eMedicine Specialties > Emergency Medicine > Rheumatology
Reactive Arthritis: Treatment & Medication
Updated: Jun 18, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Emergency Department Care
- Treatment based on symptoms
- Physical therapy during recovery phase
Consultations
- Consult a rheumatologist to discuss appropriate additional tests and medications for symptomatic relief or microbiologic cure and to ensure follow-up treatment.
- Consider an infectious disease (ID) consultation for consideration of empiric antibiotic therapy as well as for patients with coincident manifestations of coincident AIDS-defining illnesses.
Medication
Mainstays of therapy for joint symptoms are nonsteroidal anti-inflammatory drugs (NSAIDs).
Sulfasalazine may be used for patients who do not experience relief with NSAIDs or who have contraindications to NSAIDs.
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.
Extra-articular manifestations are treated individually. Second-line therapies for reactive arthritis, such as systemic or intra-articular steroids, are left to the discretion of the consulting rheumatologist. Antibiotic treatment is indicated for cervicitis or urethritis but not generally for postdysenteric cases.
Cytotoxic therapy, such as methotrexate or azathioprine, is reserved for severe cases and should not be started in the ED. HIV testing must be completed first.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
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.
Indomethacin (Indocin)
DOC; however, other nonsteroidal drugs often are effective. Rapidly absorbed and metabolism occurs in the liver by demethylation, deacetylation, and glucuronide conjugation.
Adult
25 mg PO qid; increase to 50 mg qid prn
Pediatric
1-2 mg/kg/d PO, divided bid/qid; not to exceed 4 mg/kg/d or 150-200 mg/d
Probenecid may increase concentrations and possibly toxicity of NSAIDs; indomethacin may decrease effect of beta-blockers, hydralazine, and captopril; also may decrease diuretic effects of furosemide and thiazides; may prolong PT when coadministered with anticoagulants; monitor PT closely and instruct patients to watch for signs and symptoms of bleeding; indomethacin may increase serum lithium levels and risks of methotrexate toxicity, such as stomatitis, bone marrow suppression, and nephrotoxicity
Documented hypersensitivity (because of potential cross-sensitivity to other NSAIDs, do not give these agents to patients whom aspirin, iodides, or other NSAIDs induce hypersensitivity); GI bleed; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; low WBC counts occur rarely, are transient, and usually return to normal while therapy continues; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuing the drug
Topical corticosteroids
These agents are used for dermatologic manifestations, such as keratoderma blennorrhagica and circinate balanitis.
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.
Adult
Apply sparingly to affected areas bid/qid
Pediatric
Apply as in adults
None reported
Documented hypersensitivity; avoid as monotherapy in primary bacterial infections such as cellulitis, angular cheilitis, impetigo, erysipelas, erythrasma (clobetasol), paronychia, or treatment of rosacea, perioral dermatitis, or acne; do not use on face, groin, or axilla
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
Systemic absorption of topical corticosteroids may cause reversible HPA-axis suppression, Cushing syndrome, hyperglycemia, and glycosuria; conditions that augment systemic absorption include application of potent steroids, prolonged use, use over large surface areas, and addition of occlusive dressings
Antibiotics
Empiric antimicrobial should cover all likely pathogens in the context of the clinical setting.
Erythromycin ophthalmic ointment (EryPed)
Indicated for treatment of infections caused by susceptible strains of microorganisms and for prevention of corneal and conjunctival infections.
Adult
Apply 1-cm ribbon under lid; not to exceed q4h
Pediatric
Apply as in adults
None reported
Documented hypersensitivity; epithelial herpes simplex keratitis, fungal and mycobacterial infections of the eye, and patients using steroid combinations after uncomplicated removal of a corneal foreign body
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Do not use topical antibiotics in ocular infections that are likely to become systemic; prolonged or repeated antibiotic therapy may result in bacterial or fungal overgrowth of nonsusceptible organisms; such overgrowth may lead to a secondary infection; take appropriate measures if superinfection occurs
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.
Adult
100 mg PO bid for 3 mo
Pediatric
<8 years: Not recommended
>8 years: 2-5 mg/kg/d PO once or divided bid; not to exceed 200 mg/d
Antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate may decrease doxycycline bioavailability; tetracyclines may increase the hypoprothrombinemic effects of anticoagulants; prothrombin activity should be monitored in patients taking both of these types of medications concurrently; coadministration of tetracyclines may decrease pharmacologic effects of oral 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
Avoid prolonged exposure to sunlight or tanning equipment because a photosensitivity reaction may occur; use lower than usual doses in patients with renal impairment;
if therapy is prolonged, drug serum level determinations may be advisable; use of tetracyclines during tooth development (last one half of pregnancy through 8 y) may cause permanent discoloration of teeth; never administer outdated tetracyclines; degradation products of tetracyclines are highly nephrotoxic and have, on occasion, produced a Fanconilike syndrome
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.
Adult
250-500 mg PO bid
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids, iron salts, and zinc salts may interfere with GI absorption of fluoroquinolones, resulting in decreased serum levels (administer antacids 2-4 h before or after taking fluoroquinolones)
Cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin may reduce therapeutic effects of phenytoin; probenecid may reduce ciprofloxacin renal clearance by 50% and increase serum concentration by 50%; ciprofloxacin may increase theophylline and caffeine concentrations and prolong their duration of action; ciprofloxacin may increase nephrotoxic effect of cyclosporine; digoxin serum levels may be increased when used concurrently with ciprofloxacin; digoxin levels should be monitored; ciprofloxacin may increase effects of anticoagulants; prothrombin time should be monitored
Documented hypersensitivity
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
In prolonged therapy, perform periodic evaluations of organ system functions, including renal, hepatic, and hematopoietic; patients with renal function impairment may require a dose adjustment; prolonged or repeated antibiotic therapy may result in bacterial or fungal overgrowth of nonsusceptible organisms; such overgrowth may lead to a secondary infection; take appropriate measures if superinfection occurs
Anti-inflammatory agents
These agents are used when NSAIDs do not control arthritis and for inflammatory lesions of intestinal mucosa.
Sulfasalazine (Azulfidine)
Useful in management of ulcerative colitis and acts locally in colon to decrease inflammatory response and systemically inhibits prostaglandin synthesis.
Adult
1000 mg enteric-coated PO bid
Pediatric
<2 years: Not established
>2 years: 40-60 mg/kg/d PO in 3-6 divided doses; follow with a maintenance dose of 20-30 mg/kg/d divided qid
Sulfasalazine decreases effect of iron, digoxin, and folic acid, and, conversely, increases effect of oral anticoagulants, oral hypoglycemic agents, and methotrexate
Documented hypersensitivity; GI or GU obstruction
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Use 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 |
| Further Reading |
| « Previous Page | Next Page » |
References
Lu DW, Katz KA. Declining use of the eponym "Reiter's syndrome" in the medical literature, 1998-2003. J Am Acad Dermatol. Oct 2005;53(4):720-3. [Medline].
Kataria RK, Brent LH. Spondyloarthropathies. Am Fam Physician. Jun 15 2004;69(12):2853-60. [Medline].
Kaarela K, Jantti JK, Kotaniemi KM. Similarity between chronic reactive arthritis and ankylosing spondylitis.A 32-35-year follow-up study. Clin Exp Rheumatol. Mar-Apr 2009;27(2):325-8. [Medline].
Rihl M, Barthel C, Klos A, Schmidt RE, Tak PP, Zeidler H, et al. Identification of candidate genes for susceptibility to reactive arthritis. Rheumatol Int. Jun 9 2009;[Medline].
Dworkin MS, Shoemaker PC, Goldoft MJ, Kobayashi JM. Reactive arthritis and Reiter's syndrome following an outbreak of gastroenteritis caused by Salmonella enteritidis. Clin Infect Dis. Oct 1 2001;33(7):1010-4. [Medline].
Connor BA, Johnson EJ, Soave R. Reiter syndrome following protracted symptoms of Cyclospora infection. Emerg Infect Dis. May-Jun 2001;7(3):453-4. [Medline].
Amor B. Reiter's syndrome. Diagnosis and clinical features. Rheum Dis Clin North Am. Nov 1998;24(4):677-95, vii. [Medline].
Bauman C, Cron RQ, Sherry DD, Francis JS. Reiter syndrome initially misdiagnosed as Kawasaki disease. J Pediatr. Mar 1996;128(3):366-9. [Medline].
Cuttica RJ, Scheines EJ, Garay SM, Romanelli MC, Maldonado Cocco JA. Juvenile onset Reiter's syndrome. A retrospective study of 26 patients. Clin Exp Rheumatol. May-Jun 1992;10(3):285-8. [Medline].
Fan PT, Yu DTY. Reiters syndrome. In: Ruddy S, Harris ED Jr, Sledge CB, eds. Kelley's Textbook of Rheumatology. 6th ed. WB Saunders; 2001:1039-1067.
Hoogland YT, Alexander EP, Patterson RH, Nashel DJ. Coronary artery stenosis in Reiter's syndrome: a complication of aortitis. J Rheumatol. Apr 1994;21(4):757-9. [Medline].
Hughes RA, Keat AC. Reiter's syndrome and reactive arthritis: a current view. Semin Arthritis Rheum. Dec 1994;24(3):190-210. [Medline].
Kasper DL, ed. Reactive arthritis. In: Harrison's Online. Part 13. Section 2. Chap 305. McGraw Hill;2004.
Natarajan UR, Tan TL, Lau R. Reiter's disease following Mycoplasma pneumoniae infection. Int J STD AIDS. May 2001;12(5):349-50. [Medline].
Petersel DL, Sigal LH. Reactive arthritis. Infect Dis Clin North Am. Dec 2005;19(4):863-83. [Medline].
Rihl M, Klos A, Kohler L, Kuipers JG. Infection and musculoskeletal conditions: Reactive arthritis. Best Pract Res Clin Rheumatol. Dec 2006;20(6):1119-37. [Medline].
Further Reading
Clinical guidelines
Chlamydial urethritis and cervicitis.
Finnish Medical Society Duodecim - Professional Association. 2001 Jun 5 (revised 2006 Jun 3). Various pagings. NGC:005276
Diagnostic imaging guideline for musculoskeletal complaints in adults - an evidence-based approach. Part 2: upper extremity disorders.
Canadian Protective Chiropractic Association - Professional Association l'Université du Québec à Trois-Rivières - Academic Institution. 2008 Jan. 31 pages. NGC:006702
Clinical trials
New Immunomodulatory Therapy Strategies in Chronic Reactive Arthritis
Lovastatin for the Treatment of Mildly Active Rheumatoid Arthritis
Related eMedicine topics
Reactive Arthritis (Dermatology)
Reactive Arthritis (Rheumatology)
Reactive Arthritis, Musculoskeletal (Radiology)
Reactive Arthritis (Ophthalmology)
Ankylosing Spondylitis and Undifferentiated Spondyloarthropathy (Rheumatology)
Keywords
Reiter's syndrome, Reiter syndrome, reactive arthritis, ReA, peripheral arthritis, arthritis, nongonococcal urethritis, conjunctivitis, seronegative spondyloarthropathies, rheumatic disease, urogenital infections, chronic arthritis, Shigella flexneri, Salmonella typhimurium, Salmonella enteritidis, Streptococcus viridans, Mycoplasma pneumonia, Cyclospora, Chlamydia trachomatis, Yersinia enterocolitica, Yersinia pseudotuberculosis
