Treatment of Reactive Arthritis
NSAIDs at the minimum effective dose for the shortest duration are the first-line treatment for reactive arthritis, with intra-articular glucocorticoid injections for localized joint inflammation, and methotrexate reserved for severe or persistent cases lasting beyond 6 months. 1
Initial Symptomatic Management
NSAIDs form the cornerstone of acute treatment for reactive arthritis, though they must be used judiciously after evaluating gastrointestinal, renal, and cardiovascular risks. 1, 2 High doses of potent NSAIDs are recommended for initial symptom control. 3
- Intra-articular glucocorticoid injections should be administered for relief of local inflammatory symptoms, particularly in patients with large-joint involvement. 1, 3
- Systemic glucocorticoids are generally avoided in reactive arthritis management, unlike in rheumatoid arthritis, as the evidence base is primarily derived from other inflammatory arthritides. 2
Antibiotic Therapy Considerations
For Chlamydia-induced urogenital reactive arthritis with positive cultures, treat the infection with doxycycline 100mg twice daily or erythromycin 500mg four times daily for 10-14 days, or a single dose of azithromycin 1g. 4, 3 The sexual partner must be treated concurrently to prevent reinfection. 4
- Antibiotics are NOT recommended for enteric forms of reactive arthritis (following Salmonella, Shigella, Yersinia, or Campylobacter infections), as controlled studies show no benefit over placebo despite bacterial remnants in joints. 4
- For Chlamydia-induced reactive arthritis without positive cultures, a 3-month antibiotic course may provide some benefit, though evidence remains insufficient for routine recommendation. 4
Disease-Modifying Therapy for Persistent Disease
For reactive arthritis lasting longer than 6 months, sulfasalazine 2g/day should be added to continued NSAID therapy. 4 This represents the only DMARD with placebo-controlled evidence in reactive arthritis, showing moderate superiority with good tolerability. 4
Methotrexate is the anchor drug for persistent inflammatory arthritis when sulfasalazine fails or is contraindicated. 1, 2 While no controlled trials exist specifically for methotrexate in reactive arthritis, its established efficacy in other inflammatory arthritides and guideline recommendations for persistent inflammatory arthritis support its use. 2
- Other DMARDs can be considered in individual patients unresponsive to sulfasalazine, though the risk-benefit ratio must be carefully discussed given the absence of controlled trial data. 4
Monitoring Strategy
Disease activity should be assessed every 1-3 months until the treatment target is reached. 1, 2 Monitoring should include:
- Tender and swollen joint counts 1, 2
- Patient and physician global assessments 1, 2
- ESR and CRP levels 1, 2
Non-Pharmacologic Interventions
Dynamic exercises and occupational therapy should be incorporated as adjuncts to pharmacologic treatment. 1, 2
- Patient education programs addressing pain management, disability coping, work ability maintenance, and social participation are important adjunctive interventions. 1, 2
Clinical Pitfalls
Avoid prolonged antibiotic therapy for enteric reactive arthritis—this is a common error with no evidence of benefit and potential for harm. 4 The typical course involves one knee or ankle affected for weeks to several months, with up to 20% developing chronic disease lasting over 1 year. 4 Without proper management, reactive arthritis can progress to chronic destructive arthritis, making prompt recognition and appropriate treatment essential. 5