What is the treatment for reactive arthritis?

Treatment of Reactive Arthritis

For acute reactive arthritis, start NSAIDs immediately for symptomatic relief, treat any active urogenital Chlamydia infection with doxycycline 100mg twice daily for 10-14 days, and reserve sulfasalazine 2g/day for cases persisting beyond 6 months. 1

Acute Phase Management (First 6 Months)

Initial Symptomatic Treatment

• NSAIDs are the cornerstone of acute reactive arthritis treatment for managing pain, inflammation, and stiffness 1, 2
• Add local measures including arthrocentesis (joint aspiration), cold pads, and rest of the affected joint 1
• Intra-articular glucocorticoid injections can be used when inflammatory symptoms are resistant to NSAIDs 2

Antibiotic Therapy: Critical Decision Point

The role of antibiotics depends entirely on the triggering infection:

For Chlamydia-induced urogenital reactive arthritis:

• 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 the sexual partner concurrently to prevent reinfection 1
• This recommendation applies only when Chlamydia can be isolated from the urogenital tract 1

For enteric reactive arthritis (Yersinia, Shigella, Salmonella, Campylobacter):

• Do not use antibiotics—they provide no benefit over placebo even when given for prolonged periods 1
• This is true despite evidence that bacterial remnants and RNA can be demonstrated in the joint 1

Important Caveat on Extended Antibiotic Use

• For Chlamydia-induced reactive arthritis without positive urogenital cultures, 3-month antibiotic courses may provide some benefit, but this remains investigational and is not currently recommended for routine practice 1

Chronic Phase Management (Beyond 6 Months)

Disease-Modifying Therapy

For reactive arthritis lasting longer than 6 months, add sulfasalazine 2g/day while continuing NSAIDs 1, 2

• Sulfasalazine is the only DMARD with placebo-controlled evidence showing moderate superiority in reactive arthritis 1
• It is well-tolerated and represents the standard disease-modifying approach 1

Refractory Cases

For patients unresponsive to sulfasalazine:

• Other DMARDs (azathioprine, methotrexate, cyclosporine) can be tried in individual cases 2
• Carefully discuss the risk-benefit ratio with the patient, as no controlled studies exist for these agents in reactive arthritis 1
• TNF-alpha blockers may be effective in aggressive cases or when reactive arthritis evolves toward ankylosing spondylitis 2
• JAK inhibitors are used in individual cases for persistent disease 3

Clinical Course and Prognosis

• Typical reactive arthritis affects one knee or ankle for weeks to several months 1
• The disease is usually self-limiting, subsiding within weeks to months in many cases 4
• Up to 20-30% of patients experience a chronic course lasting more than 1 year 1, 4
• Relapses can occur even after initial resolution 4

Common Pitfalls to Avoid

• Do not use antibiotics for enteric reactive arthritis—multiple studies confirm no benefit despite the presence of bacterial components in joints 1
• Do not delay sulfasalazine beyond 6 months in persistent cases—this is the only DMARD with proven efficacy 1
• Do not forget to treat the sexual partner in Chlamydia-induced cases—reinfection will perpetuate the arthritis 1
• Do not use other DMARDs before trying sulfasalazine, as they lack evidence in reactive arthritis 1