Reactive Arthritis: Chronic or Self-Limiting?

Lucchino et al. recommend a three- to six-month period of observation before consideration of treatment with a conventional synthetic disease-modifying anti-rheumatic drug (DMARD) to avoid treating self-limiting disease.¹¹ Sulfasalazine has been the most studied among these options and has been demonstrated to induce remission more rapidly than placebo. It can be used in chronic disease, but is only effective for peripheral, rather than axial disease.²²

If sulfasalazine is contradicted due to G6PD deficiency or sulfonamide allergy, for example, or demonstrates a lack of efficacy, DMARDs, such as azathioprine or methotrexate, can be considered.

“When reactive arthritis becomes chronic,” says Dr. Miller, “its management begins to align closely with other spondyloarthropathies. Use DMARDs and/or biologic immunosuppression, guided by disease severity, axial and extra-articular manifestations.”

Biologic agents have been studied in small case series and case reports. Although there was initial concern regarding the possibility of bacterial proliferation in the setting of tumor necrosis factor (TNF) inhibition, available data suggest biologic efficacy without the risk of precipitating infection.¹¹

Looking Ahead

Reactive arthritis, although rare, remains a significant diagnostic and therapeutic challenge due to its diverse presentation and unpredictable course.

Gaps in knowledge and areas for future study include the lack of diagnostic criteria and treatment guidelines, absence of biomarkers for disease activity and diagnosis, and limited data in long-term clinical trials, particularly related to biologic DMARDs.²³ Additional areas of potential study include examining the role of the microbiome in disease pathogenesis and risk factors for progression to chronic spondyloarthritis.^24,25

Expanding research efforts can help bridge gaps in knowledge and optimize care for this complex disease.

Michael Cammarata, MD, is an assistant professor of medicine at the Johns Hopkins School of Medicine, Baltimore.

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Acknowledgment

The author thanks Javohir Mullokulov MD, assistant professor, and Khalmurad Akhmedov, DSc, professor, both of Tashkent Medical Academy, Uzbekistan, for the idea that inspired this article and for their assistance in its development.