Medical Care: The treatment of reactive arthritis is modified according to the severity of symptoms.
" Nonsteroidal anti-inflammatory drugs
o NSAIDs are the foundation of therapy. These agents should be used on a regular basis to achieve a good anti-inflammatory effect.
o The choice of a specific agent depends on the individual response to treatment, although the general impression is that indomethacin has greater potency.
o Physical therapy needs to be implemented to help reduce pain and to avoid muscle wasting in severe cases.
" Corticosteroids
o These agents can be used as either intra-articular injection or systemic therapy.
o Joint injections can produce long-lasting symptomatic improvement and help avoid the use of other systemic therapy. Sacroiliac joints can be injected, usually under fluoroscopic guidance.
o Systemic corticosteroids can be used, particularly in patients with poor response to NSAIDs or in those who develop adverse effects related to their use. The starting dose is guided by a patient's symptoms and objective evidence of inflammation. Prednisone 0.5-1 mg/kg/d can be used initially and tapered according to response.
" Antibiotics
o The current concepts on the pathogenesis of reactive arthritis indicate that an infectious agent is the trigger of the disease, but antibiotic treatment does not change the course of the disease, even when a microorganism is isolated. In these cases, antibiotics are used to treat the underlying infection, but specific treatment for reactive arthritis is lacking. However, in chlamydial-induced reactive arthritis, studies have suggested that appropriate treatment of the acute urogenital infection can prevent reactive arthritis and that treatment of acute reactive arthritis with a 3-month course of tetracycline reduces the duration of illness. No evidence indicates that antibiotic therapy benefits enteric-related reactive arthritis or chronic reactive arthritis of any cause.
o Quinolones have been studied because of their broad coverage, but no beneficial effect has been noted.
o Lymecycline was studied in a double-blind placebo-controlled study of patients with chronic reactive arthritis for a treatment period of 3 months.
o Those patients with Chlamydia-induced disease had a significant decrease in duration of illness, as opposed to those with disease triggered by enteric infections. More studies are needed before definite recommendations can be made as to the role of antibiotics in the management of reactive arthritis.
" Disease-modifying antirheumatic drugs
o In patients with chronic symptoms or in patients with persistent inflammation despite the use of the agents mentioned above, other second-line drugs may be used. Clinical experience with these so-called disease-modifying antirheumatic drugs (DMARDs) has been mostly in rheumatoid arthritis and in psoriatic arthritis. DMARDs have also been used in reactive arthritis, although their disease-modifying effects in the reactive arthritis setting are uncertain.
o Sulfasalazine can be beneficial in some patients. The use of this drug in reactive arthritis is of interest because of the finding of clinical or subclinical inflammation of the bowel in many patients. Sulfasalazine is more widely used in ankylosing spondylitis. In a recent 36-week trial of sulfasalazine versus a placebo in the spondyloarthropathies, patients with reactive arthritis who were taking sulfasalazine had a 62.3% response rate compared to 47.7% for the placebo group in peripheral arthritis (P = 0.09).
o In patients who present with rheumatoid-like disease, methotrexate can be used. Several reports have shown good response, but controlled studies are lacking. Reports also describe the use of azathioprine and bromocriptine in reactive arthritis, but, again, large studies have not been published. Patients with reactive arthritis and HIV/AIDS should not be placed on methotrexate or other immunosuppressive agents.
o Although biologic agents such as TNF-blockers have been demonstrated to be beneficial and formally approved for the treatment of psoriatic arthritis and ankylosing spondylitis, double-blind, randomized trials have not been performed to prove clinical benefit in reactive arthritis or in undifferentiated spondyloarthropathy. A recent uncontrolled study in patients with either undifferentiated spondyloarthropathy or reactive arthritis showed potential efficacy in symptom relief.
Surgical Care: No surgical treatment of reactive arthritis is recommended.
Activity: Physical therapy may be instituted to avoid muscle wasting and to reduce pain. Activities should otherwise be as tolerated by the patient.