Reactive arthritis medical therapy: Difference between revisions
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{{Reactive arthritis}} | {{Reactive arthritis}} | ||
{{CMG}} | {{CMG}};{{AE}}{{Akshun}} | ||
== Overview == | == 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== | ||
*Reactive arthritis is generally seen with preceeding GI or GU infections. Antibiotics may be given if there is an ongoing infection, but generally patients of reactive arthritis | *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. | ||
*Pharmacologic medical therapies for reactive arthritis include symptomatic control: | Antibiotics for treatment of reactive arthritis: a systematic review and metaanalysis J. Rheumatol., 40 (2013), pp. 916–928</ref> | ||
** 1.1 '''NSAIDs such as the COX-2 inhibitors''' | *[[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> | ||
**:* Preferred regimen (1): Naproxen 500 mg PO q8-12h daily. | *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> | ||
**:* Preferred regimen (2): Diclofenac 50 mg PO q8h daily. | *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> | ||
**:* Preferred regimen (3): Indomethacin 50 mg PO q6-8h daily. | ** 1.1 '''NSAIDs; such as the COX-2 inhibitors''' | ||
**:: '''Note(1):'''NSAIDs are usually given for a duration of two weeks. | **:* Preferred regimen (1): [[Naproxen]] 500 mg PO q8-12h daily. | ||
**:: '''Note(2):'''NSAIDs are contraindicated in patients with GI bleeding, heart disease and renal disease. | **:* Preferred regimen (2): [[Diclofenac]] 50 mg PO q8h daily. | ||
**:* Preferred regimen (3): [[Indomethacin]] 50 mg PO q6-8h daily. | |||
** 2.1 '''Steroid therapy''' Patients with inadequate response to NSAID are given intra-articular steroids initially and in case of no response are given systemic | **:: '''Note(1):''' [[NSAIDs]] are usually given for a duration of two weeks. | ||
**:* Preferred regimen (1): Triamcinolone acetonide 40 mg given as intra-articular injection. | **:: '''Note(2):''' [[NSAIDs]] are contraindicated in patients with [[Gastrointestinal bleeding|GI bleeding]], [[heart disease]] and [[renal disease]]. | ||
**:* Preferred regimen (2): Methylprednisolone acetate 20-60 mg as intra-articular injection. | ** 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]]. | ||
**:: '''Note(1):'''Intra-articular injections are given 1- 5 weeks depending upon response. | **:* Preferred regimen (1): [[Triamcinolone acetonide]] 40 mg given as [[Intraarticular|intra-articular]] injection. | ||
**:: '''Note(2):''' | **:* Preferred regimen (2): [[Methylprednisolone acetate]] 20-60 mg as [[Intraarticular|intra-articular]] injection. | ||
**:* Alternative regimen (1): Patients unresponsive to NSAIDs and intra-articular steroids are advised systemic glucocorticoids such as prednisone 20 mg PO q24 daily. | **:: '''Note(1):''' [[Intraarticular|Intra-articular]] injections are given every 1- 5 weeks depending upon response. | ||
**:: '''Note(1):'''Glucocorticoids should be started with the minimum dose and gradually increased if desired effect is not achieved. | **:: '''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. | |||
** 3.1 '''Steroid therapy'''Patients unresponsive to | **:: '''Note(1):''' [[Glucocorticoids]] should be started with the minimum dose and gradually increased if desired effect is not achieved. | ||
**:* Preferred regimen (1): Sulfasalazine 500 mg PO q24 daily, if unresponsive dose can be increased to 1000-3000 mg BID daily. | ** 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 (2): Methotrexate 15 to 25 mg PO one day weekly. | **:* Preferred regimen (1): [[Sulfasalazine]] 500 mg PO q24 daily, if unresponsive dose can be increased to 1000-3000 mg BID daily. | ||
**:: '''Note(1):'''The duration of therapy with DMARDs is four months for sulfasalazine. | **:* Preferred regimen (2): [[Methotrexate]] 15 to 25 mg PO one day weekly. | ||
**:: '''Note(2):'''For methotrexate the duration of therapy is three months. | **:: '''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== | ||
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
- Reactive arthritis is generally seen with preceeding GI or 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.[1][2]
- Arthritis (mono or oligoarthritis) is most common initial symptom and therefore primary medical therapy is aimed at alleviating arthritis.[3]
- Pharmacologic medical therapies for reactive arthritis include symptomatic control starting initially with NSAIDs.[4]
- As the disease progresses or in case of no response, further management includes intra-articular and systemic steroids, DMARDs and finally TNF inhibitors.[5]
- 1.1 NSAIDs; such as the COX-2 inhibitors
- Preferred regimen (1): Naproxen 500 mg PO q8-12h daily.
- Preferred regimen (2): Diclofenac 50 mg PO q8h daily.
- Preferred regimen (3): Indomethacin 50 mg PO q6-8h daily.
- Note(1): NSAIDs are usually given for a duration of two weeks.
- Note(2): NSAIDs are contraindicated in patients with GI bleeding, heart disease and renal disease.
- 2.1 Steroid therapy: Patients with inadequate response to NSAID are given intra-articular steroids initially and in case of no response are given systemic steroids.
- Preferred regimen (1): Triamcinolone acetonide 40 mg given as intra-articular injection.
- Preferred regimen (2): Methylprednisolone acetate 20-60 mg as intra-articular injection.
- Note(1): 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 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.[6]
- 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 inhibitors.[7]
- 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.
- 1.1 NSAIDs; such as the COX-2 inhibitors
- For treatment of ocular symptoms such as conjunctivitis, please click here
- For treatment of urethritis please click here
- Skin and mucous membrane lesions are generally self limited and therefore do not require further intervention.
References
- ↑ 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.
- ↑ 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
- ↑ 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.
- ↑ 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
- ↑ 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.
- ↑ Treatment of juvenile spondyloarthritis and reactive arthritis with sulfasalazine Monatsschr. Kinderheilkd, 140 (1992), pp. 658–660
- ↑ K.S. Oili, H. Niinisalo, T. Korpilähde, J. Virolainen Treatment of reactive arthritis with infliximab Scand. J. Rheumatol., 32 (2003), pp. 122–124