Reactive arthritis

Complaints

Reactive arthritis belongs to the group of rheumatic diseases under the collective name Spondyloarthritis (SpA). Spondyloarthritis is a collective name for a group of rheumatic diseases with a number of common features, such as spinal inflammation, pelvis and inflamed joints in the arms or legs. We distinguish: axial spondyloarthritis, peripheral spondyloarthritis and a mixed form.
• axial spondyloarthritis, in which you mainly suffer from the back, causing pain or inflammation of the joints of the pelvis (the SI joints) and/or the spine.
• peripheral spondyloarthritis, in which you mainly have symptoms of arthritis in the shoulders, hips, knees or feet. In the case of peripheral spondyloarthritis, especially the large joints in the arms or legs become inflamed. Reactive arthritis is a form of peripheral spondyloarthritis.
• a mixed form, where you suffer from axial spondyloarthritis with peripheral arthritis and vice versa you can suffer from back pain (axial spondyloarthritis) in peripheral spondyloarthritis.

Reactive arthritis is a form of peripheral spondyloarthritis and can have any or all of these features:
• pain and swelling of certain joints, often the knees and/or ankles.
• swelling and pain at the heels.
• extensive swelling of the toes or fingers.
• persistent low back pain, which tends to be worse at night or in the morning.
• some patients with this type of arthritis also have eye redness and irritation.
• a rash on the palms or the soles of the feet.
• inflammation at the attachment points of the tendons to the bone.
• inflammation of the sternum joint or the collarbone joint.
• an eye inflammation called uveitis or iridocyclitis.
• skin complaints or complaints to your nails.
• inflammatory bowel disease or infections.
• urinary tract infections, an inflamed prostate, vaginal discharge, pain when urinating.

Symptoms of reactive arthritis due to joint inflammation are:
• pain and inflammation in one or more joints, for example pain under the heel, at the ribs, low back and in the knees and ankles.
• patients suffer from fever and fatigue.
• the affected joint is swollen, tense and feels warm.
• the skin around the joint can be red and tense.
• functional impairment of the joint: bending and stretching can be difficult due to swelling, pain or stiffness.
• pain in the joint.
• inflammation of the tendons (tendinitis).
• inflammation at the site where one or more tendons are stuck to the bone (enthesitis).
• sometimes (low) back pain due to inflammation of the spine (spondylitis).
• sometimes back pain due to inflammation of the joints in the lower back (sacroiliitis).

Other complaints
• conjunctivitis or uveitis. Red, irritated eyes due to inflammation of the connective tissue of the eyeball and inside of the eyelids, burning sensation and strong tearing.
• skin rash. A chronic skin rash with flaky red spots (keratodermia blenorrhagia), resembling psoriasis. The red rash is mainly on the soles of the feet and palms. Usually the rash disappears after a few weeks. You can also get small red spots on the palate, on the tongue and on your penis. Some people suffer from blisters filled with pus or some kind of wart on the skin. Pus is a whitish-yellow, yellow, or brown-yellow protein-rich fluid that accumulates at the site of an infection. It consists of a buildup of dead, white blood cells that form when the body’s immune system responds to the infection. When the buildup is on or near the surface of the skin, it is called a pustule or pimple. An accumulation of pus in an enclosed tissue space is called an abscess.
• sores in the mouth. Sometimes small, painless or sensitive sores develop in the mouth.

Diagnosis of reactive arthritis

Your doctor will base your diagnosis on a combination of the medical history, his findings and additional test results.

Anamneses
At the first visit, the doctor asks you a number of questions to get a good picture of your condition. You can think of the following questions:
– When did your complaints start?
– Can you describe your complaints?
– How are your working conditions?
– What medication do you use?
– Do rheumatic diseases occur in your family?
– What is your medical history?
– Are you under the treatment of other specialists and for what?

The diagnosis is largely based on symptoms of the inducing infections and appearance of typical musculoskeletal (joint and muscle) involvement. The doctor will ask if you have recently had an infection in your throat, stomach, intestines, urinary tract or genital organs. The symptoms that occur 2 to 4 weeks after an infection may indicate reactive arthritis. Depending on the type of infection and whether or not it has been treated, your urine, blood or secretion of the genitals can be examined.

It may take a while for your doctor to be sure that you have reactive arthritis. The disease is difficult to determine, because most people do not get all symptoms at the same time. For example, you could first have had a urethritis, which is an inflammation of the urethra. That is the tube that carries urine from the bladder to outside the body. Pain with urination is the main symptom of urethritis, which is commonly due to infection by bacteria. Some time later you could have inflammation of joints. To make the diagnosis, the doctor will have to combine the results of different studies.

Blood test
Additional information comes from blood tests, where an increased CRP level and the sedimentation rate of the red blood cells may indicate active inflammation. The blood test helps your doctor to determine if you have an inflammation. This can be the result of infections (bacteria, viruses), tumors and autoimmune diseases (such as arthritis).
• C-reactive protein (CRP) is a substance produced by the liver in response to an inflammation. A high level of CRP in the blood is therefore a marker of inflammation.
• Sedimentation speed. Blood tests also measure the degree of inflammation through the sedimentation rate of the red blood cells. The erythrocyte sedimentation rate (ESR) is measured by a laboratory test. An erythrocyte sedimentation rate (ESR) test is also called a sedimentation rate test or sed rate test. The test measures the sedimentation rate of red blood cells (erythrocytes) through the speed at which the red blood cells settle, due to gravity, in an upright, narrow tube of blood. The upper part of the blood in the tube is the plasma, which becomes visible as a column of clear, yellowish liquid after the sedimentation of the red blood cells. The length of this column of plasma is measured after one hour and expressed in millimetres per hour (mm/hour). If you have a condition that causes inflammation or cell damage, your red blood cells tend to clump together. This makes them heavier, so they settle faster. The faster your red blood cells settle and fall, the higher your ESR. A high ESR tells your doctor that you may have an active disease process in your body. This blood test does not diagnose one specific condition. Instead, it helps your doctor to determine whether you are experiencing an inflammation.
• Genetic factor HLA-B27. Your doctor can test whether you have the genetic factor HLA-B27 in your blood. This factor occurs in the blood of 80% of people with reactive arthritis. Healthy people also can have it in their blood, so it does not immediately mean that you have reactive arthritis. However, it is an indication that you are more likely to have reactive arthritis.

Physical examination
• When a joint causes pain, swells, is red or has limited range of motion, a doctor may use a needle and syringe to remove fluid from the joint. This clinical procedure is called arthrocentesis and it is done to obtain synovial fluid for diagnostic lab testing, to alleviate pressure and relieve joint pain or both.
• If indicated, the doctor might order a test for a Chlamydia infection. The test for Chlamydia uses a urine sample or a swab of the genitals. The chlamydia bacterium causes contamination of the urethra, the anus, the throat or the cervix. Complaints in women are • pain or a burning sensation when urinating • pain and blood loss during or after sex • blood loss while you are not on your period • more or abnormal vaginal discharge • itching at the anus, (bloody) discharge at the stool or diarrhea • severe pain in the lower abdomen, with or without fever • pelvic inflammatory disease with fever. Complaints in men are • pain or burning sensation when urinating • discharge from the urethra, especially in the morning • itching at the anus, (bloody) discharge in the stools and diarrhea • pain in the scrotum.

Treatment

The type of treatment for reactive arthritis depends on the stage of  the reactive arthritis in your body.

Drug treatment
Drugs without a prescription
• For the pain you can get a simple painkiller with the active ingredient paracetamol without a prescription. Paracetamol helps against pain and fever, does not cause stomach problems, usually does not cause side effects and can be easily combined with other medications.
• An NSAID, an anti-inflammatory analgesic in a lower dose. The abbreviation NSAID stands for Non-Steroidal Anti-Inflammatory Drugs. These painkillers inhibit inflammation.

Do you have physical complaints? Always go to your doctor or specialist for a proper diagnosis and proper treatment.

Drugs on prescription
This is provided by your doctor or rheumatologist or internist.
• Antibiotics. Your doctor will treat the infection that causes the reactive arthritis with antibiotics or an antiviral agent in a post-viral arthritis. New research suggests that long-term treatment with two or more antibiotics may be effective in patients with chronic Chlamydia-induced reactive arthritis. However, this needs to be further investigated.

The early stage of reactive arthritis is considered acute (early). An acute inflammation can be treated with non-steroidal anti-inflammatory drugs.
• An NSAID, an anti-inflammatory drug, such as naproxen (Aleve), diclofenac (Voltaren), indomethacin (Indocin) or celecoxib (Celebrex). NSAID stands for Non-Steroidal Anti-Inflammatory Drugs. These are drugs that are effective against inflammation, swelling, pain, stiffness and fever, but do not contain corticosteroids (steroids). They do not prevent joint damage. There is no proof that any one NSAID is better than others. Your doctor will prescribe these prescription drugs with a higher dose of the active substance. The exact effective dose varies from patient to patient. High doses of short‐acting NSAIDs give the fastest relief of symptoms. Given in the correct dose and duration, these drugs give great relief for most patients. An NSAID may cause stomach upset, gastrointestinal (GI) bleeding, ulcers or diarrhea, but they are well tolerated by most people when used for the short term. Some people cannot take NSAIDs because of health conditions such as ulcer disease, impaired kidney function or the use of blood thinners.

The late stage of reactive arthritis is considered chronic and can be treated with the following drugs.
• A synthetic DMARD (Disease-Modifying Anti Rheumatic Drug), for example Methotrexate and Sulfasalazine may be prescribed. Sulfasalazine can slow down chronic inflammations and help prevent or limit joint damage. A DMARD has different mechanisms of action and suppresses joint inflammations in a number of forms of arthritis. When using a DMARD at an early stage of your condition, your joints will therefore be less damaged by the inflammations. This class of medication is especially useful in people with a form of arthritis that also affects the joints of the arms and legs. If regular anti-inflammatory drugs do not work or if the condition recurs or becomes chronic, your doctor may decide to prescribe a classic anti-inflammatory agent such as sulfasalazine or methotrexate. Sulfasalazine may be more useful when the reactive arthritis is triggered by a gastrointestinal (GI) infection.
In addition to the DMARD, the specialist can also prescribe an NSAID or a corticosteroid at the same time or a combination of rheumatic inhibitors to directly combat the pain and to tackle the inflammation more effectively. Not everyone responds well to a DMARD and it can take weeks or sometimes months before you notice the effect.
• A corticosteroid (an artificial adrenal cortex hormone) is an anti-inflammatory drug that resembles the natural hormone that the body produces in the adrenal cortex. Corticosteroids mimic the effects of hormones your body produces naturally in your adrenal glands, which sit on top of your kidneys. When prescribed in doses that exceed your body’s usual levels, corticosteroids suppress inflammation. This can reduce the signs and symptoms of inflammatory conditions, such as arthritis. Corticosteroids also suppress your immune system, which can help control conditions in which your immune system mistakenly attacks its own tissues. A corticosteroid drug can be quickly effective for a joint swelling that is localized (not widespread) by an injection or shot into the effected joint or tendon sheath (the membrane around a tendon). Very inflamed joints may benefit from corticosteroid injections (cortisone shots). Prednisone (glucocorticoid) reduces inflammation throughout your body. It does so by interfering with the way certain chemicals in your body cause inflammation.
• A biologic DMARD (biologic inhibitor). In more severe cases, stronger immune lowering drugs called “biologics” may be used such as Etanercept (Enbrel) or Adalimumab (Humira). TNF alpha inhibitors (a class of drugs known as biologics) are very effective in treating both the spinal and peripheral joint symptoms of spondyloarthritis. However, anti-TNF treatment is expensive and not without side-effects, including an increased risk for serious infections. That is why first, the doctor will check if you do not have other infections, tuberculosis, heart failure or a malignant disease. These diseases can in fact be exacerbated by treatment with a biologic and must therefore be treated first. If you are a patient with a latent tuberculosis (no symptoms) you may develop an active infection. Therefore, you and your doctor should weigh the benefits and risks when considering treatment with a biologic. Patients with arthritis in the knees, ankles, elbows, wrists, hands and feet should try a DMARD therapy before an anti-TNF treatment. A biologic is a drug that can affect your immune system. If you are healthy, the immune system itself produces enough antibodies to defend itself against pathogens (viruses and bacteria). This balance is disrupted in people with chronic inflammatory disease. A biologic can restore that balance.
• A biosimilar. A biosimilar drug is a drug that is developed to be highly similar and clinically equivalent to an existing biologic. A biosimilar drug contains a version of an active substance of an already approved biologic drug (the ‘reference drug’ or ‘originator drug’). Similarity to the reference biologic in terms of quality, structural characteristics, biological activity, safety and efficacy must be established, so that there are no clinically meaningful differences from the biologic in terms of quality, safety and efficacy. Research has shown that the biosimilar is just as effective as the original biologic inhibitor in the treatment of arthritis.
Biosimilar drugs are not the same as generic drugs, which contain simpler chemical structures and are identical, in terms of molecular structure, to their reference drugs.

Talk to your doctor about what to expect from treatment with NSAIDs and DMARDs. New research suggests that a prolonged course of two or more antibiotics might be effective in patients with chronic Chlamydia-induced reactive arthritis. However, this should be researched further.

Other medications
If you have an eye infection, your doctor may prescribe eye drops.
The skin rash is usually not serious, it generally disappears naturally.

Use of drugs and adherence

• It is important that you take the drugs as prescribed. In order to get your illness under control, it is very important that you take your drugs on a regular basis every day. If you do not, there is no good concentration of the drug in your blood and therefore the drug will work less well.
• Do you have trouble remembering when and how many of your drugs you should take on a daily basis and at what time of the day? Then buy a drug dispenser, in which you can sort your drugs per day.
• Do you have difficulty or objection to taking the drug prescribed to you, for example because of possible side-effects? Then that can lead to you no longer taking the drug regularly. Discuss this with your doctor!

Deterioration of your illness and/or complications
The doctor will look at:
• The dosage and amount of drugs you use.
• Switching to another drug in the same type or a completely new type of drug.
• Combining different drugs at the same time.

Your doctor can tell you
• whether the drug can work for you.
• how you can best use the drug.
• how much and how often you can use the drug.
• how you can best reduce the drug.

You should always tell your doctor or specialist
• if you use other drugs (bought or prescribed by another doctor).
• if you have another medical condition.
• whether you will be operated on soon.
• if you have previously been prescribed an anti-inflammatory analgesic that has caused side effects.
• whether you want to become pregnant or are pregnant.
• if you are breast-feeding.
This is important because your doctor or specialist has to make a careful choice between different medicines.

Side-effects
• All drugs may have side-effects when used, so ask your doctor or pharmacist what side-effects you can expect or read the leaflet.

Reduce or stop
• If you stop using a drug yourself or reduce the number of drugs yourself, your symptoms may worsen. Always consult your doctor or specialist first if you want to use less drugs or want to stop.

Alternative treatments

There are many types of alternative treatments. This refers to all treatments that fall outside normal scientific medical care. No scientific evidence has been provided for the operation of these treatments. The alternative treatments are also called ‘complementary‘ because they can supplement the regular medical treatment by your doctor.
Many people choose an alternative treatment in addition to their regular medical treatment. They hope that this helps extra against their complaints or better helps to deal with the complaints.

Can an alternative treatment be a replacement for your regular medical treatment?
No, if you opt for an alternative treatment method, it is always a supplement to your regular medical treatment. You should not stop your regular treatment, because otherwise you run unnecessary health risks. Always consult your attending doctor before you start an alternative treatment.

What alternative treatments are there for example?
There are many different alternative treatment methods available, which can also be combined. Some examples are:
• Chinese medicine (acupuncture, pressure point massage, nutrition and tai chi).
• homeopathy (products made from plants and minerals).
• Bowen therapy.
• Ayurveda.
• Bach flower treatment.
• shiatsu, foot-sole and classic massage.
• Touch for Health.
• Reiki.
• dietary supplements.

What do you have to pay attention to?
• Many alternative treatments have not shown that they actually work. If you choose to try alternative treatment, make sure that your complaints do not increase. Stop an alternative treatment as soon as your symptoms increase.
• Always consider first why you want to follow an alternative treatment.
• Prepare yourself by looking up and reading information about the alternative treatment. Consult with your attending doctor, because certain complaints may be reduced by some alternative treatment methods.
• Determine yourself in which alternative method you trust for the relief of your complaints and whether you want to start.

What can you do best when choosing an alternative treatment?
• Always consult your doctor about the alternative treatment method you want to follow.
• Consult with your attending doctor and with the alternative therapist if they want to discuss your treatment with each other.
• Choose an alternative therapist who has followed a recognized vocational training and is affiliated to a professional organization.
• Ask your alternative therapist in advance about the purpose, duration, costs and risks of the treatment. How much money you spend depends on which treatment you choose and how long it takes.
• Do not stop your regular medical treatment, as this may worsen your symptoms.
• Weigh during treatment whether you want to continue or stop if your symptoms get worse, if you do not notice any effect of the alternative treatment or if you get side-effects.

Why is your food important?

• Healthy nutrition is important to get the vitamins and minerals and other nutrients that your body needs.
• Obesity creates risks for your health and disease progression. In the case of arthritis and obesity, for example, obesity plays an important role in overburdening and osteoarthritis in the knees, hips and ankles. The pressure on your joints is then simply too great. Healthy eating and exercise (exercising a sport and active in the home and outdoors) can help to reduce or prevent excess weight.
• A healthy diet is always important and the dietitian can support you with the right dietary advice.

What is a healthy diet?
With a healthy diet your body gets the right amount of good nutrients, which it needs. You eat the quantities that your body needs. The dietitian can support you with the right nutritional advice.
The 5 courses to choose from are:
• Vegetables and fruit
• Bread, cereal products and potatoes
• Fish, legumes, meat, egg, nuts and dairy
• Lubrication and preparation fats
• Drinks.

Where can you get advice for a healthy diet?
• You can request advice from your doctor or a dietitian. The doctor can refer you to a dietitian. Some diets may possibly help against your symptoms. Consult with your doctor or dietitian if you want to try a certain diet. And make sure that you do not omit important foods from your daily diet.

What can you do with a painful or dry mouth?
Sometimes you can suffer from a dry or painful mouth for various reasons, also due to your illness. Tips:
• by chewing (for example piece of cucumber, sugar-free candy or chewing gum) and sucking (ice cube) the salivary glands are stimulated to produce saliva.
• good oral care is important: good tooth brushing, flossing and the use of mouthwash.
• rinse your mouth regularly, drink small amounts of water and use a mouth sprayer if necessary.
• let hot drinks cool down first.
• use ice or cold dishes, because the cold numbs the pain.
• do not use sharp herbs and spices, fruit juice, carbonated soft drinks, alcoholic beverages, very salty foods and sour food.
• food with hard crusts, nuts, bones and bones can cause injuries.
• use soup, gravy or sauce with the hot meal to make the food smoother.
• spreadable cheese, spreadable paté or salad, jam or honey on bread, porridge, drinking breakfast and custard, for example, swallows easier than dry spreads.
• if you need to use ground or liquid food, you can use a mixer to grind your meal with some extra moisture.

In some forms of arthritis or use of certain drugs intestinal complaints can occur. The intestinal complaints can arise from the influence of certain drugs on food intake. Conversely, the food you eat can have an effect on the way your drugs work.

Dietary supplements, fish fatty acids, glucosamine and vitamin D?
• Dietary supplements are available as pills, powders, drops, capsules or drinks and are intended as a supplement to inadequate daily nutrition. They contain vitamins, minerals or bio-active substances. These synthetic or isolated vitamins, minerals or bio-active substances have the same effect as the vitamins and minerals that are already naturally in your food and drink.
Many people choose an additional supplement, in addition to their daily diet. The users of dietary supplements indicate that they experience positive effects of the use of certain herbs, vitamins and minerals. The body absorbs the nutrients in pills more easily than the nutrients in food. But if you eat healthy and varied, you do not need additional nutritional supplements, because you already get enough nutrients, minerals and vitamins. Always report to your doctor and pharmacist that you are using dietary supplements.
• Fish fatty acids appear to have a mild anti-inflammatory effect with a high intake. Research has been done especially in rheumatoid arthritis. The advice is to eat oily fish twice a week.
• Glucosamine can act as a mild painkiller for osteoarthritis in the knee, but does not stop arthritis.
• Our body naturally makes vitamin D under the influence of outdoor sunlight. Vitamin D may have a beneficial effect in inflammatory arthritis, but that has not yet been proven sufficiently. People with Lupus erythematosus get vitamin D prescribed as they are not often outside, because sun exposure can lead to lupus flares and skin problems. Vitamine D is given with calcium tablets to ensure a good intake in the body, when you have osteoporosis or osteoarthritis.

Living with reactive arthritis

• Let your inflamed joint rest in the beginning. Lay the joint up and cool it.
• When the inflammation is less severe, you must move the weight regularly (such as in cycling, walking, swimming). This prevents stiffness and can reduce the pain. You can better avoid sports that put a heavy load on the joints.