What is the management and treatment of Reiter's syndrome (Reactive Arthritis)?

Management and Treatment of Reactive Arthritis (Reiter's Syndrome)

The management of reactive arthritis should focus on controlling inflammation, treating the underlying infection if present, and addressing specific symptoms with a combination of pharmacological and non-pharmacological approaches.

Diagnosis and Initial Assessment

• Reactive arthritis is characterized by the classic triad of:

  • Arthritis (typically asymmetric, affecting large joints)
  • Conjunctivitis/uveitis
  • Urethritis 1

• Additional manifestations may include:

  • Dermatologic features: keratoderma blennorrhagicum, circinate balanitis, nail changes
  • Oral lesions
  • Gastrointestinal symptoms (if triggered by enteric infection)

• Laboratory evaluation should include:

  • Complete blood count
  • Urinalysis
  • Transaminases
  • Antinuclear antibodies 2
  • HLA-B27 testing (positive in >2/3 of cases) 3
  • Cultures or PCR testing to identify triggering infection

Treatment Algorithm

1. Address Underlying Infection

• For post-chlamydial reactive arthritis:

  • Doxycycline 100mg twice daily for 7-10 days may shorten course or abort onset of arthritis 3
  • Early antibiotic treatment is crucial within the first 3 months of symptoms 4

• For post-enteric reactive arthritis (Salmonella, Shigella):

  • Antibiotics have not shown consistent effectiveness 3
  • Treatment focuses on symptom management

2. Control Joint Inflammation

• First-line therapy:

  • NSAIDs at high doses (e.g., indomethacin 50mg three times daily or naproxen 500mg twice daily)
  • Use the lowest effective dose for shortest time after evaluating gastrointestinal, renal, and cardiovascular status 2

• For persistent arthritis:

  • Intra-articular glucocorticoid injections for localized inflammation 2, 4
  • Systemic glucocorticoids at lowest effective dose, temporarily (<6 months) as adjunct therapy 4

• For chronic or refractory cases:

  • Disease-modifying antirheumatic drugs (DMARDs) with methotrexate as the anchor drug 2, 4
  • For inadequate response to conventional DMARDs with poor prognostic factors, consider biologic DMARDs (TNF inhibitors) 4

3. Management of Extra-articular Manifestations

• Conjunctivitis/Uveitis:

  • Ophthalmology consultation
  • Topical steroids and cycloplegics as directed by ophthalmologist

• Urethritis:

  • Ensure adequate hydration
  • Appropriate antibiotics if infection is still present

• Dermatologic manifestations:

  • Topical steroids for skin lesions
  • Keratolytics for keratoderma blennorrhagicum

Non-Pharmacological Interventions

• Exercise therapy:

  • At least 12 supervised sessions
  • Initially 2 sessions per week of aerobic, aquatic, and/or resistance exercises 4

• Physical and occupational therapy:

  • Joint protection techniques
  • Assistive devices
  • Thermal modalities 4

• Weight management for overweight patients 4

Monitoring and Follow-up

• Disease activity assessment every 1-3 months until treatment target is reached 4

  • Monitor tender and swollen joint counts
  • Patient and physician global assessments
  • ESR and CRP

• Structural damage assessment:

  • Radiographs of affected joints every 6-12 months during first few years 2
  • Functional assessment using validated tools (e.g., HAQ)

Prognosis and Complications

• Variable prognosis: 15-20% of patients may develop severe chronic sequelae 1
• Without proper management, reactive arthritis can progress to chronic destructive arthritis 5
• HIV-positive patients may have more difficult-to-treat disease 1

Patient Education

• Provide information about the disease, its triggers, and expected course
• Education programs focused on coping with pain, disability, and maintaining work ability 2
• Self-management strategies to manage flares and maintain joint function

Early recognition and prompt intervention are essential for better outcomes and fewer complications in reactive arthritis 5.