What is the treatment for reactive arthritis?

Treatment for 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. 1

Initial Symptomatic Management

• NSAIDs should be initiated immediately after evaluating gastrointestinal, renal, and cardiovascular risks 2, 1
• Intra-articular glucocorticoid injections are recommended for relief of local inflammatory symptoms in affected joints 2, 1
• Local measures including arthrocentesis, cold pads, and rest of the affected joint provide additional symptomatic relief 3

Antibiotic Therapy (Chlamydia-Induced Cases Only)

• If Chlamydia can be isolated from the urogenital tract, treat with antibiotics: doxycycline 100mg twice daily or erythromycin 500mg four times daily for 10-14 days, or azithromycin 1g as a single dose 3
• Treat sexual partners concurrently to prevent reinfection 3
• Do not use antibiotics for enteric reactive arthritis (Salmonella, Shigella, Yersinia, Campylobacter), as they show no benefit over placebo even with prolonged treatment 3

Critical pitfall: Antibiotics are ineffective for enteric forms of reactive arthritis despite the presence of bacterial remnants in joints 3. Only treat with antibiotics when Chlamydia is culture-positive from the urogenital tract.

Disease-Modifying Therapy for Persistent Disease

• For reactive arthritis lasting longer than 6 months, add sulfasalazine 2g/day while continuing NSAIDs 3
• Sulfasalazine is moderately superior to placebo in placebo-controlled studies and well-tolerated 3, 4
• If sulfasalazine fails, methotrexate is the anchor drug for persistent inflammatory arthritis unless contraindicated 1
• Other DMARDs (azathioprine, cyclosporin) can be tried in individual patients unresponsive to sulfasalazine, though no controlled studies support their use 3, 4
• For severe or refractory cases evolving toward ankylosing spondylitis, TNF-alpha blockers represent an effective choice 4

Monitoring Protocol

• Assess disease activity at 1-3 month intervals until treatment target is reached 1
• Monitor tender and swollen joint counts, patient and physician global assessments, ESR, and CRP 1
• Continue monitoring until inflammatory activity resolves 1

Non-Pharmacological Interventions

• Dynamic exercises and occupational therapy should be considered as adjuncts to drug treatment 1
• Patient education about the disease, outcome, and treatment is essential 1
• Education programs aimed at coping with pain, disability, work maintenance, and social participation should be utilized 1

Important consideration: Up to 20% of reactive arthritis patients experience a chronic course lasting more than 1 year 3. Early recognition and appropriate escalation to DMARDs at 6 months prevents progression to chronic destructive arthritis 3, 5.