What is the management of reactive arthritis?

Management of Reactive Arthritis

The management of reactive arthritis should begin with NSAIDs as first-line therapy, followed by disease-modifying antirheumatic drugs (DMARDs) like sulfasalazine for persistent cases, and biologic agents for refractory disease. This approach prioritizes controlling inflammation, preventing joint damage, and improving quality of life.

Initial Assessment and Treatment

• Identify the triggering infection: Reactive arthritis typically follows urogenital infections (Chlamydia) or enteric infections (Yersinia, Shigella, Salmonella, Campylobacter) 1, 2
• First-line therapy: NSAIDs for symptomatic relief of joint inflammation 1, 3
• Local measures: Arthrocentesis, cold pads, and rest of affected joints 1
• Antibiotic treatment:
  • For Chlamydia-induced urogenital reactive arthritis with positive cultures: Doxycycline 100mg twice daily or erythromycin 500mg 4 times daily for 10-14 days, or single-dose azithromycin 1g 1
  • Treat sexual partners concurrently to prevent reinfection 1
  • Note: Antibiotics have not shown benefit over placebo for enteric forms of reactive arthritis 1

Management of Persistent Disease (>6 months)

• Add sulfasalazine: 2g/day for patients with persistent symptoms beyond 6 months 1, 3
• Corticosteroids: Consider low-dose glucocorticoids (≤10 mg/day prednisone) as bridge therapy, tapered as rapidly as clinically feasible 4
• Disease monitoring: Assess disease activity every 1-3 months using validated disease activity scores to determine if treatment targets are being met 4

Management of Refractory Disease

• Second-line DMARDs: Consider methotrexate for patients who don't respond to sulfasalazine 3

  • Start with 15 mg/week orally with folic acid 1 mg/day
  • Optimize to 20-25 mg/week within the first 3 months
  • Consider switching from oral to subcutaneous administration if response is inadequate 4

• Biologic therapy: For severe, refractory cases unresponsive to conventional DMARDs 3

  • TNF inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab) have shown effectiveness 3
  • Other biologics like IL-6 inhibitors (tocilizumab, sarilumab) may be considered based on individual response 4

Non-Pharmacologic Interventions

• Exercise therapy: Incorporate dynamic exercise programs with both aerobic exercise and progressive resistance training 4
• Occupational therapy: For instruction about joint protection and assistive devices 4
• Education: Inform patients about the typically self-limiting nature of reactive arthritis, with most cases resolving within weeks to months 2

Common Pitfalls to Avoid

• Delayed treatment: Early and aggressive treatment is essential for controlling inflammation and preventing joint damage 4
• Inadequate monitoring: Regular assessment of disease activity and medication side effects is crucial 4
• Overlooking non-pharmacologic interventions: Exercise and rehabilitation are important components of comprehensive management 4
• Misdiagnosis: Reactive arthritis can be confused with septic arthritis, which presents with fever, systemic signs of infection, and monoarthritis 5

Prognosis

• The majority of patients have a self-limiting course, but approximately 20% may develop chronic disease lasting more than 1 year 1, 2
• HLA-B27 positivity serves as a prognostic indicator and is associated with a higher risk of chronic disease 2

By following this structured approach to the management of reactive arthritis, clinicians can effectively control symptoms, prevent joint damage, and improve patients' quality of life while minimizing the risk of chronic disease progression.