Treatment of Reactive Arthritis
NSAIDs at the minimum effective dose for the shortest duration should be initiated first-line for reactive arthritis, with methotrexate reserved as the anchor drug for persistent or severe inflammatory arthritis. 1
Initial Pharmacologic Management
First-line therapy consists of NSAIDs, which should be prescribed after evaluating gastrointestinal, renal, and cardiovascular risks 1. The goal is to use the lowest effective dose for the shortest time possible to minimize adverse effects including ulcers, bleeding, fluid retention, and cardiovascular events 2. NSAIDs should be used for no more than 10 days without physician supervision 2.
Intra-articular glucocorticoid injections are recommended for localized symptom relief when specific joints are significantly inflamed 1. This approach provides targeted anti-inflammatory effects while avoiding systemic corticosteroid exposure.
Treatment for Severe or Refractory Disease
Methotrexate is the anchor drug when reactive arthritis persists beyond the acute phase or fails to respond adequately to NSAIDs 1. This represents a critical escalation point, as untreated persistent inflammatory arthritis can progress to chronic destructive arthritis 3.
Before initiating methotrexate, be aware of contraindications including pregnancy (Category X), active infection, significant hepatic or renal impairment, and bone marrow suppression 4. Required monitoring includes complete blood count, hepatic function tests, and renal function 4.
Monitoring Strategy
Disease activity assessment should occur at 1-3 month intervals until the treatment target is reached 1. Monitoring parameters include:
For patients on methotrexate, additional monitoring for hepatotoxicity, bone marrow suppression, and pulmonary toxicity is essential, particularly in elderly patients who may have decreased renal function 4.
Non-Pharmacological Interventions
Dynamic exercises and occupational therapy should be incorporated as adjuncts to pharmacologic treatment 1. These interventions help maintain joint function and prevent disability.
Patient education is a critical component addressing disease course, treatment expectations, pain management strategies, and maintaining work capacity and social participation 1.
Critical Clinical Pitfalls
Avoid confusing reactive arthritis with septic arthritis, which presents with fever, systemic infection signs, and monoarthritis with positive cultures 5. Reactive arthritis is characterized by sterile inflammatory arthritis developing 1-6 weeks after infection, with negative cultures but positive serum antibodies 5.
Do not rely on HLA-B27 testing for diagnosis of acute reactive arthritis, though it is present in over two-thirds of patients and represents a predisposing factor 5, 6. The diagnosis is primarily clinical based on oligoarthritis of large joints following genitourinary or gastrointestinal infection 5.
Antibiotic therapy has limited utility in most cases of reactive arthritis once arthritis has developed, with the exception of Chlamydia-induced reactive arthritis where prolonged doxycycline treatment may be beneficial 6, 7. For enteric reactive arthritis (Salmonella, Shigella), antibiotics have not been shown effective for treating the arthritis itself 6.
NSAIDs alone provide only symptomatic relief without disease modification 8. If symptoms persist beyond several weeks or months, escalation to methotrexate is necessary to prevent progression to chronic arthritis 1.