What is the management approach for post-streptococcal arthritis (Nonsteroidal Anti-Inflammatory Drugs (NSAIDs), Disease-Modifying Antirheumatic Drugs (DMARDs), antibiotics)?

Management of Post-Streptococcal Arthritis

Post-streptococcal reactive arthritis (PSRA) should be treated primarily with NSAIDs as first-line therapy, with corticosteroids reserved for NSAID-refractory cases, and antibiotic prophylaxis considered for at least 1 year due to the risk of subsequent cardiac involvement. 1, 2

Initial Pharmacologic Management

First-Line: NSAIDs

• NSAIDs are the primary treatment for PSRA and provide good symptomatic relief in approximately 85% of cases 3
• NSAIDs should be used at the minimum effective dose for the shortest time possible after evaluating gastrointestinal, renal, and cardiovascular risks 4
• Unlike acute rheumatic fever (ARF), PSRA typically responds poorly to aspirin but shows at least partial response to other NSAIDs in all cases 5
• Indomethacin has demonstrated symptomatic relief in documented cases 5

Second-Line: Corticosteroids

• Corticosteroids should be reserved for patients with inadequate response to NSAIDs (approximately 15% of cases) 3
• Systemic glucocorticoids should be used at the lowest effective dose as temporary adjunctive treatment when NSAIDs fail 4
• Prednisone has shown efficacy in NSAID-refractory cases 5
• Intra-articular glucocorticoid injections may be considered for localized symptoms, particularly given that PSRA can present with asymmetric oligoarthritis or monoarthritis 3, 4

Antibiotic Therapy

Acute Treatment

• Antibiotics are NOT indicated for treating the arthritis itself once PSRA has developed, as the arthritis is a post-infectious reactive phenomenon 1
• If active pharyngitis is present, complete a standard 10-day course of penicillin to eradicate the streptococcal infection 5

Prophylactic Antibiotics

• Antistreptococcal prophylaxis should be administered for at least 1 year, then discontinued if there is no evidence of cardiac involvement 2
• This recommendation is based on the finding that up to 6% of PSRA patients develop mitral valve disease, and one documented case progressed to classic ARF with valvulitis 18 months after initial presentation 6, 2
• Prophylactic penicillin was given to 57% of patients in one case series, though practice varies 3
• PSRA appears to be part of the disease spectrum of ARF, justifying prophylactic antibiotic therapy to prevent subsequent ARF and carditis 6

DMARDs: Not Indicated

Disease-modifying antirheumatic drugs (DMARDs) including methotrexate are NOT indicated for PSRA, as this is a self-limited post-infectious reactive arthritis, not a chronic inflammatory arthritis like rheumatoid arthritis 1, 5

The evidence provided regarding DMARDs relates to rheumatoid arthritis and psoriatic arthritis management, which are entirely different disease entities from PSRA 4

Clinical Monitoring and Follow-Up

Cardiac Surveillance

• All patients require cardiac evaluation at presentation and follow-up to exclude carditis, as PSRA can progress to ARF with cardiac involvement 6, 2
• Echocardiography should be performed to assess for valvular disease 2
• If cardiac involvement develops, continue antistreptococcal prophylaxis beyond 1 year per ARF guidelines 2

Disease Course Monitoring

• Most cases resolve spontaneously within a few weeks, though some are recurrent or prolonged (mean duration 2 months) 1, 2
• PSRA causes acute asymmetrical non-migratory polyarthritis that is more persistent than ARF (which typically lasts days to 3 weeks) 1
• Monitor for recurrent episodes: approximately 17-33% of patients experience additional episodes of arthritis or arthralgia 6, 3

Key Distinguishing Features from Other Conditions

PSRA vs. Acute Rheumatic Fever

• PSRA occurs within 10 days of streptococcal infection (vs. 2-3 weeks for ARF) 1
• Arthritis is additive and non-migratory (vs. migratory in ARF) 2
• Poor response to salicylates (vs. dramatic response in ARF) 2
• Does not fulfill Jones criteria for ARF diagnosis 1

PSRA vs. Reactive Arthritis

• PSRA is not associated with HLA-B27 (unlike classic reactive arthritis) 1, 2
• Associated with HLA-DRB1*01 instead 2
• Axial skeleton involvement including sacroiliitis is uncommon 1

Common Pitfalls to Avoid

• Do not withhold antibiotic prophylaxis: Despite the self-limited nature of arthritis, the risk of cardiac progression justifies prophylaxis 6, 2
• Do not assume aspirin will be effective: PSRA responds poorly to aspirin unlike ARF; use other NSAIDs 2, 5
• Do not overlook periarticular manifestations: Polytendonitis, tenosynovitis, and enthesitis occur in 35% of cases and may be the only manifestation 3
• Do not initiate DMARDs: This is a reactive, self-limited condition, not chronic inflammatory arthritis requiring immunosuppression 1