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Persistent Reactive Arthritis — SCE Rheumatology MCQ

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ModerateSpondyloarthropathyPersistent Reactive ArthritisSCE Rheumatology

A 35-year-old man developed reactive arthritis after Chlamydia trachomatis urethritis. The urethritis was treated appropriately, and repeat testing shows no persistent infection. Six months later, he has continuing active asymmetric oligoarthritis of the knees and ankles despite adequate NSAID treatment and intra-articular glucocorticoid injections. He has no axial symptoms. Which systemic treatment is most appropriate to consider next?

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Correct answer: D — Oral sulfasalazine

The best answer is sulfasalazine. This patient has chronic, active peripheral reactive arthritis despite NSAIDs and local glucocorticoid treatment, making a conventional DMARD appropriate. NICE recommends a standard DMARD for persistent peripheral oligoarthritis, and sulfasalazine has direct trial evidence in NSAID-refractory chronic reactive arthritis, although the evidence base is modest. Prolonged antibiotics should not be used solely to treat established reactive arthritis once the triggering infection has been adequately treated. TNF inhibition is not first-line for peripheral reactive arthritis and has limited supporting evidence; it may be considered only in exceptional refractory disease under specialist care. Hydroxychloroquine and colchicine have no established disease-modifying role in persistent reactive arthritis.

Reference: Clegg DO et al. Comparison of sulfasalazine and placebo in the treatment of reactive arthritis (Reiter's syndrome): a Department of Veterans Affairs Cooperative Study. Arthritis Rheum. 1996;39:2021–2027. https://pubmed.ncbi.nlm.nih.gov/8961907/