What is the management and treatment of reactive arthritis?

Management and Treatment of Reactive Arthritis

First-Line Treatment: NSAIDs

NSAIDs are the cornerstone of initial therapy for reactive arthritis, providing symptomatic relief of pain and inflammation in the acute phase. 1, 2, 3 Use the minimum effective dose for the shortest duration possible after evaluating gastrointestinal, renal, and cardiovascular risks. 4

• NSAIDs should be continued throughout the acute arthritis phase, which typically lasts weeks to several months. 2
• Local measures including arthrocentesis, cold pads, and rest of the affected joint should be employed as adjunctive therapy. 2
• Intra-articular glucocorticoid injections can be used for localized joint symptoms when NSAIDs alone are insufficient. 5

Antibiotic Therapy: Pathogen-Specific Approach

For Chlamydia-induced urogenital reactive arthritis with positive cultures, treat with doxycycline 100mg twice daily or erythromycin 500mg four times daily for 10-14 days, or a single dose of azithromycin 1g. 2

• Sexual partners must be treated concurrently to prevent reinfection. 2
• For enteric forms of reactive arthritis (Salmonella, Shigella, Campylobacter, Yersinia), antibiotics show no benefit over placebo and should not be used. 2
• Long-term antibiotics (3 months) for Chlamydia-induced reactive arthritis without positive cultures may provide some benefit, but evidence is insufficient for routine recommendation. 2

Glucocorticoids for Refractory Cases

Systemic or intra-articular glucocorticoids should be administered when inflammatory symptoms are resistant to NSAIDs. 1, 3

• Oral glucocorticoids can be used as bridging therapy, but long-term use should be avoided due to cumulative side effects. 4
• No correlation exists between the number of poor prognostic factors and the need for systemic steroids. 3

Disease-Modifying Therapy for Chronic Disease

For reactive arthritis lasting longer than 6 months, add sulfasalazine 2g/day to continued NSAID therapy. 2, 3

• Sulfasalazine is moderately superior to placebo in placebo-controlled studies and is well tolerated. 2
• Sulfasalazine remains the most commonly used DMARD for reactive arthritis alongside NSAIDs. 1
• Other DMARDs (methotrexate, azathioprine, cyclosporine) can be tried in individual patients unresponsive to sulfasalazine, though no controlled studies support their use. 1, 2
• The risk-benefit ratio of alternative DMARDs should be carefully discussed with the patient given the lack of controlled trial data. 2

Biologic Therapy for Severe or Progressive Disease

In aggressive cases or when reactive arthritis evolves toward ankylosing spondylitis, TNF-alpha inhibitors (such as adalimumab) represent an effective choice. 1, 3

• Increased use of TNF inhibitors correlates strongly with an increased number of poor prognostic factors and non-response to conventional therapy. 3
• Consider biologics when patients fail NSAIDs, glucocorticoids, and sulfasalazine, particularly with evidence of axial involvement or progression to chronic destructive arthritis. 1, 6

Monitoring and Treatment Adjustment

Monitor disease activity every 1-3 months, and adjust therapy if no improvement occurs by 3 months or the treatment target is not reached by 6 months. 4

• Up to 20% of patients experience a chronic course lasting more than 1 year, requiring escalation to DMARDs or biologics. 2
• Without proper management, reactive arthritis can progress to chronic destructive arthritis, making prompt recognition and early intervention critical for better outcomes and fewer complications. 6

Common Pitfalls and Caveats

• Do not use antibiotics for enteric reactive arthritis—they provide no benefit and delay appropriate anti-inflammatory therapy. 2
• Avoid prolonged NSAID use without gastroprotection in high-risk patients (elderly, history of ulcers, concurrent anticoagulation). 4
• Do not delay DMARD initiation beyond 6 months in patients with persistent symptoms, as this increases risk of chronic destructive arthritis. 6, 2
• Screen for and treat urogenital Chlamydia infection in sexual partners to prevent reinfection and recurrent arthritis. 2