What are the guideline sources, guidelines and references for Reactive arthritis ?
Guideline 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). 1 2 3 4 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 https://web.pathway.md/diseases/recHNBhS7Gic9HfSp 1/4 6/24/23, 2:57 PM Reactive arthritis Pathway Pretreatment evaluation: screen for HBV infection in all patients eligible for treatment with conventional synthetic, biological, or targeted synthetic DMARDs, immunosuppressants, or corticosteroids (according to dose and duration). B Show 3 more 2. Medical management Antimicrobial therapy: treat any identified genital infection with antimicrobial therapy as in uncomplicated infection, as directed by relevant infection guidelines. B Show 2 more Nonsteroidal anti-inflammatory drugs: initiate NSAIDs as the mainstay for the treatment of inflammatory arthritis. Advise taking them regularly for maximum anti-inflammatory benefit. B Show 6 more Systemic corticosteroids: Consider initiating systemic corticosteroids (PO, as a single intramuscularly injection, or occasionally as an IV bolus) in patients with several joint involvements or with severe constitutional symptoms. C Consider initiating osteoporosis prophylaxis if systemic corticosteroids are used, recognizing that this is unlikely to be required if a short course or single injection is used. C Disease-modifying antirheumatic drugs: initiate DMARDs in patients with disabling joint symptoms persisting > 3 months, earlier in patients with severe disease, or if erosive joint damage is identified. B Show 2 more Biologic agents: insufficient evidence to support the use of biological agents, I including IL-17A and JAK inhibitors, for the treatment of patients with reactive arthritis. I Tricyclic antidepressants: consider offering low-dose TCAs, such as amitriptyline 10-25 mg at night, for severe post-inflammatory pain and fatigue. C Topical therapies: Consider offering topical NSAIDs for symptoms of enthesitis. B Consider offering topical corticosteroids for cutaneous or mucosal lesions. Prefer low potency options for mucosal lesions. Consider offering topical salicylic acid ointments, vitamin D3 analogs (such as calcitriol) for mild-to-moderate lesions, and retinoids (such as acitretin) for more severe lesions, as alternative options. B Management of uveitis: Offer topical corticosteroid eye drops or oral corticosteroids and mydriatics for the treatment of uveitis. Offer more aggressive therapy for posterior uveitis. A Perform slit-lamp examination and provide specialist ophthalmological advice to all patients with eye symptoms. A https://web.pathway.md/diseases/recHNBhS7Gic9HfSp 2/4 6/24/23, 2:57 PM Reactive arthritis Pathway 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 Supportive measures: consider offering cold pads to alleviate joint pain and edema, orthotics with insoles, cushioning and heel supports for enthesitis. B Physiotherapy: offer physiotherapy as necessary to prevent muscle wasting, and when symptoms improve, to strengthen muscles and improve the range of movement in the affected joints and tendons. Offer physiotherapy and exercise particularly if there is axial involvement. B 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 Medical synovectomy: consider offering procedures with yttrium-90, osmic acid, samarium153, or rhenium-186 for short-term benefit in symptomatic chronic single-joint synovitis, recognizing that their advantage over intra-articular corticosteroids has not been confirmed. C Radiotherapy: consider offering radiotherapy exceptionally for severe, disabling heel pain from enthesitis. C 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 Patients with HIV: insufficient evidence to suggest that treatments should be any different in human immunodeficiency virus-positive patients. Take into account drug interactions and overlapping toxicities with antiretroviral drugs. I 7. Preventative measures https://web.pathway.md/diseases/recHNBhS7Gic9HfSp 3/4 6/24/23, 2:57 PM Reactive arthritis Pathway 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 Show 17 more Prophylaxis for Pneumocystis jirovecii pneumonia: consider administering prophylaxis against P. jirovecii pneumonia in patients initiating high-dose corticosteroids, especially in combination with immunosuppressants and depending on the risk-benefit ratio. C References 1. Elizabeth Carlin, Helena Marzo-Ortega, Sarah Flew. 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. Open 2. Expert Panel on Musculoskeletal Imaging:, Jon A Jacobson, Catherine C Roberts et al. ACR Appropriateness Criteria Chronic Extremity Joint Pain-Suspected Inflammatory Arthritis. J Am Coll Radiol. 2017 May;14 5S S81 S89. Open 3. Anne R Bass, Eliza Chakravarty, Elie A Akl et al. 2022 American College of Rheumatology Guideline for Vaccinations in Patients With Rheumatic and Musculoskeletal Diseases. Arthritis Rheumatol. 2023 Jan 4. Online ahead of print. Open 4. George E Fragoulis, Elena Nikiphorou, Mrinalini Dey et al. 2022 EULAR recommendations for screening and prophylaxis of chronic and opportunistic infections in adults with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis. 2022 Nov 3;ard-2022 223335. Open https://web.pathway.md/diseases/recHNBhS7Gic9HfSp 4/4