Monitor for NSAID-related adverse effects (gastrointestinal, renal)
• Regular laboratory monitoring for patients on DMARDs
• Long-term follow-up is important as 25-50% of patients may experience recurrent acute arthritis 3

Prognosis

• Most cases (75-80%) resolve within 3-12 months
• Approximately 25% of patients develop chronic arthritis or progress to chronic spondyloarthropathy 3
• Early and appropriate treatment improves outcomes and reduces risk of chronic joint damage 6

Common Pitfalls and Caveats

• Failure to identify and treat the triggering infection in Chlamydia-induced reactive arthritis
• Inappropriate use of antibiotics in enteric forms of reactive arthritis
• Inadequate NSAID dosing during the acute phase
• Delayed introduction of DMARDs in persistent disease
• Overlooking extra-articular manifestations that may require specific management

Remember that without proper management, reactive arthritis can progress to chronic destructive arthritis, making early recognition and appropriate treatment essential for optimal outcomes 6.