Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

symptomatic relief

1st line – non-steroidal anti-inflammatory drug (NSAID)

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ACUTE
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symptomatic relief
1st line – 

non-steroidal anti-inflammatory drug (NSAID)

No NSAID has been shown to be superior to any other in ReA.

Primary options

naproxen: 250-500 mg orally twice daily when required, maximum 1250 mg/day

OR

ibuprofen: 300-400 mg orally three to four times daily when required, maximum 2400 mg/day

OR

diclofenac potassium: 50 mg orally (immediate-release) twice or three times daily when required

OR

diclofenac sodium: 100 mg orally (extended-release) once daily when required

OR

indometacin: 25 mg orally two to three times daily when required

2nd line – corticosteroid

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ACUTE
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symptomatic relief
2nd line – 

corticosteroid

Corticosteroids may be used if symptoms are unresponsive to NSAIDs or during an acute flare.

Intra-articular injections in monoarticular and oligoarticular forms may provide short-term relief, but systemic corticosteroids may be required if many joints are affected. Systemic corticosteroids can be helpful in treating ocular manifestations, such as iritis.

Topical corticosteroids can be used to treat skin involvement, such as for circinate balanitis and keratoderma blennorrhagicum.[Figure caption and citation for the preceding image starts]: Balanitis in a patient with reactive arthritis.Image provided by the CDC Public Health Image Library [Citation ends].com.bmj.content.model.Caption@1ebd625f[Figure caption and citation for the preceding image starts]: Keratoderma blenorrhagia in a patient with reactive arthritis.Image provided by the CDC Public Health Image Library [Citation ends].com.bmj.content.model.Caption@36c320ba

Primary options

prednisolone: 0.5 to 1 mg/kg/day orally, taper dose gradually as soon as practical

Secondary options

methylprednisolone: consult specialist for further guidance on intra-articular dose

OR

triamcinolone topical: (0.1% cream) apply sparingly to the affected area(s) twice daily

ONGOING

persisting or chronic reactive arthritis

1st line – disease-modifying antirheumatic drug (DMARD)

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ONGOING
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persisting or chronic reactive arthritis
1st line – 

disease-modifying antirheumatic drug (DMARD)

DMARDs are considered either when NSAIDs fail or when more aggressive treatments are needed to prevent radiographic joint destruction.

In a prospective double-blind placebo-controlled trial, sulfasalazine improved response rates in patients with ReA unresponsive to NSAID therapy.[71] If the medication is not effective within 3 to 4 months, it should be discontinued.

Primary options

sulfasalazine: 500 mg orally once daily initially, increase by 500 mg/day increments at weekly intervals according to response, maximum 2 g/day given in 2-3 divided doses

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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