Reactive Arthritis
Management SARAA eligibility criteria for b/tsDMARD therapies for other SpA (including ReA, IBD-associated arthritis and undifferentiated SpA) Reactive arthritis (ReA) is an inflammatory arthritis that manifests several days to weeks after a gastrointestinal or genitourinary infection. Because the pathogens cannot be cultured from the affected joints, this is not a septic arthritis but rather an
Reactive arthritis (ReA) is an inflammatory arthritis that manifests several days to weeks after a gastrointestinal or genitourinary infection. Because the pathogens cannot be cultured from the affected joints, this is not a septic arthritis but rather an aberrant immune response to the preceding infection. Organisms causing ReA include salmonella, shigella, yersinia, campylobacter and chlamydia, with HIV, Escherichia coli, Clostridioides difficile and Chlamydia pneumoniae recently added to the list of causative agents. The triad of arthritis, urethritis and conjunctivitis was previously called ‘Reiter syndrome’.
More common in men, and in patients who are HLA-B27 positive, ReA typically presents as an asymmetrical oligoarthritis of the lower limbs. While large joints are most often involved, the small joints of the hands may also be affected. Enthesitis, including plantar fasciitis or Achilles tendon enthesitis, may also be noted, as may dactylitis and sacroiliitis. Other features include urethritis, iritis, conjunctivitis and mucocutaneous lesions (balanitis, keratoderma blenorrhagicum).
ReA is usually self-limiting, with most patients having a complete resolution of the articular symptoms within 6 months. Five to 10% of patients develop persistent arthritis/axial SpA. Prognostic markers for chronicity include HLA-B27 positivity, positive family history for SpA and the presence of chronic gut inflammation. Apart from increasing the probability of chronicity, HLA-B27 positivity is associated with severe disease, frequent spine involvement and extra-articular features.
Management
Symptomatic treatment of the joints using NSAIDs and intra-articular steroid injections is recommended. Treatment of antecedent infection with antibiotics is not recommended, although there is controversy regarding benefits of long-term antibiotic treatment of chlamydiarelated ReA.[48] Patients with persistent (>3 - 6 months) peripheral joint involvement may require csDMARDs, including SSZ or MTX. Failure to respond to csDMARDs is an indication for TNFi. Patients with axial involvement should to follow the axSpA guidelines.
SARAA eligibility criteria for b/tsDMARD therapies for other SpA (including ReA, IBD-associated arthritis and undifferentiated SpA)
Failure of conventional therapy for peripheral arthritis, enthesitis, dactylitis, axSpA or severe extra-articular disease.
Benitha, R., Maharaj, A. B., Makan, K., Potts, J., Lai, A., Carter, R., van Dam, M., & Hodkinson, B. (2024). South African Rheumatism and Arthritis Association 2024 guidelines for the management of peripheral spondyloarthritis. South African Medical Journal, 114(10), e2669.