Reactive arthritis medical therapy

The majority of cases (two-thirds) of reactive arthritis are self-limited and require only supportive care. Arthritis is the most common symptom and initially treated with NSAIDs. As the disease progresses or in case of no response, further management includes intra-articular and systemic steroids, DMARDs and finally TNF inhibitors. The role of antibiotics in reactive arthritis is not clear and their efficacy in reactive arthritis is not completely established.

• Reactive arthritis is generally seen with preceeding GI or GU infections. Antibiotics may be given if there is an ongoing infection, but generally patients of reactive arthritis do not require antibiotic therapy. Recent studies have shown that antibiotic therapy does not alter the course of disease and their role in reactive arthritis is not completely established.^[1][2]
• Arthritis (mono or oligoarthritis) is most common initial symptom and therefore primary medical therapy is aimed at alleviating arthritis.^[3]
• Pharmacologic medical therapies for reactive arthritis include symptomatic control starting initially with NSAIDs.^[4]
• As the disease progresses or in case of no response, further management includes intra-articular and systemic steroids, DMARDs and finally TNF inhibitors.^[5]
  • 1.1 NSAIDs; such as the COX-2 inhibitors

    • Preferred regimen (1): Naproxen 500 mg PO q8-12h daily.
    • Preferred regimen (2): Diclofenac 50 mg PO q8h daily.
    • Preferred regimen (3): Indomethacin 50 mg PO q6-8h daily.

    Note(1): NSAIDs are usually given for a duration of two weeks.

    Note(2): NSAIDs are contraindicated in patients with GI bleeding, heart disease and renal disease.

  • 2.1 Steroid therapy: Patients with inadequate response to NSAID are given intra-articular steroids initially and in case of no response are given systemic steroids.

    • Preferred regimen (1): Triamcinolone acetonide 40 mg given as intra-articular injection.
    • Preferred regimen (2): Methylprednisolone acetate 20-60 mg as intra-articular injection.

    Note(1): Intra-articular injections are given every 1- 5 weeks depending upon response.

    Note(2): Most common side effects of intra-articular steroids include osteonecrosis and acute synovitis.

    • Alternative regimen (1): Patients unresponsive to NSAIDs and intra-articular steroids are advised systemic glucocorticoids such as prednisone 20 mg PO q24 daily.

    Note(1): Glucocorticoids should be started with the minimum dose and gradually increased if desired effect is not achieved.

  • 3.1 Steroid therapy: Patients unresponsive to NSAIDs and steroids are advised DMARDs.^[6]

    • Preferred regimen (1): Sulfasalazine 500 mg PO q24 daily, if unresponsive dose can be increased to 1000-3000 mg BID daily.
    • Preferred regimen (2): Methotrexate 15 to 25 mg PO one day weekly.

    Note(1): The duration of therapy with DMARDs is four months for sulfasalazine.

    Note(2): For methotrexate the duration of therapy is three months.

  • 4.1 Tumor necrosis factor (TNF) inhibitors: Patients unresponsive to above therapy are advised TNF inhibitors.^[7]

    • Preferred regimen (1): Etanercept 50 mg/week given as subcutaneous injection.
    • Preferred regimen (2): Infliximab 3 to 5 mg/kg administered intravenously on weeks zero, two, and six and then every eight weeks.

    Note(1): The duration of treatment is 3 months.

    Note(2): If the patient does not respond to one TNF inhibitor, another TNF agent may be given

    Note(3): Treatment is discontinued when patient goes into remission for at least three months.

• For treatment of ocular symptoms such as conjunctivitis, please click here
• For treatment of urethritis please click here
• Skin and mucous membrane lesions are generally self limited and therefore do not require further intervention.

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