Treatment of Reactive Arthritis
The first-line treatment for reactive arthritis consists of NSAIDs for symptomatic relief, with antibiotics recommended specifically for Chlamydia-induced cases, and disease-modifying antirheumatic drugs (DMARDs) such as sulfasalazine for chronic cases lasting longer than 6 months. 1
Initial Management
- NSAIDs are the cornerstone of initial therapy for reactive arthritis, providing effective symptomatic relief for pain and inflammation 1, 2
- Local measures including arthrocentesis, cold packs, and rest of the affected joints should be implemented alongside systemic therapy 1
- For acute flares, colchicine can be used with a loading dose of 1 mg followed 1 hour later by 0.5 mg on day 1, particularly effective when given within 12 hours of symptom onset 3
- Short courses of oral corticosteroids (prednisolone 30-35 mg/day for 3-5 days) are effective alternatives, especially for multi-joint involvement 3
Antibiotic Therapy
- For Chlamydia-induced urogenital reactive arthritis, specific antibacterial treatment is essential 1, 4:
- 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 reinfection 1
- For Chlamydia-induced reactive arthritis, a prolonged 3-month course of antibiotics may provide benefit even in the absence of positive cultures 1, 4
- For enteric forms of reactive arthritis (triggered by Salmonella, Shigella, Campylobacter, or Yersinia), short-term antibiotics have not shown benefit over placebo 1, 4
- In chronic reactive enteroarthritis, prolonged courses of quinolones such as ciprofloxacin might be beneficial 4
Management of Chronic Reactive Arthritis
- For reactive arthritis lasting longer than 6 months, sulfasalazine 2 g/day is recommended in addition to continued NSAIDs 1, 2
- Sulfasalazine has demonstrated moderate superiority to placebo in several controlled studies and is generally well-tolerated 1, 4
- Other DMARDs to consider in sulfasalazine non-responders include 2, 5:
- Methotrexate
- Azathioprine
- Cyclosporine
- For severe, highly active disease that evolves toward ankylosing spondylitis or is unresponsive to conventional DMARDs, TNF-alpha blockers may be an effective option 2, 5
Monitoring and Follow-up
- Disease activity should be monitored regularly using validated measures such as joint counts, inflammatory markers (CRP, ESR), and functional assessments 3
- A treat-to-target approach aiming for remission or low disease activity is recommended 3
- For patients with frequent flares, adjusting baseline therapy is recommended 3
- Up to 30% of patients may develop chronic symptoms, requiring long-term management strategies 5
Special Considerations
- NSAIDs should be used with caution in patients with cardiovascular risk factors or renal impairment 3
- Long-term corticosteroid use increases risk of cataracts, osteoporosis, and potentially cardiovascular disease 3
- The risk-benefit ratio of DMARDs should be carefully discussed with patients, especially when using agents without controlled studies supporting their use in reactive arthritis 1
- Combination antibiotic treatment has shown response rates up to 63% in recent studies of chronic reactive arthritis 5