What is the management of reactive arthritis?

Management of Reactive Arthritis

The management of reactive arthritis should begin with NSAIDs and sulfasalazine as first-line treatments, with antibiotics considered for Chlamydia-induced cases, and progression to methotrexate or biologics for refractory disease. 1, 2

First-Line Treatment Approach

• NSAIDs are the initial treatment of choice for controlling pain and inflammation in reactive arthritis 1, 2
• Sulfasalazine (2 g/day) should be used in patients with persistent symptoms lasting longer than 6 months, showing moderate superiority to placebo in controlled studies 3
• Local measures such as arthrocentesis, cold pads, and rest of affected joints can provide symptomatic relief during acute phases 3
• Glucocorticoids (low-dose) should be administered when inflammatory symptoms are resistant to NSAIDs 1, 2

Antibiotic Therapy

• For Chlamydia-induced urogenital reactive arthritis, antibiotics should be prescribed if the triggering bacterium is isolated 3
  • Doxycycline 100mg twice daily for 10-14 days
  • Erythromycin 500mg 4 times daily for 10-14 days
  • Single dose of azithromycin 1g
• Sexual partners should be treated concurrently to prevent reinfections 3
• For enteric forms of reactive arthritis (Salmonella, Shigella, Campylobacter, Yersinia), antibiotics have not shown benefit over placebo despite bacterial remnants being found in joints 3

Second-Line and Advanced Therapies

• For patients unresponsive to NSAIDs and sulfasalazine, other DMARDs can be considered 1:
  • Methotrexate
  • Azathioprine
  • Cyclosporin
• In more aggressive cases or when reactive arthritis evolves toward ankylosing spondylitis, TNF-alpha blockers represent an effective treatment option 1, 2
• Janus kinase inhibitors (JAKi) may be considered in individual refractory cases 2

Monitoring and Treatment Duration

• Reactive arthritis typically affects one knee or ankle for weeks to several months 3
• Up to 20% of patients may experience a chronic course lasting more than 1 year 3
• Regular monitoring of disease activity should be performed to assess treatment response
• Treatment should aim at achieving remission or low disease activity 2

Special Considerations

• HLA-B27 is associated with approximately 50% of reactive arthritis cases and may indicate a higher risk for chronic or recurrent disease 2
• Extra-articular manifestations such as enthesitis, tenosynovitis, bursitis, and dactylitis are frequent and may require specific management approaches 1
• The diagnosis is based on a typical clinical picture, evidence of previous or persistent infection, and exclusion of other causes of arthritis 2

Treatment Algorithm

1. Begin with NSAIDs for symptom control
2. Add antibiotics only if Chlamydia infection is confirmed
3. For persistent symptoms >6 months, add sulfasalazine 2g/day
4. If inadequate response, consider methotrexate or other DMARDs
5. For severe or refractory disease, consider TNF-alpha inhibitors or JAK inhibitors