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Reactive arthritis

Key sources
The following summarized guidelines for the evaluation and management of reactive arthritis are prepared by our editorial team based on guidelines from the American College of Rheumatology (ACR 2023), the European League Against Rheumatism (EULAR 2022), the British Association for Sexual Health and HIV (BASHH 2021), and the American College of Radiology (ACR 2017).
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Guidelines

1.Diagnostic investigations

Diagnostic imaging
Obtain radiography (often showing characteristic osseous findings) as initial imaging in patients with suspected seronegative spondyloarthropathy.
E
Obtain ultrasound or MRI to complement radiography by showing synovitis and identifying additional erosions.
E
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  • Pretreatment evaluation

2.Medical management

Antimicrobial therapy: treat any identified genital infection with antimicrobial therapy as in uncomplicated infection, as directed by relevant infection guidelines.
B
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  • NSAIDs

  • Systemic corticosteroids

  • DMARDs

  • Biologic agents

  • TCAs

  • Topical therapies

  • Management of uveitis

3.Nonpharmacologic interventions

Rest: advise rest as part of first-line treatment for constitutional symptoms, enthesitis and arthritis, particularly in weight-bearing joints and tendons.
B

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  • Supportive measures

  • Physiotherapy

4.Therapeutic procedures

Intra-articular corticosteroid injections
Insufficient evidence to recommend intra-articular corticosteroid injections in patients with sexually acquired reactive arthritis for single troublesome joints.
I
Consider administering local corticosteroid injections for enthesitis, with judicious use at weight-bearing sites.
C

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  • Medical synovectomy

  • Radiotherapy

5.Surgical interventions

Indications for surgery: consider offering surgical procedures, such as synovectomy and arthroplasty, in certain circumstances. Insufficient evidence regarding the effectiveness of a 3-month course of azithromycin given alongside the synovectomy.
C

6.Specific circumstances

Pregnant patients: avoid using drugs not licensed in pregnancy or during breastfeeding unless the potential benefit outweighs the risk.
D

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  • Patients with HIV

7.Preventative measures

Routine immunizations: consider offering high-dose or adjuvanted influenza vaccination, rather than regular-dose influenza vaccination, in ≥ 65 years old patients with rheumatic or musculoskeletal diseases and in 18-65 years old patients with rheumatic or musculoskeletal diseases on immunosuppressive medications.
C
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  • Prophylaxis for P. jirovecii pneumonia