Reactive Arthritis: Chronic or Self-Limiting?

Dr. Miller

Dr. Miller says reactive arthritis “provides a unique opportunity to explore the complex interplay between infection and autoimmunity, particularly trying to understand why only a fraction of patients develop chronic symptoms.”

Dr. Ogdie notes that due to the self-limited nature of the disease, “by the time patients get to us, it has resolved. However, once diagnosed, patients should be followed intermittently over time to see if they develop a chronic arthritis. I might see a patient with reactive arthritis every year for a couple of years, then increase the interval to every three years, although patients with self-limited disease are often lost to follow-up.

“If the disease is persisting,” Dr. Ogdie stressed, “do a full evaluation for spondyloarthritis and treat it as such. Patients who are HLA-B27 positive with a severe and protracted course are simply patients who have spondyloarthritis that is revealing itself. If I had a magic wand, I would want to know, ‘Is this an isolated episode of arthritis, or will this become a more chronic inflammatory arthritis?’ Time is all we have to sort that out.”

Management

Dr. Ogdie

The primary goal of treatment should start with the prompt identification and treatment of the triggering infection.¹¹ Treatment of Chlamydia is known to reduce the risk of developing reactive arthritis from about 37% to 10%.²⁰ Treatment of sexual partners is also essential to prevent re-infection.

The role for antibiotics after an enteric infection is less clear. At present, antibiotics are not recommended for reactive arthritis secondary to gastrointestinal infection, but can be considered in cases of severe diarrhea, in immunocompromised or elderly patients, or in patients with prior reactive arthritis susceptible to relapse.²¹

After identification of the antecedent infection, the next step is to provide relief of acute symptoms and minimize the risk of joint and organ damage and disability. Depending on the spectrum of manifestations, disease management may need to be coordinated with a team of specialists, including dermatologists, ophthalmologists and cardiologists.

Non-steroidal anti-inflammatory drugs (NSAIDs) are first-line therapy for musculoskeletal manifestations of reactive arthritis. These can be given at high doses, and agents with a long half-life are preferred for patients with axial involvement.

Intra-articular glucocorticoids can be helpful for cases of mono- or oligo-arthritis, as well as enthesopathy. Oral glucocorticoids are generally reserved for more severe polyarticular involvement or high-risk manifestations, such as severe cardiac disease.