Management of acute reactive arthritis

Kwiatkowska, 2009

Although reactive arthritis typically presents after an infection has resolved, active infection or asymptomatic infection may still be present at the time of the arthritis diagnosis. Further investigation may be required to distinguish persistent infection from the inflammatory manifestations of reactive arthritis (eg urethritis). Treat active infection as indicated. If an asymptomatic sexually transmitted infection is suspected, see Principles of sexually transmitted infection management for advice.

Many people will require referral to a specialist for management, as they often have florid inflammation and may be disabled. Mild cases with no functional or employment impact can often be managed in primary care.

The treatment of acute reactive arthritis (duration of less than 6 months) depends on the extent and severity of joint involvement, and the nature of any extra-articular involvement.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective at treating mild to moderate peripheral arthritis and spondylitis. All of the NSAIDs listed below are equally effective and drug choice should be based on patient factors (eg comorbidities); see Choosing an NSAID for advice on drug choice. For acute reactive arthritis, use:

People who suffer from pain throughout the night and stiffness in the morning may find a rectal NSAID improves their sleep quality. If a rectal NSAID is preferred, use:

The potential benefits of an NSAID should be weighed against its potential harms, particularly in people at high risk of harms (see Principles of NSAID use for musculoskeletal pain for more information).

Intra-articular corticosteroid injections may be effective for severe peripheral arthritis if a small number of accessible joints are involved. Peritendinous corticosteroid injections may be beneficial for enthesitis. They should be used with caution in enthesitis involving major weightbearing tendons such as the Achilles tendons; consider seeking specialist advice and avoid multiple injections. For principles of use and example doses of local corticosteroid injections, see Principles of local corticosteroid injection use for musculoskeletal pain.

Oral corticosteroids may be required for severe articular and extra-articular disease in acute reactive arthritis, provided active infection has been excluded. The usual dosage is:

For information on adverse effects associated with long-term corticosteroid therapy (such as bone density loss) and advice on how to minimise and monitor for such complications, see Principles of immunomodulatory drug use.

Topical corticosteroids may be needed for ocular inflammation.