What is the management of reactive arthritis?

Management of Reactive Arthritis

For acute reactive arthritis, start with NSAIDs at the minimum effective dose for symptomatic relief, combined with rest and local measures such as arthrocentesis for affected joints, while treating any active urogenital Chlamydia infection with doxycycline 100mg twice daily for 10-14 days. 1

Acute Phase Management (First 6 Months)

Symptomatic Treatment

• Initiate NSAIDs as first-line therapy for pain and inflammation control, using the minimum effective dose for the shortest duration necessary after evaluating gastrointestinal, renal, and cardiovascular risks 2
• Apply local measures including arthrocentesis to drain effusions, cold pads, and rest of the affected joint 1
• Consider intra-articular glucocorticoid injections for relief of local inflammatory symptoms in severely affected joints 2
• Systemic glucocorticoids at low doses (≤10 mg/day prednisone equivalent) can be used as temporary adjunctive treatment for up to 6 months, then tapered rapidly 2

Antibiotic Therapy

• For Chlamydia-induced urogenital reactive arthritis with positive cultures: treat with doxycycline 100mg twice daily for 10-14 days, or erythromycin 500mg four times daily for 10-14 days, or single-dose azithromycin 1g 1
• Treat sexual partners concurrently to prevent reinfection 1
• Do not use antibiotics for enteric forms of reactive arthritis (Yersinia, Shigella, Salmonella, Campylobacter), as they show no benefit over placebo even with prolonged treatment 1
• For Chlamydia-induced reactive arthritis without positive cultures, prolonged antibiotics (3 months) may provide some benefit, but evidence is insufficient for routine recommendation 1

Chronic/Persistent Disease (>6 Months)

DMARD Therapy

• For reactive arthritis persisting beyond 6 months, add sulfasalazine 2g/day to continued NSAID therapy 1, 3
• Sulfasalazine is moderately superior to placebo in placebo-controlled studies and is well-tolerated 1
• If sulfasalazine fails or is contraindicated, consider methotrexate, azathioprine, or cyclosporine as second-line DMARDs, though controlled trial data are lacking 1, 3
• Carefully discuss the risk-benefit ratio with patients before initiating DMARDs other than sulfasalazine given the absence of controlled studies 1

Severe or Refractory Cases

• For aggressive cases or when reactive arthritis evolves toward ankylosing spondylitis, TNF-alpha blockers represent an effective choice 3, 4
• Biologic treatment results for refractory reactive arthritis are promising 4
• Consider referral to a rheumatologist for patients with persistent disease, severe symptoms, or those requiring biologic therapy 2

Monitoring and Follow-Up

• Monitor disease activity at 1-3 month intervals during active disease using tender and swollen joint counts, patient and physician global assessments, and acute phase reactants (ESR, CRP) 2
• Assess for extra-articular manifestations including enthesitis, tenosynovitis, bursitis, dactylitis, conjunctivitis, and urethritis 3, 5
• Recognize that approximately 20% of patients develop a chronic course lasting more than 1 year, and 30% may develop chronic forms with relapses 1, 6

Non-Pharmacological Interventions

• Recommend dynamic exercises and occupational therapy as adjuncts to drug treatment 2
• Provide patient education about the disease, its typical course, and self-management strategies 2
• Address modifiable risk factors including smoking cessation and weight control 2

Common Pitfalls to Avoid

• Do not prescribe prolonged antibiotics for enteric reactive arthritis, as this provides no benefit and exposes patients to unnecessary risks 1
• Do not escalate DMARD therapy in the acute phase (<6 months); allow time for spontaneous resolution with symptomatic treatment alone 1
• Do not overlook the need to treat sexual partners in Chlamydia-induced cases, as reinfection will perpetuate the arthritis 1
• Avoid prolonged systemic glucocorticoid use beyond 6 months due to cumulative side effects 2