Reactive Arthritis in Emergency Medicine Medication

  • Author: Nima Sarani, MD; Chief Editor: Robert E O'Connor, MD, MPH   more...
 
Updated: May 21, 2012
 

Medication Summary

Mainstays of therapy for joint symptoms are nonsteroidal anti-inflammatory drugs (NSAIDs). Etretinate/acitretin may been shown to decrease the required dosage of NSAIDs.[24]

Sulfasalazine or methotrexate may be used for patients who do not experience relief with NSAIDs after 1 month or who have contraindications to NSAIDs. In addition, sulfasalazine-resistant reactive arthritis could be successfully treated with methotrexate.[42]

Case reports exist that demonstrate the effectiveness of anti-TNF medications,[26, 43] such as etanercept and infliximab. TNF-alpha concentrations are high in the serum and joints of patients with persistent reactive arthritis, and therefore this cytokine could be targeted in patients who do not respond to NSAIDS and DMARDs. Anti-TNF alpha therapy has been demonstrated to be effective treatment for reactive arthritis, with a corticosteroid-sparing effect.[44] TNF-alpha antagonists, however, can increase the risk of serious infection and it is important to conduct infectious screening and monitoring with a high index of suspicion, as well as preemptive treatment, when such medications are used.[45] They can also be associated with severe glomerulonephritis, and it is recommended that renal function be closely monitored in patients treated with anti-TNF medications.[46]

IL-6 plays an important role in regulating immune response. Unregulated overproduction of IL-6, however, is pathologically involved in various immune-mediated inflammatory diseases, including reactive arthritis. In has recently been shown that tocilizumab, a humanized anti–IL-6 receptor antibody, can have clinical benefit in patients who are refractory to conventional therapy or anti-TNF therapy. However, further clinical studies regarding safety and efficacy are required.[47]

No published data are available on the effectiveness of selective COX-2 inhibitors; however, COX-2 inhibitors may be tried in patients who do not tolerate NSAIDs and in whom no preexisting contraindication to COX-2 use exists.

Extra-articular manifestations are treated individually. Second-line therapies for reactive arthritis, such as systemic or intra-articular steroids or cyclosporine, are left to the discretion of the consulting rheumatologist or dermatologist. Antibiotic treatment is indicated for cervicitis or urethritis but not generally for postdysenteric cases. In Chlamydia -induced reactive arthritis, recent data suggest prolonged combination antibiotics could be an effective treatment strategy.[28]

Circinate balanitis can be recurrent and create a therapeutic challenge. Balanitis refractory to conventional therapy can be successfully treated with complementary use of topical 0.1 % tacrolimus.[48]

Cytotoxic therapy, such as methotrexate, azathioprine, and infliximab is reserved for severe cases and should not be started in the ED. HIV and TB testing must be completed first.

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Nonsteroidal anti-inflammatory drugs (NSAIDs)

Class Summary

Although most NSAIDs are used primarily for their anti-inflammatory effects, they are effective analgesics and are useful for relief of mild to moderate pain. To relieve joint symptomatology, a month's treatment at maximum dose is needed before full effectiveness can be evaluated.

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Indomethacin (Indocin)

 

DOC; however, other nonsteroidal drugs often are effective. Rapidly absorbed and metabolism occurs in the liver by demethylation, deacetylation, and glucuronide conjugation.

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Topical corticosteroids

Class Summary

These agents are used for dermatologic manifestations, such as keratoderma blennorrhagica and circinate balanitis.

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Hydrocortisone valerate (Cortaid, Dermacort, Westcort)

 

Topical corticosteroids are adrenocorticosteroid derivatives suitable for application to skin or external mucous membranes and have mineralocorticoid and glucocorticoid effects, resulting in a nonspecific anti-inflammatory activity.

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Antibiotics

Class Summary

Empiric antimicrobial should cover all likely pathogens in the context of the clinical setting.

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Erythromycin ophthalmic (EryPed)

 

Indicated for treatment of infections caused by susceptible strains of microorganisms and for prevention of corneal and conjunctival infections.

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Doxycycline (Doryx, Vibramycin, Vibra-Tabs)

 

Interferes with bacterial cell wall synthesis during active multiplication, causing cell wall death and resultant bactericidal activity against susceptible bacteria.

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Ciprofloxacin (Cipro)

 

DOC for improvement in clinical parameters, except joint involvement, in enterogenic reactive arthritis. Ciprofloxacin is a bactericidal antibiotic that inhibits bacterial DNA synthesis and, consequently, growth by inhibiting DNA-gyrase in susceptible organisms.

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Anti-inflammatory agents

Class Summary

These agents are used when NSAIDs do not control arthritis and for inflammatory lesions of intestinal mucosa.

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Sulfasalazine (Azulfidine)

 

Useful in management of ulcerative colitis and acts locally in colon to decrease inflammatory response and systemically inhibits prostaglandin synthesis.

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Contributor Information and Disclosures
Author

Nima Sarani, MD  Resident Physician, Department of Emergency Medicine, Oklahoma University College of Medicine

Nima Sarani, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physicians, and Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Bo Burns, DO, FACEP, FAAEM  Assistant Professor, Associate Residency Director, Medical Clerkship Director, Department of Emergency Medicine, University of Oklahoma School of Community Medicine; Attending Physician, Department of Emergency Medicine

Bo Burns, DO, FACEP, FAAEM, is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Dana A Stearns, MD  Assistant Director of Undergraduate Education, Department of Emergency Medicine, Massachusetts General Hospital; Assistant Professor of Surgery, Harvard Medical School

Dana A Stearns, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Gino A Farina, MD, FACEP, FAAEM  Associate Professor of Clinical Emergency Medicine, Albert Einstein College of Medicine; Program Director, Department of Emergency Medicine, Long Island Jewish Medical Center

Gino A Farina, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH  Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, Thomas Scoggins, MD, and Igor Boyarsky, DO, to the development and writing of this article.

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Circinate balanitis in a patient with reactive arthritis.
Plaques on the soles of a patient with reactive arthritis.
Painful erosions on the fingers in a patient with reactive arthritis.
Plaques and erosions of the tongue in a patient with reactive arthritis.
Radiograph of the feet in a 27-year-old man shows erosions in all the left metatarsophalangeal (MTP) joints with subluxation and valgus deformity of most of the toes. Smaller erosions in the four and fifth MTP joints of the right foot are also shown.
Lateral radiograph of the foot (same patient as in the photo above) reveals a calcaneal spur and enthesitis.
Radiograph of both hands shows small erosive changes in both first metacarpal heads associated with minimal subluxation. Bone density is normal.
Radiography of the pelvis reveals bilateral asymmetric sacroiliitis.
Image in 40-year-old man with nonmarginal syndesmophytes predominantly in the lower thoracic and upper lumbar spine.
 
 
 
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