What is the management approach for Reiter's (Reactive Arthritis) syndrome?

Management of Reactive Arthritis (Reiter's Syndrome)

Reactive arthritis should be treated initially with high-dose NSAIDs as first-line therapy, with consideration of antibiotics (specifically doxycycline or tetracyclines) for genitourinary-triggered cases, particularly those associated with Chlamydia trachomatis infection. 1, 2

Initial Assessment and Diagnosis

When evaluating suspected reactive arthritis, confirm the classic clinical pattern:

• Asymmetric mono-oligoarthritis predominantly affecting lower limb joints following a preceding infection (typically 1-4 weeks prior) 1
• Look specifically for the triggering infection: urogenital (Chlamydia trachomatis) or gastrointestinal (Salmonella, Shigella, Campylobacter, Yersinia) 1, 2
• Extra-articular manifestations including conjunctivitis, urethritis, enthesitis, tenosynovitis, bursitis, and dactylitis 1
• Dermatologic findings such as keratoderma blennorrhagicum, circinate balanitis, oral lesions, and nail changes 3
• HLA-B27 testing may be helpful as it is positive in over two-thirds of patients, indicating genetic susceptibility 2

Treatment Algorithm

First-Line Pharmacologic Management

NSAIDs remain the cornerstone of initial treatment:

• Start with high-dose potent NSAIDs immediately upon diagnosis 1, 2
• Continue until inflammatory symptoms are adequately controlled 1

Antibiotic Therapy (Infection-Specific)

For urogenital-triggered reactive arthritis (Chlamydia-associated):

• Administer doxycycline or tetracycline analogs, as this may shorten the disease course or abort onset of arthritis 1, 2
• This approach is specifically effective for uroarthritis cases 1

For enteric-triggered reactive arthritis:

• Antibiotics have NOT been shown to be effective for Salmonella or Shigella-associated cases 2
• Do not routinely prescribe antibiotics for enteroarthritis 1

Second-Line Therapy for NSAID-Resistant Disease

If inflammatory symptoms persist despite adequate NSAID therapy:

• Intra-articular corticosteroid injections for patients with large-joint involvement 2
• Systemic corticosteroids when symptoms are resistant to NSAIDs 1

Disease-Modifying Therapy for Chronic or Severe Cases

Sulfasalazine is the most commonly used DMARD for reactive arthritis 1

For refractory cases unresponsive to conventional treatment:

• Consider methotrexate, azathioprine, or cyclosporin (though evidence is limited to sporadic reports) 1
• TNF-alpha blockers may be effective in aggressive cases or when reactive arthritis evolves toward ankylosing spondylitis 1

Critical Clinical Considerations

Always consider reactive arthritis in young men presenting with polyarthritis, as it is the most common inflammatory polyarthritis in this demographic 2

Screen for HIV infection, as reactive arthritis may be the first manifestation of HIV, and treatment is particularly difficult in HIV-positive patients 3, 2

Recognize that prognosis is variable:

• Symptoms may persist for prolonged periods 2
• 15-20% of patients develop severe chronic sequelae 3
• Without proper management, reactive arthritis can progress to chronic destructive arthritis 4
• Long-term disability is possible in some cases 2

Common Pitfalls to Avoid

Do not delay treatment while awaiting confirmatory testing—prompt recognition and early intervention lead to better outcomes with fewer complications 4

Do not prescribe antibiotics indiscriminately—they are only beneficial for Chlamydia-associated uroarthritis, not for enteric-triggered cases 1, 2

Do not overlook extra-articular manifestations—conjunctivitis, urethritis, skin lesions, and enthesitis are common and may require specific management 3, 1

Do not assume the complete classic triad is required for diagnosis—many patients never fulfill all three components (urethritis, conjunctivitis, arthritis), and the term "reactive arthritis" encompasses incomplete presentations 5