Reactive Arthritis Treatment

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Reactive Arthritis Treatment

What is reactive arthritis?

Sometimes, a bacterial infection in your gut or urinary tract can trigger chronic inflammatory arthritis known as reactive arthritis, previously called Reiter’s syndrome. Reactive arthritis usually affects the knees, ankles, and feet but can also affect the eyes & skin. The bacterial infection that causes this type of arthritis is usually contracted from contaminated food, leading to gastrointestinal infection. Sexual transmission, and particularly infection with chlamydia, may also lead to reactive arthritis. Reactive arthritis itself is not contagious, but the bacteria that causes the inflammatory response can spread from person to person through sex or contaminated food.

Who can develop reactive arthritis?

Men typically are more prone than women to developing reactive arthritis caused by a sexually transmitted infection. However, men and women can develop this type of arthritis equally when it involves contaminated food. Younger men, age 20-40, are impacted more frequently due to increased sexual activity in this age range. Individuals who carry a gene called HLA-B27 and people infected with HIV may be more prone to developing reactive arthritis.

What areas are affected by reactive arthritis?

Reactive arthritis typically involves the lower back and joints of the lower extremities and can have overlapping features with other forms of axial spondyloarthritis conditions like ankylosing spondylitis, psoriatic arthritis and inflammatory bowel disease associated arthritis.

Causes

What is the cause of reactive arthritis?

Reactive arthritis occurs when a bacterial infection triggers an immune reaction that causes inflammation in the joints and various locations in the body. The inflammatory response usually begins about one to four weeks after exposure to the infection. The bacteria usually enter the body either through the vagina or urethra from sexual activity or through the gastrointestinal tract after eating contaminated food. The most common bacteria known to cause reactive arthritis includes:

  • Chlamydia trachomatis and Chlamydia pneumoniae
    • Sexually transmitted
  • Salmonella, Shigella, Yersinia, Clostridium difficile, and Campylobacter
    • Transmitted through the gastrointestinal tract from infected food

What risk factors are there for developing reactive arthritis?

Risk factors associated with developing reactive arthritis include:

  • Genetics - People with a gene known as HLA-B27 have a higher predisposition for this type of arthritis than those without the gene.
  • Sex - Women and men can develop reactive arthritis due to food contamination at the same rate. However, men have a higher chance of developing reactive arthritis when it is due to sexual transmission.
  • Age - reactive arthritis is most common in young adults.

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Symptoms

What are the symptoms of reactive arthritis?

Reactive arthritis symptoms mostly involve the joints, eyes, and urinary tract. Initially, the symptoms may not be easily recognized as they may be very mild. Symptoms can vary from person to person, being very mild to severe, and lasting for a few weeks to several months. Urinary tract symptoms are usually the first to appear. Arthritic symptoms are often the last to develop and can last up to a year. Various symptoms include:

  • Pain and swelling in joints
  • Joint stiffness
  • Heel pain
    • Achilles tendinitis
    • Plantar fasciitis
  • Sausage digits (Dactylitis)
  • Inflammatory back pain: To find out if you could have inflammatory back pain, visit this website to watch a video and take the back pain quiz: https://spondylitis.org/about-spondylitis/could-i-have-spondylitis/
  • Rashes
    • Seen on the palms, soles, and head of the penis
  • Redness of eyes
  • Eye irritation
  • Blurred vision
  • Eye inflammation or conjunctivitis
  • Uveitis / Iritis - inflammation of the front of the eye which causes tearing, redness & pain
  • Frequent urination
  • Pain when urinating

What complications arise from reactive arthritis?

Recurrence of this condition is quite common, but this is usually related to re-infection. Education and prevention are key with this condition for reducing long-term complications.

Complications may include but are not limited to the following:

  • Recurrent arthritis (15 to 50%)
  • Chronic arthritis or sacroiliitis.
  • Ankylosing spondylitis (30 to 50% if the patient is also HLA-B27–positive)
  • Urethral stricture.
  • Aortic root necrosis.
  • Cataracts.
  • Cystoid macular edema.

Diagnosis

How is reactive arthritis diagnosed?

Proper diagnosis of this condition may be difficult as it mirrors many other conditions. There are also no specific tests that confirm this condition. Therefore, a thorough medical history and physical examination is the most effective way to learn if this is in fact the cause of your symptoms.

Are there any diagnostic tests that can be performed to confirm reactive arthritis?

Certain blood tests may be helpful but not definitive for an accurate diagnosis of reactive arthritis. Testing for sexually transmitted illnesses, antibody tests more commonly found in other arthritic conditions, and blood panels to evaluate for infection or inflammation may all be helpful. Tests that may be helpful in diagnosis include:

  • Joint fluid analysis - fluid is usually removed from the affected joints, usually the knee, and tested for bacteria, inflammatory cells, and crystals. If bacteria is detected, this usually confirms reactive arthritis.
  • X Rays - helpful with detecting joint damage, swelling, and calcium deposits found in reactive arthritis. Usually, views of the back, pelvis and joints are taken to rule out a variety of arthritic conditions.
  • Genetic testing - testing to determine the gene HLA-B27 can be performed to help with the diagnosis of reactive arthritis.

Treatment

What are treatment options for reactive arthritis?

For the infection, antibiotic treatment for the particular bacteria causing the infection will be prescribed. Many times the other symptoms will disappear on their own. Sometimes symptoms will linger and become severe enough that medical intervention may be required. Different types of medications currently available for the management of other symptoms associated with reactive arthritis include:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs) are usually the initial treatment option for this condition as there are over-the-counter as well as prescription forms available. 
  • Corticosteroids - often delivered as an injection to the affected joint, can be helpful in quickly reducing inflammation.

Fortunately, most patients with reactive arthritis, do NOT have a chronic course, however, if your arthritis symptoms do become chronic (lasts for more than 3 months) there are other arthritis treatments to consider to manage your symptoms and prevent permanent joint damage: 

  • Disease-modifying antirheumatic drugs (DMARDs) - reserved for severe cases of reactive arthritis, but there is limited evidence that these medications actually improve the symptoms of reactive arthritis. Examples include:
    • methotrexate (Rheumatrex, Trexall, Otrexup, Rasuvo)
    • sulfasalazine (Azulfidine), which is more effective for reactive arthritis caused by gastrointestinal illness

*If you are taking methotrexate, make sure you are also taking a folic acid supplement like MTX Advanced Support: https://theralogix.com/products/mtx-support-folic-acid-b12-supplement 

  • Biologic response modifiers (biologic agents) - another option when traditional medications fail and include:
    • adalimumab (Humira)
    • etanercept (Enbrel)

What preventative options are there for reactive arthritis?

Unlike many other arthritic conditions, reactive arthritis can actually be prevented. Limiting exposure to bacterial infections is key for the prevention of this type of arthritis. Making sure foods are properly prepared will prevent foodborne infections. Practicing safe sex can be used to prevent bacterial infections that may cause reactive arthritis as well.

Reactive arthritis is a less common form of arthritis whose cause is not completely understood, as not all bacterial infections may cause this arthritis. Research does confirm that prompt diagnosis and treatment of the bacterial infection provides the best chance of preventing long-lasting pain and symptoms. TeleMed2U providers are always available to help with the accurate diagnosis of this arthritis and also help with the management of lingering symptoms if they occur.

References

Arthritis Foundation. (n.d.). Reactive arthritis. https://www.arthritis.org/diseases/reactive-arthritis 
Mayo Clinic.  (2019, March).  Reactive arthritis. https://www.mayoclinic.org/diseases-conditions/reactive-arthritis/symptoms-causes/syc-20354838  
Sukfa, P. (2019, March). Reactive arthritis.American College of Rheumatology. https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Reactive-Arthritis

Information

Medically reviewed by:

Dr Roy Kedem, MD

Dr Roy Kedem started his premedical studies at Harvard, and research in genetics and gene sequencing at Harvard, Beth Israel. He attended medical school in the UK at the Cambridge Overseas Medical Program in 1998.  Dr Kedem then completed his residency in Internal Medicine at Columbia College of Physicians and Surgeons in Stamford, Connecticut and his fellowship in Hospital Medicine at the Cleveland Clinic in Cleveland, Ohio.

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