eMedicine Specialties > Rheumatology > Spondyloarthropathies
Reactive Arthritis: Treatment & Medication
Updated: Jan 5, 2010
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
The treatment of reactive arthritis is depends on the severity of symptoms.
- Nonsteroidal anti-inflammatory drugs
- NSAIDs are the foundation of therapy. These agents should be used regularly to achieve a good anti-inflammatory effect.
- The choice of a specific agent depends on the individual response to treatment, although the general impression is that indomethacin has greater potency.
- Physical therapy needs to be implemented to help reduce pain and to avoid muscle wasting in severe cases of reactive arthritis.
- Corticosteroids
- These agents can be used as either intra-articular injection or systemic therapy.
- 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.21
- Systemic corticosteroids can be used, particularly in patients in whom NSAIDs elicit a poor response 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
- 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 guidelines for reactive arthritis are lacking. However, in chlamydia-induced reactive arthritis, studies have suggested that the 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.
- Lymecycline was studied in a double-blind placebo-controlled study of patients with chronic reactive arthritis for a treatment period of 3 months.4 The duration of illness was significantly decreased in patients with chlamydia-induced disease, as opposed to those with disease triggered by enteric infections.
- Azithromycin was shown to be ineffective in a placebo-controlled trial.22 Nevertheless, in a recent abstract presentation, azithromycin or doxycycline in combination with rifampin for 6 months was reported to be significantly superior to placebo and significantly improved symptoms associated with chlamydia–induced reactive arthritis.23
- Quinolones have been studied because of their broad coverage, but no clear benefit has been reported.24
- More studies are needed before definite recommendations can be made for the role of antibiotics in the management of reactive arthritis.
- Disease-modifying antirheumatic drugs
- 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.
- Sulfasalazine may 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 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).25
- Methotrexate can be used in patients who present with rheumatoidlike disease. 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.26,27 Patients with reactive arthritis and HIV/AIDS should not receive methotrexate or other immunosuppressive agents.
- 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. Case reports using the chimeric monoclonal antibody infliximab have shown potential efficacy in symptom relief in patients in whom other therapies failed.28,29,30
Surgical Care
No surgical treatment of reactive arthritis is recommended.
Consultations
A rheumatologist should be consulted for confirmation of diagnosis and formulation of management plan. Consultation with a urologist may be necessary if particularly prominent genitourinary manifestations develop. An ophthalmologist may be consulted to confirm the diagnosis and to treat the ophthalmologic manifestations of reactive arthritis.
Activity
Physical therapy may be instituted to avoid muscle wasting and to reduce pain. Activities should otherwise be as tolerated by the patient.
Medication
The goals of pharmacotherapy are to reduce morbidity, to prevent joint damage, and to alleviate extra-articular disease.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Several NSAIDs are available and have similar effectiveness, although indomethacin may be more effective in the spondyloarthropathies. These agents are used to treat symptoms. Cyclooxygenase-2 (COX-2)–specific inhibitors can be used in patients at high risk for GI complications.
Ibuprofen (Motrin, Advil)
Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
400-600 mg PO qid or 800 mg PO tid
Pediatric
Not established
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; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in CHF, hypertension, and in PT with decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Indomethacin (Indocin, Indochron E-R)
Rapidly absorbed. Metabolism occurs in liver by demethylation, deacetylation, and glucuronide conjugation. Inhibits prostaglandin synthesis.
Adult
25-50 mg PO bid/tid
75 mg SR PO bid; not to exceed 200 mg/d
Pediatric
1-2 mg/kg/d PO divided bid/qid; not to exceed 4 mg/kg/d or 150-200 mg/d
Coadministration with aspirin increases risk of inducing serious NSAID-related side 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 taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; GI bleeding; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with pre-existing renal disease or compromised renal perfusion; reversible leukopenia may occur (discontinue if persistent leukopenia, granulocytopenia, or thrombocytopenia occurs)
Tetracyclines
These agents are used to treat urethritis or cervicitis caused by chlamydial organisms. Some evidence shows that, in chlamydia-induced Reiter syndrome, tetracycline treatment may reduce duration and perhaps severity of illness. Collagenase inhibitors have been used to treat early rheumatoid arthritis.
Doxycycline (Bio-Tab, Vibramycin)
Inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Adult
Urethritis or cervicitis: 100 mg PO bid 7d
Decrease severity: 100 mg PO bid for 8-12 wk
Pediatric
Not established
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of PO contraceptives, causing breakthrough bleeding and increased 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 (ie, <8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracycline
Corticosteroids
These agents have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.
Prednisone (Sterapred)
May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity.
Adult
0.5 mg/kg/d PO initially, taper according to response
Pediatric
Not established
Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Documented hypersensitivity; viral infection; peptic ulcer disease; hepatic dysfunction; connective tissue infections; fungal or tubercular skin infections; GI disease
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia; edema; osteonecrosis; myopathy; peptic ulcer disease; hypokalemia; osteoporosis; euphoria; psychosis; myasthenia gravis; growth suppression; infections may occur with glucocorticoid use
Aminosalicylic acid derivatives
These agents are used to reduce inflammation.
Sulfasalazine (Azulfidine, EN-tabs)
Acts locally in colon to decrease the inflammatory response and systemically inhibits prostaglandin synthesis.
Adult
500 mg PO bid initially; 1000 mg PO bid
Pediatric
Not established
Decreases effects of iron, digoxin, and folic acid; conversely, increases effect of PO anticoagulants, PO hypoglycemic agents, and methotrexate
Documented hypersensitivity; hypersensitivity to sulfa drugs or any component; GI or GU obstruction
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in patients with renal or hepatic impairment, blood dyscrasias, or urinary obstruction
More on Reactive Arthritis |
| Overview: Reactive Arthritis |
| Differential Diagnoses & Workup: Reactive Arthritis |
 Treatment & Medication: Reactive Arthritis |
| Follow-up: Reactive Arthritis |
| References |
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Further Reading
Keywords
reactive arthritis, Reiter syndrome, Reiter's syndrome, RS, ReA, nongonococcal urethritis, conjunctivitis, oculo-urethro-synovial syndrome, Chlamydia reactive arthritis, chlamydial reactive arthritis , Shigella dysentery, gastrointestinal infections, Salmonella, Campylobacter, Chlamydia trachomatis, C trachomatis, Yersinia, ankylosing spondylitis, psoriatic arthritis, seronegative spondyloarthropathy, infectious diarrhea, genitourinary infection
