Treatment Pathway
Treatment of Reactive Arthritis
Reactive arthritis is joint inflammation triggered by an infection elsewhere in the body, usually intestines, genitals, or urinary tract. The classic triad includes joint, eye, and urethral inflammation.
ACR (American College of Rheumatology)EULAR (European League Against Rheumatism)BSR (British Society for Rheumatology)NICEOARSI (osteoarthritis)
Reactive arthritis is joint inflammation triggered by an infection elsewhere in the body, usually intestines, genitals, or urinary tract. The classic triad includes joint, eye, and urethral inflammation.
First-Line Treatment Principles
- ✓Treat-to-target (T2T) strategy in RA and SpA: aim for remission or low disease activity
- ✓Disease-modifying antirheumatic drugs (DMARDs) initiated early in RA — methotrexate first-line
- ✓Biologic DMARDs (anti-TNF, anti-IL-6, JAK inhibitors) when csDMARD inadequate
- ✓Hydroxychloroquine and low-dose prednisolone for SLE; immunosuppressives for organ-threatening disease
- ✓Analgesia stepped approach: paracetamol → NSAIDs → opioids (short-term); topical agents in OA
Non-Pharmacological Management
- •Physical therapy: joint protection, range-of-motion exercises, strengthening — essential in OA and RA
- •Weight management: reduces mechanical load on hips/knees; reduces systemic inflammation
- •Occupational therapy: joint protection aids, assistive devices, workplace adaptations
- •Hydrotherapy and aquatic exercise: low-impact joint rehabilitation in OA
- •Dietary: Mediterranean diet reduces RA disease activity; omega-3 supplementation may reduce inflammation
- •Smoking cessation: major independent risk factor for RA initiation and worse disease course
- •Sun protection in SLE (UV can trigger flares)
Treatment Goals
🎯Remission or low disease activity (DAS28 <2.6 or <3.2) in RA
🎯Prevention of joint damage: minimal erosion progression on X-ray/MRI
🎯Functional preservation: HAQ score improvement; work and activity maintenance
🎯Control of systemic manifestations: uveitis, enthesitis, skin in SpA/PsA
🎯Minimise corticosteroid dose and long-term toxicity
Monitoring Parameters
- ◆Disease activity scores: DAS28 (RA), BASDAI/ASDAS (SpA), SLEDAI (lupus) — at 1, 3, 6 months
- ◆Shared care monitoring for methotrexate: FBC, LFTs monthly × 6, then every 3 months
- ◆Anti-TNF monitoring: TB screening (IGRA) before initiation; LTBI prophylaxis if positive
- ◆Bone mineral density: DEXA scan at baseline and every 2 years on long-term corticosteroids
- ◆Anti-dsDNA and complement (C3/C4) in SLE flare surveillance
- ◆Opthalmology: hydroxychloroquine retinopathy screening annually after 5 years use
Escalation Criteria
- →Inadequate response to methotrexate at 3 months → add hydroxychloroquine/sulfasalazine or switch to biologic
- →Lupus nephritis → high-dose prednisolone + mycophenolate or cyclophosphamide
- →Vasculitis with organ involvement → IV methylprednisolone + cyclophosphamide or rituximab
- →Septic arthritis: urgent joint aspiration + IV antibiotics; surgical washout if joint destruction
Special Populations
Pregnancy: methotrexate, leflunomide, mycophenolate contraindicated — switch before conception; hydroxychloroquine and sulfasalazine continued
Elderly: increased infection risk with immunosuppressives; bone protection mandatory with steroids
Children: paediatric rheumatology specialist; treat early to preserve growth and development
Vaccinations: ensure up to date (pneumococcal, influenza, shingles) before biologic initiation
Clinical Insights
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