Doctor En Ciencias Medicas

Eular On-line Course on Rheumatic Diseases – module n°11 Marjatta Leirisalo-Repo, Ben A. Dijkmans, Kari K. Eklund

INFECTION AND ARTHRITIS
IN-DEPTH DISCUSSION I Reactive arthritis – treatment of acute and prolonged/chronic arthritis
Marjatta Leirisalo-Repo, Ben A. Dijkmans, Kari K. Eklund

Patients with acute reactive arthritis are treated with non-steroidal anti-inflammatory drugs, whichthe patients often need high doses. Most patients have oligoarticular disease with arthritis in larger joints. Intra-articular injections with glucocorticoids are usually effective. In the case of a patient with fever, low back pain, hip/knee arthritis not responding to the above-mentioned therapeutic interventions,. systemic use of prednisone/prednisolone is indicated. Compared with patients withrheumatoid arthritis, who usually respond to very low doses, patients with reactive arthritis need considerably higher doses, eg. 40 mg prednisolone as starting dose. Physiotherapy, local cold, use of appliances (crutches to alleviate pressure of inflamed hip/knee/ankle) are part of the routine treatment in severe cases.

Extra-articular symptoms are usually mild and disappear with time. Thereare no controlled studies concerning various treatment modalities. Entesopathy and dactylitis respond to local corticosteroid injections. Keratodermia responds to topical glucocorticoids, erythema nodosum usually also responds to topical glucocorticoids, but if the patient has systemic symptoms (fever), systemic glucocorticoids can be used. If the patient has balanitis, Chlamydia and Candidainfections should be searched for and treated appropriately. If there is no infection, mild topical glucocorticoid ointment can be used for short periods of time. Conjunctivitis can be a sign of reactive arthritis but also sometimes can be infectious due to Chlamydia trachomatis. If that is the case, treatment should be focussed to the eradication of Chlamydia. If there is no infectious cause,conjunctivitis can be treated, if symptomatic, with topical vasoconstrictors. About 5% of patients with reactive arthritis have more serious eye symptoms, usually acute anterior uveitis, but also keratitis or posterior uveitis have been described. Acute anterior uveitis is usually affecting only one eye, and the eye is painful, red, and the patient has photophobia. Such a patient should be referredimmediately to an ophthalmologist to be treated with glucocorticoids and mydriates.

The use of antibiotics to treat acute reactive arthritis has been extensively studied, and the results have been largely negative. The use of antibiotics is indicated in the case of symptomatic infection (eg. positive stool culture for salmonella, campylobacter, yersinia or shigella): for salmonella and yersiniainfections, ciprofloxacin 750 mg twice a day for 10 days; for Shigella dysenteriae norfloxacin 400 mg twice a day or ciprofloxacin 500 mg twice a day for 5-10 days, and for campylobacter a macrolide antibiotic e.g. roxithromycin 150 mg twice a day for 10 days.
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Eular On-line Course on Rheumatic Diseases – module n°11 Marjatta Leirisalo-Repo, Ben A. Dijkmans, Kari K. Eklund

Theuse of antibiotics in reactive arthritis triggered by gastroenteritis does not shorten the duration of the arthritis. For Chlamydia trachomatis infection, both the patient and the sexual partner(s) should be treated with antibiotics (azithromycin 1 g as a single dose) irrespective of arthritis. For Chlamydia trachomatis induced arthritis, there is limited evidence that a prolonged use oftetracyclines might be effective for the arthritis (1).

The prognosis of a patient with reactive arthritis is usually good. In a previous Finnish study, the average duration of arthritis was 3-5 months, and about 15 % of patients developed chronic sequels or proceeded into chronic spondyloarthritis (2). Often, after objective recovery and with normal laboratory markers of inflammation and absence of...