eMedicine Specialties > Dermatology > Papulosquamous Diseases
Reactive Arthritis: Treatment & Medication
Updated: Jun 12, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
No curative treatment for reactive arthritis exists. Almost two thirds of patients have a self-limited course and need no treatment other than symptomatic and supportive care. However, reactive arthritis may be associated with chronic recurrent ocular inflammation that mandates systemic therapy (including immunosuppressive treatment) to control the ocular inflammation and to prevent progressive visual loss.24
- Urethritis usually is treated with tetracyclines or macrolides because of the frequency of coexisting infections. The treatment of urethritis has not been shown to modify the course of the disease, but, in the absence of contraindications, treatment is commonly recommended. The antibiotic treatment of enteritis is even more controversial.
- Arthritis in reactive arthritis is amenable to successful treatment with nonsteroidal anti-inflammatory drugs (eg, indomethacin). Occasionally, intra-articular injections of corticosteroids are prescribed. Treatment with methotrexate, azathioprine, gold salts, and penicillamine is proposed in severe cases of reactive arthritis.
- Cutaneous lesions can be treated as those of psoriasis vulgaris. The author recommends beginning with topical 0.1% triamcinolone cream 3 times per day for adults and 2.5% hydrocortisone cream twice per day for children. A topical keratolytic, such as 10% salicylic acid ointment, can be added if needed. Topical salicylic acid and hydrocortisone with oral aspirin has also been suggested.15
- Systemic therapy, if required, consists of the administration of oral acitretin and/or psoralen plus UVA (PUVA), methotrexate, or cyclosporine.
- The treatment of reactive arthritis in the setting of HIV infection poses special problems. However, potentially immunosuppressive therapies (eg, cyclosporine, methotrexate, PUVA) have been used in some cases, with variable success and a relative scarcity of severe complications.
The clinical trial, New Immunomodulatory Therapy Strategies in Chronic Reactive Arthritis, is currently recruiting and may be of interest.
Medication
The goals of pharmacotherapy are to reduce morbidity and prevent complications.
Antibiotics
Antibiotics may be used to treat antibacterial and anti-inflammatory effects, as well for possible coexistent infection.
Minocycline (Dynacin, Minocin)
Used to treat infections caused by susceptible gram-negative and gram-positive organisms, in addition to infections caused by susceptible Chlamydia, Rickettsia, and Mycoplasma organisms. Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Adult
50-100 mg PO qd/bid (usually 100 mg bid)
Pediatric
<12 years: Not recommended
>12 years: Administer as in adults
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increasing risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of anticoagulants
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Doxycycline (Vibramycin, Doryx, Bio-Tab)
Used to treat infections caused by susceptible gram-negative and gram-positive organisms, in addition to infections caused by susceptible Chlamydia, Rickettsia, and Mycoplasma organisms. Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Adult
200 mg PO qd
Pediatric
<8 years: Not recommended
>8 years: Administer as in adults
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increasing risk of pregnancy
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Azithromycin (Zithromax)
Used to treat mild-to-moderate microbial infections.
Adult
500 mg PO qd
Pediatric
10-20 mg/kg PO qd
May increase toxicity of theophylline, warfarin, and digoxin; effects reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur with coadministered cyclosporine
Documented hypersensitivity; hepatic impairment; do not administer with pimozide
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Site reactions can occur with IV; bacterial or fungal overgrowth may result with prolonged antibiotic use; may increase hepatic enzyme levels and cholestatic jaundice; caution in impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients
Cefdinir (Omnicef)
Third-generation cephalosporin indicated for the treatment of susceptible infections.
Adult
300 mg PO bid
Pediatric
7 mg/kg PO q12h
May increase hypoprothrombinemic effects of anticoagulants; coadministration with potent diuretics and aminoglycosides (eg, loop diuretics) may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Reduce dose by one half if CrCl is 10-30 mL/min and by one fourth if <10 mL/min; bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy
Vitamins
These agents are essential for normal DNA synthesis and metabolism of proteins, carbohydrates, and fats.
Calcipotriene (Dovonex)
Synthetic vitamin D-3 analog that regulates skin-cell production and development. Use 0.005% cream, ointment, or solution.
Adult
Apply thin film to affected skin bid until response achieved
Pediatric
Apply as in adults
None reported
Documented hypersensitivity; hypercalcemia; vitamin D toxicity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue if skin becomes irritated or if serum calcium level increases beyond the reference range
Nonsteroidal anti-inflammatory drugs
These agents have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclo-oxygenase activity and prostaglandin synthesis. Other mechanisms may include inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.
Indomethacin (Indocin)
Potent inhibitor of cyclo-oxygenase, which may decrease the local production of arachidonic acid–derived chemotactic factors for eosinophils present in sebum.
Adult
50 mg PO pc tid; taper as symptoms resolve
Pediatric
<14 years: Not established
>14 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when patient is taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of MTX toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; GI bleeding or renal insufficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Category D in third trimester of pregnancy (may cause closure of ductus arteriosus during the third trimester of pregnancy); may mask signs of infection; may cause fluid retention, peripheral edema, and deterioration of circulatory hemodynamics; can inhibit platelet aggregation and prolong bleeding time; liver and kidney damage may occur (rare)
Antineoplastic agents
These agents have antiproliferative and immunosuppressive effects.
Azathioprine (Imuran)
May be used alone or as a steroid-sparing agent. Antagonizes purine metabolism and inhibits synthesis of DNA, RNA, and proteins. May decrease proliferation of immune cells, which results in lower autoimmune activity. Used more commonly for reactive arthritis and psoriasis. Thiopurine methyltransferase levels should be checked prior to the use of azathioprine.
Adult
100-200 mg PO qd in combination with prednisone
Pediatric
Not established
Toxicity increases with allopurinol; concurrent use with ACE inhibitors may induce severe leukopenia; may increase levels of MTX metabolites and decrease effects of anticoagulants, neuromuscular blockers, and cyclosporine
Documented hypersensitivity; thiopurine methyltransferase deficiency; severe bone marrow suppression; severe liver abnormalities
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Adverse effects include teratogenicity, hepatitis, bone marrow suppression, and increased risk of cancer; perform urine analysis, CBC count, and renal and liver function tests and determine serum electrolyte levels before initiating therapy and regularly thereafter; increases risk of neoplasia; caution in liver disease and renal impairment; hematologic toxicities may occur; check serum thiopurine methyltransferase levels prior to therapy
Methotrexate (Folex PFS, Rheumatrex)
Indicated for the symptomatic control of severe, recalcitrant, disabling psoriasis, and severe reactive arthritis. Also used alone or in combination with other anticancer agents in the treatment of advanced mycosis fungoides and cancer of the head, neck, or lung, particularly those of the squamous cell and small cell types.
Adult
7.5 mg as single dose PO qwk or 3 doses of 2.5 mg at 12-h intervals qwk; doses may be adjusted gradually to achieve optimal response, but not ordinarily to exceed a total weekly dose of 20 mg
Pediatric
Not established
Oral aminoglycosides may decrease absorption and blood levels of concurrent oral MTX; charcoal lowers MTX levels; coadministration with etretinate may increase hepatotoxicity; folic acid or its derivatives contained in some vitamins may decrease response to MTX; probenecid, NSAIDs, salicylates, procarbazine, and sulfonamides, including TMP-SMZ, can increase plasma levels; may decrease phenytoin plasma levels; may increase plasma levels of thiopurines
Documented hypersensitivity; alcoholism; hepatic insufficiency; documented immunodeficiency syndromes; preexisting blood dyscrasias (eg, bone marrow hypoplasia, leukopenia, thrombocytopenia, significant anemia); renal insufficiency
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Monitor CBC counts monthly and liver and renal function q1-3mo during therapy (monitor more frequently during initial dosing, dose adjustments, or when risk of elevated MTX levels, eg, dehydration); has toxic effects on hematologic, renal, GI, pulmonary, and neurologic systems; discontinue if significant drop in blood counts occur; fatal reactions reported when administered concurrently with NSAIDs
Antimalarials
Derivatives of 4-aminoquinoline are active against a variety of autoimmune disorders. Use with caution because hydroxychloroquine has a known risk of exacerbating psoriasis. These agents should probably be used only in conjunction with rheumatologic evaluation because it is used for the arthritis and not the skin involvement.
Hydroxychloroquine (Plaquenil)
Inhibits chemotaxis of eosinophils, locomotion of neutrophils, and impairs complement-dependent antigen-antibody reactions. Hydroxychloroquine sulfate 200 mg is equivalent to 155 mg hydroxychloroquine base and 250 mg chloroquine phosphate
Adult
200 mg PO qd/bid
Pediatric
Not established
Serum levels increase with cimetidine; magnesium trisilicate may decrease absorption
Documented hypersensitivity to 4-aminoquinoline derivatives; psoriasis; retinal and visual field changes attributable to 4-aminoquinolines
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in liver disease or alcoholism and other drugs known to be hepatotoxic; beware of retinopathy and corneal deposits producing blindness; discontinue medication and reevaluate if any eye changes occur after full ophthalmologic examination including slit lamp, funduscopic and visual acuity, and visual field tests, severe exacerbation of psoriasis is reported
Retinoids
Retinoids decrease the cohesiveness of abnormal hyperproliferative keratinocytes and may reduce the potential for malignant degeneration. They also modulate keratinocyte differentiation.
Isotretinoin (Accutane)
Oral agent used to treat serious dermatologic conditions. Synthetic 13-cis isomer of the naturally occurring tretinoin (trans -retinoic acid). Both agents are structurally related to vitamin A. Alters pattern of keratinization, reduces bacterial flora, and has an anti-inflammatory effect.
A US Food and Drug Administration–mandated registry is now in place for all individuals prescribing, dispensing, or taking isotretinoin. For more information on this registry, see iPLEDGE. This registry aims to further decrease the risk of pregnancy and other unwanted and potentially dangerous adverse effects during a course of isotretinoin therapy.
Adult
0.5-1 mg/kg/d PO
Pediatric
Administer as in adults
Toxicity may occur with vitamin A coadministration; pseudotumor cerebri or papilledema may occur when coadministered with tetracyclines; may reduce plasma levels of carbamazepine; microdosed progesterone tablets may be inadequate contraception
Documented hypersensitivity; young children (because of skeletal symptoms); pregnant women or women of childbearing age (unless contraception is accurate), renal or hepatic failure, hypertriglyceridemia, and elevated cholesterol level
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
May decrease night vision; inflammatory bowel disease association with hepatitis, occasional exaggerated healing response of acne lesions (excessive granulation with crusting), and problems with contact lenses may occur; problems in controlling blood sugar in diabetes possible; avoid exposure to UV light or sunlight until tolerance achieved; discontinue treatment if rectal bleeding, abdominal pain, or severe diarrhea occurs; women of childbearing age must simultaneously use 2 effective forms of contraception and sign consent form 1 mo before, during, and after therapy; patients should not donate blood during or 1 mo afterward; patients should avoid skin resurfacing procedures and waxing during therapy and 6 mo afterward; patients should avoid UV or sunlight exposure; may cause depression, psychosis, or even suicidal attempts; musculoskeletal symptoms including skeletal hyperostosis and premature epiphyseal closure reported with prolonged use of high doses (2.24 mg/kg/d), especially in children
Other adverse effects include cheilitis; dry mouth, nose, and skin; epistaxis; flushing; fragility of skin; bruising; pruritus; nail dystrophy; alopecia; pyogenic granuloma; rash; abnormal wound healing; allergic reactions fatigue; dizziness; drowsiness; headaches; malaise; arthralgia; anaphylactic reactions and other allergic reactions; allergic vasculitis; pseudotumor cerebri; calcification of tendons and ligaments; pancreatitis; corneal opacities and decreased night vision; hearing impairment; hypertriglyceridemia; elevation of serum cholesterol levels; alterations in blood sugar levels; anemia; thrombocytopenia; neutropenia; agranulocytosis; elevated CPK levels; hyperuricemia; increased alkaline phosphatase, SGOT, and SGPT levels
Acitretin (Soriatane)
Retinoic acid analog, similar to etretinate and isotretinoin. Etretinate is the main metabolite and has clinical effects similar to those of etretinate. Its mechanism of action is unknown.
Adult
25-50 mg/d PO given as single dose with main meal; terminate therapy when lesions have resolved
Pediatric
Not established
Increases toxicity of MTX (avoid concomitant use); interferes with effects of microdosed progestin minipill; coadministration with alcohol may enhance synthesis of etretinate, which has a much longer half-life (>120 d)
Documented hypersensitivity
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Do not use in severe obesity; women of childbearing age must be capable of complying with effective contraceptive measures; contraception should be continued for at least 3 y after treatment is stopped; etretinate may form from acitretin, which takes about 2-3 y to clear from the body; caution in impaired renal or liver function; perform AST, ALT and LDH tests prior to therapy at 1- to 2-wk intervals until levels are stable and thereafter at intervals as clinically indicated
More on Reactive Arthritis |
| Overview: Reactive Arthritis |
| Differential Diagnoses & Workup: Reactive Arthritis |
 Treatment & Medication: Reactive Arthritis |
| Follow-up: Reactive Arthritis |
| Multimedia: Reactive Arthritis |
| References |
| « Previous Page | Next Page » |
References
Wu IB, Schwartz RA. Reiter's syndrome: the classic triad and more. J Am Acad Dermatol. Jul 2008;59(1):113-21. [Medline].
Fiessinger N, Leroy E. Contribution a l etude d'une epidemie de dysenterie dans la somme. Bull Soc Med Hop. 1916;40:2030-2069.
Reiter H. Spirochateninfektion (Spirochaetosis arthritica). Deutsche Medizinische Wochenschrift. 1916;42:1535-6.
Bauer W, Engelman EP. A syndrome of unknown etiology characterized by urethritis, conjunctivitis, and arthritis (so-called Reiter's disease). Trans Assoc Am Physicians. 1942;57:307-313.
Panush RS, Wallace DJ, Dorff RE, Engleman EP. Retraction of the suggestion to use the term "Reiter's syndrome" sixty-five years later: the legacy of Reiter, a war criminal, should not be eponymic honor but rather condemnation. Arthritis Rheum. Feb 2007;56(2):693-4. [Medline].
Wallace DJ, Weismann M. Should a war criminal be rewarded with eponymous distinction?. J Clin Rheumatol. 2000;6:49-54.
Weyers W. The fame and infamy of Hans Reiter. Dermatopathol Pract Concept. 2000;6:340-343.
Ackerman AB. Reiter syndrome and Hans Reiter: Neither legitimate!. J Am Acad Dermatol. Mar 2009;60(3):517-8; author reply 518. [Medline].
Mahmood A, Ackerman AB. Reiter's syndrome is psoriasis!. Dermatopathol Pract Concept. 2000;6:337-339.
Kousa M, Saikku P, Richmond S, Lassus A. Frequent association of chlamydial infection with Reiter's syndrome. Sex Transm Dis. Apr-Jun 1978;5(2):57-61. [Medline].
Berlau J, Junker U, Groh A, Straube E. In situ hybridisation and direct fluorescence antibodies for the detection of Chlamydia trachomatis in synovial tissue from patients with reactive arthritis. J Clin Pathol. Nov 1998;51(11):803-6. [Medline].
Russell AL. Glycoaminoglycan (GAG) deficiency in protective barrier as an underlying, primary cause of ulcerative colitis, Crohn's disease interstitial cystitis and possibly Reiter's syndrome. Med Hypotheses. Apr 1999;52(4):297-301. [Medline].
Savolainen E, Kettunen A, Narvanen A, et al. Prevalence of antibodies against Chlamydia trachomatis and incidence of C. trachomatis-induced reactive arthritis in an early arthritis series in Finland in 2000. Scand J Rheumatol. Mar 18 2009;1-4. [Medline].
Townes JM, Deodhar AA, Laine ES, et al. Reactive arthritis following culture-confirmed infections with bacterial enteric pathogens in Minnesota and Oregon: a population-based study. Ann Rheum Dis. Dec 2008;67(12):1689-96. [Medline].
Arora S, Arora G. Reiter's disease in a six-year-old girl. Indian J Dermatol Venereol Leprol. Jul-Aug 2005;71(4):285-6. [Medline].
Satko SG, Iskandar SS, Appel RG. IgA nephropathy and Reiter's syndrome. Report of two cases and review of the literature. Nephron. Feb 2000;84(2):177-82. [Medline].
Lin RY. Reiter's syndrome and human immunodeficiency virus infection. Dermatologica. 1988;176(1):39-42. [Medline].
Romaní J, Puig L, Baselga E, De Moragas JM. Reiter's syndrome-like pattern in AIDS-associated psoriasiform dermatitis. Int J Dermatol. Jul 1996;35(7):484-8. [Medline].
Thielen AM, Barde C, Janer V, Borradori L, Saurat JH. Reiter syndrome triggered by adalimumab (Humira) and leflunomide (Arava) in a patient with ankylosing spondylarthropathy and Crohn disease. Br J Dermatol. Jan 2007;156(1):188-9. [Medline].
Siala M, Gdoura R, Younes M, et al. Detection and frequency of Chlamydia trachomatis DNA in synovial samples from Tunisian patients with reactive arthritis and undifferentiated oligoarthritis. FEMS Immunol Med Microbiol. Mar 2009;55(2):178-86. [Medline].
Shimamoto Y, Sugiyama H, Hirohata S. Reiter's syndrome associated with HLA-B51. Intern Med. Feb 2000;39(2):182-4. [Medline].
[Guideline] U.S. Preventive Services Task Force. Screening for chlamydial infection: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. Jul 17 2007;147(2):128-34. [Medline].
Kim SH, Chung SK, Bahk YW, Park YH, Lee SY, Sohn HS. Whole-body and pinhole bone scintigraphic manifestations of Reiter's syndrome: distribution patterns and early and characteristic signs. Eur J Nucl Med. Feb 1999;26(2):163-70. [Medline].
Kiss S, Letko E, Qamruddin S, Baltatzis S, Foster CS. Long-term progression, prognosis, and treatment of patients with recurrent ocular manifestations of Reiter's syndrome. Ophthalmology. Sep 2003;110(9):1764-9. [Medline].
Amor B. Reiter's syndrome. Diagnosis and clinical features. Rheum Dis Clin North Am. Nov 1998;24(4):677-95, vii. [Medline].
Barth WF, Segal K. Reactive arthritis (Reiter's syndrome). Am Fam Physician. Aug 1999;60(2):499-503, 507. [Medline].
Carter JD, Gerard HC, Hudson AP. Psoriasiform lesions induced by tumour necrosis factor antagonists: a skin-deep medical conundrum. Ann Rheum Dis. Aug 2008;67(8):1181-3. [Medline].
Goyal NN, Dhurat RS, Jerajani HR. Carbamazepine in Reiter's syndrome. Sex Transm Infect. Jun 2000;76(3):220. [Medline].
Kim YA, Bagley MP, Thomas I. Incomplete Reiter's syndrome in a black patient showing HLA B 27. Cutis. Apr 1991;47(4):253-4. [Medline].
Reiter H. Vorschlage zur Neugestaltung des Hygieneunterrichts und zur Sicherung des Nachwuchses auf dem Gebiet der Hygiene. Munch Med Wschr. 1938;85:16-19.
Zivony D, Nocton J, Wortmann D, Esterly N. Juvenile Reiter's syndrome: a report of four cases. J Am Acad Dermatol. Jan 1998;38(1):32-7. [Medline].
Further Reading
Keywords
RS, Reiter disease, Reiter syndrome, Reiter's syndrome, Fiessinger-Leroy-Reiter syndrome, Fiessinger-Leroy syndrome, arthritis urethritica, blennorrheal idiopathic arthritis, reactive arthritis, conjunctivo-urethro-synovial syndrome, polyarthritis enterica, keratoderma blenorrhagica, urethritis
