Diseases > Reactive arthritis

The following summarized guidelines for the evaluation and management of reactive arthritis are prepared by our editorial team based on guidelines from the American College of Rheumatology (ACR 2023), the European League Against Rheumatism (EULAR 2022), the British Association for Sexual Health and HIV (BASHH 2021), and the American College of Radiology (ACR 2017).

1. Diagnostic investigations

Diagnostic imaging

• Obtain radiography (often showing characteristic osseous findings) as initial imaging in patients with suspected seronegative spondyloarthropathy.
• Obtain ultrasound or MRI to complement radiography by showing synovitis and identifying additional erosions.

Pretreatment evaluation

screen for HBV infection in all patients eligible for treatment with conventional synthetic, biological, or targeted synthetic DMARDs, immunosuppressants, or corticosteroids (according to dose and duration).

2. Medical management

Antimicrobial therapy

treat any identified genital infection with antimicrobial therapy as in uncomplicated infection, as directed by relevant infection guidelines.

Nonsteroidal anti-inflammatory drugs

initiate NSAIDs as the mainstay for the treatment of inflammatory arthritis. Advise taking them regularly for maximum anti-inflammatory benefit.

Systemic corticosteroids

• Consider initiating systemic corticosteroids (PO, as a single intramuscularly injection, or occasionally as an IV bolus) in patients with several joint involvements or with severe constitutional symptoms.
• Consider initiating osteoporosis prophylaxis if systemic corticosteroids are used, recognizing that this is unlikely to be required if a short course or single injection is used.

Disease-modifying antirheumatic drugs

initiate DMARDs in patients with disabling joint symptoms persisting > 3 months, earlier in patients with severe disease, or if erosive joint damage is identified.

Biologic agents

insufficient evidence to support the use of biological agents, I including IL-17A and JAK inhibitors, for the treatment of patients with reactive arthritis.

Tricyclic antidepressants

consider offering low-dose TCAs, such as amitriptyline 10-25 mg at night, for severe post-inflammatory pain and fatigue.

Topical therapies

• Consider offering topical NSAIDs for symptoms of enthesitis.
• Consider offering topical corticosteroids for cutaneous or mucosal lesions. Prefer low potency options for mucosal lesions. Consider offering topical salicylic acid ointments, vitamin D3 analogs (such as calcitriol) for mild-to-moderate lesions, and retinoids (such as acitretin) for more severe lesions, as alternative options.

Management of uveitis

• Offer topical corticosteroid eye drops or oral corticosteroids and mydriatics for the treatment of uveitis. Offer more aggressive therapy for posterior uveitis.
• Perform slit-lamp examination and provide specialist ophthalmological advice to all patients with eye symptoms.

3. Nonpharmacologic interventions

Rest

advise rest as part of first-line treatment for constitutional symptoms, enthesitis and arthritis, particularly in weight-bearing joints and tendons.

Supportive measures

consider offering cold pads to alleviate joint pain and edema, orthotics with insoles, cushioning and heel supports for enthesitis.

Physiotherapy

offer physiotherapy as necessary to prevent muscle wasting, and when symptoms improve, to strengthen muscles and improve the range of movement in the affected joints and tendons. Offer physiotherapy and exercise particularly if there is axial involvement.

4. Therapeutic procedures

Intra-articular corticosteroid injections

• Insufficient evidence to recommend intra-articular corticosteroid injections in patients with sexually acquired reactive arthritis for single troublesome joints.
• Consider administering local corticosteroid injections for enthesitis, with judicious use at weight- bearing sites.

Medical synovectomy

consider offering procedures with yttrium-90, osmic acid, samarium153, or rhenium-186 for short-term benefit in symptomatic chronic single-joint synovitis, recognizing that their advantage over intra-articular corticosteroids has not been confirmed.

Radiotherapy

consider offering radiotherapy exceptionally for severe, disabling heel pain from enthesitis.

5. Surgical interventions

Indications for surgery

consider offering surgical procedures, such as synovectomy and arthroplasty, in certain circumstances. Insufficient evidence regarding the effectiveness of a 3- month course of azithromycin given alongside the synovectomy.

6. Specific circumstances

Pregnant patients

avoid using drugs not licensed in pregnancy or during breastfeeding unless the potential benefit outweighs the risk.

Patients with HIV

insufficient evidence to suggest that treatments should be any different in human immunodeficiency virus-positive patients. Take into account drug interactions and overlapping toxicities with antiretroviral drugs.

7. Preventative measures

Routine immunizations

consider offering high-dose or adjuvanted influenza vaccination, rather than regular-dose influenza vaccination, in ≥ 65 years old patients with rheumatic or musculoskeletal diseases and in 18-65 years old patients with rheumatic or musculoskeletal diseases on immunosuppressive medications.

Prophylaxis for Pneumocystis jirovecii pneumonia

consider administering prophylaxis against P. jirovecii pneumonia in patients initiating high-dose corticosteroids, especially in combination with immunosuppressants and depending on the risk-benefit ratio.