Management of Reactive Arthritis (Reiter Syndrome)
The management of Reactive Arthritis (Reiter Syndrome) should follow a structured approach with NSAIDs as first-line therapy, followed by disease-modifying antirheumatic drugs (DMARDs) such as methotrexate for persistent cases, and consideration of TNF inhibitors 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 or gastrointestinal infections, with an estimated frequency of 3.5 to 5 patients per 100,000 in the United States 2. The condition is more common in men and is associated with HLA-B27 genotype in over two-thirds of patients 3.
Treatment Algorithm
First-Line Treatment
- High-dose potent NSAIDs should be initiated immediately upon diagnosis 3
- Target inflammation and provide symptomatic relief
- Continue until symptoms resolve or inadequate response is determined
Second-Line Treatment
- For persistent disease (>3 months) or inadequate response to NSAIDs:
- Methotrexate starting at 7.5-15 mg weekly, with potential escalation to 20-25 mg as needed 1
- Monitor liver function, complete blood count, and renal function regularly
Third-Line Treatment
- For refractory cases not responding to methotrexate:
- TNF inhibitors following principles similar to rheumatoid arthritis management 1
Adjunctive Measures
- Intra-articular corticosteroid injections for patients with large-joint involvement 3
- Antibiotics (doxycycline or analogs) if Chlamydia trachomatis infection is confirmed, which may shorten the course or prevent arthritis onset 3
- Note: Antibiotics have not shown efficacy for reactive arthritis following enteric infections with Salmonella or Shigella 3
Non-Pharmacological Management
- 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 4
- Without proper management, reactive arthritis can progress to chronic destructive arthritis 2
Special Considerations
- Treatment may be more challenging in HIV-positive patients 4
- The presence of HLA-B27 may influence disease course and response to therapy 3, 5
Common Pitfalls to Avoid
- Failing to recognize reactive arthritis early, delaying intervention
- Not considering the underlying infection that triggered the condition
- Inadequate duration or dosing of NSAIDs before escalating therapy
- Overlooking the need for regular monitoring and therapy adjustment
- Neglecting non-pharmacological interventions that can improve outcomes
Early recognition and prompt implementation of this treatment algorithm are essential for improving patient outcomes and reducing the risk of chronic complications.