Tumor necrosis factor (TNF)-alpha inhibitors
Mild elevations of TNF have been identified in the serum of ReA patients compared with controls.[72]Rihl M, Gu J, Baeten D, et al. Alpha beta but not gamma delta T cell clones in synovial fluids of patients with reactive arthritis show active transcription of tumour necrosis factor alpha and interferon gamma. Ann Rheum Dis. 2004;63:1673-1676.
http://www.ncbi.nlm.nih.gov/pubmed/15547094?tool=bestpractice.com
Observational data suggest clinical benefit among ReA patients receiving TNF-alpha inhibitors; prospective randomised controlled trials are required.[73]Flagg SD, Meador R, Hsia E, et al. Decreased pain and synovial inflammation after etanercept therapy in patients with reactive and undifferentiated arthritis: an open-label trial. Arthritis Rheum. 2005;53:613-617.
http://www.ncbi.nlm.nih.gov/pubmed/16082643?tool=bestpractice.com
[74]Oili KS, Niinisalo H, Korpilahde T, et al. Treatment of reactive arthritis with infliximab. Scand J Rheumatol. 2003;32:122-124.
http://www.ncbi.nlm.nih.gov/pubmed/12737333?tool=bestpractice.com
[75]Haibel H, Brandt J, Rudwaleit M, et al. Therapy of chronic enteral reactive arthritis with infliximab. Ann Rheum Dis. 2003;62:ABO380.[76]Meyer A, Chatelus E, Wendling D, et al. Safety and efficacy of anti-tumor necrosis factor α therapy in ten patients with recent-onset refractory reactive arthritis. Arthritis Rheum. 2011;63:1274-1280.
http://onlinelibrary.wiley.com/doi/10.1002/art.30272/full
http://www.ncbi.nlm.nih.gov/pubmed/21538314?tool=bestpractice.com
[77]Brinster A, Guillot X, Prati C, et al. Anti-TNF treatment of reactive arthritis. A monocentric experience. Joint Bone Spine. 2017 Mar;84(2):237-238.
https://www.doi.org/10.1016/j.jbspin.2016.02.022
http://www.ncbi.nlm.nih.gov/pubmed/27236263?tool=bestpractice.com
There is some evidence to suggest TNF-alpha inhibitors do not re-activate the infective trigger in patients with ReA.[59]Carlin E, Marzo-Ortega H, Flew S. British Association of Sexual Health and HIV national guideline on the management of sexually acquired reactive arthritis 2021. Int J STD AIDS. 2021 Oct;32(11):986-997.
http://www.ncbi.nlm.nih.gov/pubmed/34014782?tool=bestpractice.com
Antibiotics
Several prospective randomised controlled trials have indicated that antibiotic therapy may be of benefit in patients with post-chlamydial ReA.[78]Lauhio A, Leirisalo-Repo M, Lahdevirta J, et al. Double-blind, placebo-controlled study of three-month treatment with lymecycline in reactive arthritis, with special reference to Chlamydia arthritis. Arthritis Rheum. 1991;34:6-14.
http://www.ncbi.nlm.nih.gov/pubmed/1670621?tool=bestpractice.com
[46]Carter JD, Valeriano J, Vasey FB. Doxycycline versus doxycycline and rifampin in undifferentiated spondyloarthropathy with special reference to chlamydia-induced arthritis. A prospective, randomized 9-month comparison. J Rheumatol. 2004;31:1973-1980.
http://www.ncbi.nlm.nih.gov/pubmed/15468362?tool=bestpractice.com
[79]Putschky N, Pott HG, Kuipers JG, et al. Comparing 10-day and 4-month doxycycline courses for treatment of Chlamydia trachomatis-reactive arthritis: A prospective, double-blind trial. Ann Rheum Dis. 2006;65:1521-1524.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1798345/?tool=pubmed
http://www.ncbi.nlm.nih.gov/pubmed/17038453?tool=bestpractice.com
[80]Carter JD, Espinoza LR, Inman RD, et al. Combination antibiotics as a treatment for chronic Chlamydia-induced reactive arthritis: a double-blind, placebo-controlled, prospective trial. Arthritis Rheum. 2010;62:1298-1307.
http://www.ncbi.nlm.nih.gov/pubmed/20155838?tool=bestpractice.com
However, a systematic review and meta-analysis found that antibiotic treatment had no significant effect on remission of ReA triggered by chlamydial infection.[81]Barber CE, Kim J, Inman RD, et al. Antibiotics for treatment of reactive arthritis: a systematic review and meta-analysis. J Rheumatol. 2013;40:916-928.
http://www.ncbi.nlm.nih.gov/pubmed/23588936?tool=bestpractice.com
Heterogeneity in trial results was reported and may have been attributable to differences in study design.[81]Barber CE, Kim J, Inman RD, et al. Antibiotics for treatment of reactive arthritis: a systematic review and meta-analysis. J Rheumatol. 2013;40:916-928.
http://www.ncbi.nlm.nih.gov/pubmed/23588936?tool=bestpractice.com
There is no data to suggest that long-term antibiotics have any therapeutic effect in the treatment of post-enteric infection. Further high quality prospective RCTs are needed to confirm the role of antibiotic therapy in the management of post-chlamydial ReA.