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{{Reactive arthritis}}
{{Reactive arthritis}}
{{CMG}}
{{CMG}};{{AE}}{{Akshun}}
== Overview ==
The mainstay of therapy for reactive arthritis is antimicrobial therapy.  [[Analgesic]]s, [[Steroid]]s, and [[Immunosuppressant]]s may be administered to patients with severe disease that is unresponsive to treatment. 


== Overview == 
The majority of cases (two-thirds) of reactive arthritis are self-limited and require only supportive care. [[Arthritis]] is the most common [[symptom]] and initially treated with [[NSAIDs]]. As the disease progresses or in case of no response, further management includes intra-[[articular]] and [[systemic]] [[steroids]], [[DMARDs]] and finally [[TNF inhibitor|TNF inhibitors]]. The role of [[antibiotics]] in reactive arthritis is not clear and their efficacy in reactive arthritis is not completely established.


==Medical Therapy==
==Medical Therapy==
The main goal of treatment is to identify and eradicate the underlying infectious source with the appropriate [[antibiotic]]s. Otherwise, treatment is symptomatic. [[analgesia|Analgesics]], [[Steroid]]s and [[Immunosuppressant]]s may be needed for patients with severe reactive symptoms that do not respond to any other treatment.
*Reactive arthritis is generally seen with preceeding [[Gastrointestinal tract|GI]] or [[Genitourinary|GU]] [[infections]]. [[Antibiotics]] may be given if there is an ongoing [[infection]], but generally patients of reactive arthritis do not require [[antibiotic]] therapy. Recent studies have shown that [[antibiotic]] therapy does not alter the course of [[disease]] and their role in reactive arthritis is not completely established.<ref name="pmid23588936">{{cite journal |vauthors=Barber CE, Kim J, Inman RD, Esdaile JM, James MT |title=Antibiotics for treatment of reactive arthritis: a systematic review and metaanalysis |journal=J. Rheumatol. |volume=40 |issue=6 |pages=916–28 |date=June 2013 |pmid=23588936 |doi=10.3899/jrheum.121192 |url=}}</ref><ref>C.E. Barber, J. Kim, R.D. Inman, et al.
 
Antibiotics for treatment of reactive arthritis: a systematic review and metaanalysis J. Rheumatol., 40 (2013), pp. 916–928</ref>
==Antimicrobial regimen==
*[[Arthritis]] ([[Monoarthritis|mono]] or [[oligoarthritis]]) is most common initial [[symptom]] and therefore primary medical therapy is aimed at alleviating arthritis.<ref name="pmid12105678">{{cite journal |vauthors=Palazzi C, Olivieri I, Salvarani C, D'Amico E, Alleva G, Vitullo P, Petricca A |title=[Reactive arthritis: advances in diagnosis and treatment] |language=Italian |journal=Reumatismo |volume=54 |issue=2 |pages=105–12 |date=2002 |pmid=12105678 |doi= |url=}}</ref>
===Reactive arthritis, post-streptococcal  arthritis===
*Pharmacologic medical therapies for reactive arthritis include [[symptomatic]] control starting initially with [[NSAIDs]].<ref>D van der Heijde, HSB Baraf, C Ramos-Remus, et al. Evaluation of the efficacy of etoricoxib in ankylosing spondylitis: results of a fifty-two-week, randomized, controlled study Arthritis Rheum, 52 (2005), pp. 1205–1215</ref>
* Reactive arthritis, post-streptococcal  arthritis <ref>{{cite book | last = Gilbert | first = David | title = The Sanford guide to antimicrobial therapy | publisher = Antimicrobial Therapy | location = Sperryville, Va | year = 2015 | isbn = 978-1930808843 }}</ref>
*As the disease progresses or in case of no response, further management includes [[Intraarticular|intra-articular]] and [[systemic]] [[steroids]], [[DMARDs]] and finally [[TNF inhibitor|TNF inhibitors]].<ref name="pmid14680436">{{cite journal |vauthors=Palazzi C, Olivieri I, D'Amico E, Pennese E, Petricca A |title=Management of reactive arthritis |journal=Expert Opin Pharmacother |volume=5 |issue=1 |pages=61–70 |date=January 2004 |pmid=14680436 |doi=10.1517/14656566.5.1.61 |url=}}</ref>
:* Treat strep pharyngitis and then NSAIDs ([[Prednisone]] needed in some patients)
** 1.1 '''NSAIDs; such as the COX-2 inhibitors'''
 
**:* Preferred regimen (1): [[Naproxen]] 500 mg PO q8-12h daily.
===Reactive arthritis, Reiter's  syndrome===
**:* Preferred regimen (2): [[Diclofenac]] 50 mg PO q8h daily.
* Reactive arthritis, Reiter's  syndrome <ref>{{cite book | last = Gilbert | first = David | title = The Sanford guide to antimicrobial therapy | publisher = Antimicrobial Therapy | location = Sperryville, Va | year = 2015 | isbn = 978-1930808843 }}</ref>
**:* Preferred regimen (3): [[Indomethacin]] 50 mg PO q6-8h daily.
:* Only treatment is [[non-steroidal anti-inflammatory drugs]].
**:: '''Note(1):''' [[NSAIDs]] are usually given for a duration of two weeks.
**:: '''Note(2):''' [[NSAIDs]] are contraindicated in patients with [[Gastrointestinal bleeding|GI bleeding]], [[heart disease]] and [[renal disease]].
** 2.1 '''Steroid therapy:''' Patients with inadequate response to [[NSAIDs|NSAID]] are given [[Intraarticular|intra-articular]] [[steroids]] initially and in case of no response are given [[systemic]] [[steroids]].
**:* Preferred regimen (1): [[Triamcinolone acetonide]] 40 mg given as [[Intraarticular|intra-articular]] injection.
**:* Preferred regimen (2): [[Methylprednisolone acetate]] 20-60 mg as [[Intraarticular|intra-articular]]  injection.
**:: '''Note(1):''' [[Intraarticular|Intra-articular]] injections are given every 1- 5 weeks depending upon response.
**:: '''Note(2):''' Most common side effects of intra-articular [[steroids]] include [[osteonecrosis]] and acute [[synovitis]].
**:* Alternative regimen (1): Patients unresponsive to [[NSAIDs]] and [[Intraarticular|intra-articular]] steroids are advised [[systemic]] [[glucocorticoids]] such as [[prednisone]] 20 mg PO q24 daily.
**:: '''Note(1):''' [[Glucocorticoids]] should be started with the minimum dose and gradually increased if desired effect is not achieved.
** 3.1 '''Steroid therapy:''' Patients unresponsive to [[NSAIDs]] and steroids are advised [[DMARDs]].<ref>Treatment of juvenile spondyloarthritis and reactive arthritis with sulfasalazine Monatsschr. Kinderheilkd, 140 (1992), pp. 658–660 </ref>
**:* Preferred regimen (1): [[Sulfasalazine]] 500 mg PO q24 daily, if unresponsive dose can be increased to 1000-3000 mg BID daily.
**:* Preferred regimen (2): [[Methotrexate]] 15 to 25 mg PO one day weekly.
**:: '''Note(1):''' The duration of therapy with [[DMARDs]] is four months for [[sulfasalazine]].
**:: '''Note(2):''' For [[methotrexate]] the duration of therapy is three months.
** 4.1 '''Tumor necrosis factor (TNF) inhibitors:''' Patients unresponsive to above therapy are advised [[TNF inhibitor|TNF inhibitors]].<ref>K.S. Oili, H. Niinisalo, T. Korpilähde, J. Virolainen Treatment of reactive arthritis with infliximab Scand. J. Rheumatol., 32 (2003), pp. 122–124</ref>
**:* Preferred regimen (1): [[Etanercept]] 50 mg/week given as [[subcutaneous]] injection.
**:* Preferred regimen (2): [[Infliximab]] 3 to 5 mg/kg administered [[intravenously]] on weeks zero, two, and six and then every eight weeks.
**:: '''Note(1):''' The duration of treatment is 3 months.
**:: '''Note(2):''' If the patient does not respond to one [[TNF inhibitor]], another [[TNF]] agent may be given
**:: '''Note(3):''' Treatment is discontinued when patient goes into [[remission]] for at least three months.


*For treatment of [[ocular]] [[symptoms]] such as [[conjunctivitis]], please [[Conjunctivitis medical therapy|click here]]
*For treatment of [[urethritis]] please [[Urethritis medical therapy|click here]]
*[[Skin]] and [[mucous membrane]] lesions are generally self limited and therefore do not require further intervention.


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


[[Category:Arthritis]]
[[Category:Autoimmune diseases]]
[[Category:Conditions diagnosed by stool test]]
[[Category:Rheumatology]]
[[Category:Rheumatology]]
[[Category:Syndromes]]
[[Category:Infectious Disease Project]]


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Latest revision as of 13:54, 13 April 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Akshun Kalia M.B.B.S.[2]

Overview

The majority of cases (two-thirds) of reactive arthritis are self-limited and require only supportive care. Arthritis is the most common symptom and initially treated with NSAIDs. As the disease progresses or in case of no response, further management includes intra-articular and systemic steroids, DMARDs and finally TNF inhibitors. The role of antibiotics in reactive arthritis is not clear and their efficacy in reactive arthritis is not completely established.

Medical Therapy

References

  1. Barber CE, Kim J, Inman RD, Esdaile JM, James MT (June 2013). "Antibiotics for treatment of reactive arthritis: a systematic review and metaanalysis". J. Rheumatol. 40 (6): 916–28. doi:10.3899/jrheum.121192. PMID 23588936.
  2. C.E. Barber, J. Kim, R.D. Inman, et al. Antibiotics for treatment of reactive arthritis: a systematic review and metaanalysis J. Rheumatol., 40 (2013), pp. 916–928
  3. Palazzi C, Olivieri I, Salvarani C, D'Amico E, Alleva G, Vitullo P, Petricca A (2002). "[Reactive arthritis: advances in diagnosis and treatment]". Reumatismo (in Italian). 54 (2): 105–12. PMID 12105678.
  4. D van der Heijde, HSB Baraf, C Ramos-Remus, et al. Evaluation of the efficacy of etoricoxib in ankylosing spondylitis: results of a fifty-two-week, randomized, controlled study Arthritis Rheum, 52 (2005), pp. 1205–1215
  5. Palazzi C, Olivieri I, D'Amico E, Pennese E, Petricca A (January 2004). "Management of reactive arthritis". Expert Opin Pharmacother. 5 (1): 61–70. doi:10.1517/14656566.5.1.61. PMID 14680436.
  6. Treatment of juvenile spondyloarthritis and reactive arthritis with sulfasalazine Monatsschr. Kinderheilkd, 140 (1992), pp. 658–660
  7. K.S. Oili, H. Niinisalo, T. Korpilähde, J. Virolainen Treatment of reactive arthritis with infliximab Scand. J. Rheumatol., 32 (2003), pp. 122–124


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