Treatment of reactive arthritis: a practical guide

AbstractReactive arthritis follows infections of the urogenital or enteric tract with bacteriasuch as Chlamydia, Yersinia, Shigella, Salmonella or Campylobacter. Typically,one knee or ankle are affected for weeks to several months, with up to 20% ofpatients experiencing a chronic course of more than 1 year. The acute arthritis is treated nonspecifically with nonsteroidal anti-inflammatorydrugs (NSAIDs), local measures such as arthrocentesis, cold pads and rest of theaffected joint. If the triggering bacterium can be isolated in Chlamydia-induced urogenital reactive arthritis, the infection should be treatedspecifically with antibacterials. Doxycycline 100mg twice daily, or erythromycin500mg 4 times daily, for 10 to 14 days are effective for Chlamydia,as is a single dose of azithromycin 1g. To prevent reinfections, the sexual partnershould be treated concurrently. Although remnants of bacteria and even bacterial RNA, suggesting live bacteria,can be demonstrated in the joint, treatment with antibacterials, even for long periods,does not show any benefit over placebo in enteric forms of reactive arthritis. For Chlamydia-induced reactive arthritis, antibacterials given for 3months in the absence of positive cultures from the urogenital tract may providesome benefit; however, further studies are needed before such treatment isrecommended. For reactive arthritis lasting longer than 6 months, patients may benefit fromsulfasalazine 2 g/day in addition to continued use of NSAIDs. In severalplacebo-controlled studies, sulfasalazine was well tolerated and moderately superiorto placebo. Other disease-modifying antirheumatic drugs (DMARDs) can be tried inindividual patients who do not respond to sulfasalazine. However, since nocontrolled studies are available to date for DMARDs other than sulfasalazine, therisk-benefit ratio of such treatment should be carefully discussed with the patient.