Management of Reactive Arthritis (Reiter Syndrome)
The management of Reactive Arthritis (Reiter Syndrome) should follow a stepwise approach with NSAIDs as first-line therapy, followed by disease-modifying antirheumatic drugs (DMARDs) like methotrexate for persistent cases, and consideration of biologic agents for refractory disease. 1
Understanding Reactive Arthritis
Reactive arthritis, formerly known as Reiter syndrome, is a spondyloarthropathy characterized by the classic triad of:
- Conjunctivitis
- Urethritis
- Arthritis
It typically follows urogenital infections (commonly Chlamydia trachomatis) or gastrointestinal infections (certain strains of Salmonella or Shigella) 2, 3. The condition is more common in men and those with HLA-B27 genotype, which is present in over two-thirds of patients 4.
Treatment Algorithm
First-Line Therapy
- High-dose nonsteroidal anti-inflammatory drugs (NSAIDs) are the initial treatment of choice 4
- For genitourinary-triggered reactive arthritis, appropriate antibiotics (doxycycline or analogs) may shorten the course or prevent arthritis onset 4
- Note: Antibiotics have not shown benefit for enteric-triggered reactive arthritis 4
Second-Line Therapy
- For persistent symptoms beyond 3-6 months, initiate methotrexate at 7.5-15 mg weekly, with potential escalation to 20-25 mg as recommended by the American College of Rheumatology 1
- Intra-articular corticosteroid injections may benefit patients with large-joint involvement 4
Refractory Cases
- Consider biologic agents (TNF inhibitors) following principles similar to rheumatoid arthritis management, as suggested by the European League Against Rheumatism 1
Non-Pharmacological Interventions
- Exercise and physical therapy to maintain joint function and muscle strength 1
- Self-management programs to improve coping with pain and disability 1
Disease Monitoring
- Regular assessment of disease activity every 1-3 months during active disease
- Adjust therapy if no improvement after 3 months or if target is not reached by 6 months 1
Prognosis and Complications
- Prognosis is variable; 15-20% of patients may develop severe chronic sequelae 2
- Without proper management, reactive arthritis can progress to chronic destructive arthritis 3
- The condition may be more difficult to treat in HIV-positive patients 2
Clinical Pearls and Pitfalls
- Always consider reactive arthritis in young men presenting with polyarthritis 4
- Don't limit diagnosis only to patients with the complete classic triad, as many patients present with incomplete manifestations 5
- Be aware that reactive arthritis can sometimes be the first manifestation of HIV infection 4
- Prompt recognition and early intervention are key to better outcomes with fewer complications 3