What is the recommended treatment for reactive arthritis?

Treatment of Reactive Arthritis

The recommended treatment for reactive arthritis begins with nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapy for symptomatic relief, followed by disease-modifying antirheumatic drugs (DMARDs) such as sulfasalazine for cases lasting longer than 6 months. 1

Initial Management

• NSAIDs should be used at the minimum effective dose for the shortest time possible after evaluation of gastrointestinal, renal, and cardiovascular risks 2
• Local measures such as arthrocentesis, cold pads, and rest of the affected joint are recommended for acute arthritis 1
• For Chlamydia-induced urogenital reactive arthritis, if the triggering bacterium is isolated, treat with antibiotics:
  • Doxycycline 100mg twice daily for 10-14 days, or
  • Erythromycin 500mg 4 times daily for 10-14 days, or
  • Single dose of azithromycin 1g 1
• Sexual partners should be treated concurrently to prevent reinfection in cases of Chlamydia-induced reactive arthritis 1
• Intra-articular glucocorticoid injections should be considered for relief of local symptoms of inflammation 2

Persistent Reactive Arthritis (>6 months)

• Sulfasalazine 2g/day is recommended in addition to continued NSAIDs for reactive arthritis lasting longer than 6 months 1
• Sulfasalazine has been shown to be moderately superior to placebo in several controlled studies and is generally well-tolerated 1

Severe or Refractory Cases

• For patients who do not respond to sulfasalazine, other DMARDs may be considered:
  • Methotrexate is considered the anchor drug for persistent inflammatory arthritis unless contraindicated 2
  • Leflunomide or hydroxychloroquine may be alternatives 3
• In individual cases with persistent arthritis not responding to conventional DMARDs, biologics and Janus kinase inhibitors (JAKi) may be considered 4

Monitoring and Follow-up

• Disease activity should be assessed at 1-3 month intervals until treatment target has been reached 2
• Monitoring should include tender and swollen joint counts, patient and physician global assessments, ESR and CRP 2

Important Considerations

• Antibiotics for enteric forms of reactive arthritis (following Salmonella or Shigella infections) have not shown benefit over placebo 1
• For Chlamydia-induced reactive arthritis, extended antibiotic treatment (3 months) in the absence of positive cultures may provide some benefit, but further studies are needed 1
• HLA-B27 genotype is a predisposing factor in over two-thirds of patients with reactive arthritis and may indicate a higher risk for chronic disease 5
• Reactive arthritis typically presents as monoarticular or oligoarticular peripheral arthritis, often affecting knees or ankles, and may be associated with dactylitis 4

Non-pharmacological Interventions

• Dynamic exercises and occupational therapy should be considered as adjuncts to drug treatment 2
• Patient education about the disease, its outcome, and treatment is important 2
• Education programs aimed at coping with pain, disability, maintenance of ability to work, and social participation may be used as adjunct interventions 2

Remember that reactive arthritis is typically self-limiting, but up to 20% of patients may experience a chronic course lasting more than one year 1. Early intervention and appropriate treatment can help manage symptoms and potentially reduce the risk of chronic disease.