Management of chronic reactive arthritis

Kwiatkowska, 2009Meyer, 2011

Up to 20% of people with reactive arthritis may develop chronic arthritis (ie arthritis persisting beyond 6 months).

All people with chronic spondylitis or peripheral arthritis should be advised to exercise as tolerated (see Physical activity for axial spondyloarthritis). Nonsteroidal anti-inflammatory drugs (NSAIDs) are used for symptom control. Exercise and NSAIDs are continued throughout the disease course, irrespective of whether other treatments are used.

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 chronic reactive arthritis, use:

1celecoxib 100 to 200 mg orally, daily in 1 or 2 divided doses, until symptoms subside celecoxib celecoxib celecoxib

OR

1etoricoxib 30 to 60 mg orally, daily until symptoms subside etoricoxib etoricoxib etoricoxib

OR

1ibuprofen immediate-release 200 to 400 mg orally, 3 or 4 times daily until symptoms subside ibuprofen ibuprofen ibuprofen

OR

1indometacin 25 to 50 mg orally, 2 to 4 times daily until symptoms subside indometacin indometacin indometacin

OR

1ketoprofen modified-release 200 mg orally, daily until symptoms subside ketoprofen ketoprofen ketoprofen

OR

1meloxicam 7.5 to 15 mg orally, daily until symptoms subside meloxicam meloxicam meloxicam

OR

1naproxen immediate-release 250 to 500 mg orally, twice daily until symptoms subside naproxen naproxen naproxen

OR

1naproxen modified-release 750 to 1000 mg orally, daily until symptoms subside naproxen naproxen naproxen

OR

1piroxicam 10 to 20 mg orally, daily until symptoms subside piroxicam piroxicam piroxicam

OR

2diclofenac 25 to 50 mg orally, 2 or 3 times daily until symptoms subside. diclofenac diclofenac diclofenac

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:

1indometacin 100 mg rectally, once or twice daily indometacin indometacin indometacin

OR

2diclofenac 25 to 50 mg rectally, 2 or 3 times daily. diclofenac diclofenac diclofenac

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. Radiologically guided corticosteroid injections into sacroiliac joints may be beneficial for sacroiliitis. 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 using local corticosteroid injections for musculoskeletal pain.

When treatment with exercise and an NSAID is inadequate to control symptoms, or disease is severe, immunomodulatory therapy may be added. Drug choice depends on the site of disease activity. Conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) are often used by specialists to treat peripheral arthritis, although strong evidence is lacking. csDMARDs are relatively ineffective in the treatment of enthesitis. Biological disease-modifying antirheumatic drugs (bDMARDs) may be effective in refractory cases of chronic reactive arthritis; however, there is little evidence to support their use. They should only be used by specialists after persistent infection has been excluded. See Biological or targeted-synthetic disease-modifying antirheumatic drug use in axial spondyloarthritis for doses.