Reactive arthritis (ReA) is a rare type of arthritis that can affect joints of the lower body such as the feet, ankles, hips, knees and sometimes the lower back. It occurs after certain types of infections. Reactive arthritis is usually acute (sudden onset, short-term), but it can also be chronic (long-term). Chronic forms can flare up and down. ReA used to be called Reiter’s syndrome.
Reactive arthritis typically occurs 10 to 14 days after an infection of the bowels (diarrhea), the urinary tract, or following a sexually transmitted infection (STI) such as chlamydia. For some reason that is not well understood, the infection triggers an arthritic reaction.
Reactive arthritis affects adult men and women aged 30 to 40. It is a bit more common in men. There is a genetic component in people who get ReA. About 75% of all patients who get it have a gene called HLA-B27.
Reactive Arthritis (ReA) symptoms can be very typical of any inflammatory arthritic condition. At the initial onset of the disease, people can feel unwell, tired and feverish. They may have headaches or lose weight. These early symptoms can also be caused by the recent infection triggers this form of arthritis. The condition typically occurs 1 to 4 weeks after an infection of the bowels, urinary tract, or following a sexually transmitted infection (STI).
ReA tends to start very quickly and can be very intense. It most commonly affects joints in the feet, ankles, knees, and hips. They can become very stiff, swollen, painful, warm, and may be slightly red. The disease can also cause inflammation of the joints of the lower back leading to back pain and stiffness. Inflammation in the tendons is common as well.
ReA is often asymmetric, meaning it often affects just one side of the body.
In some cases, the toes can swell up like sausages (this is called dactylitis). In ReA, often only a single digit is affected. Changes to the nails might also occur.
Other conditions that can be present with ReA include inflammation of the eye (conjunctivitis) and genital or urinary symptoms such as painful urination (urethritis) or pelvic pain in women. Men can sometimes have genital sores.
In rare cases, a rash may occur on the skin and sores on the mouth or nose may develop.
There is no single diagnostic test for reactive arthritis. It is best diagnosed by a rheumatologist: a specialist who is very familiar with arthritic diseases. They will take a careful and complete history and will perform a thorough physical examination, and then will order tests to investigate further.
People who think they might have ReA should tell their doctor if they’ve recently had a bowel infection, urinary infection, or an STI.
One mnemonic, or memory aid, used by medical students to help them remember how to diagnose Reactive Arthritis is: can’t see, can’t pee, can’t climb a tree. These three features are common but they are not always all present. They describe how ReA can affect the eyes, feature genital and urinary symptoms or be associated with a recent infection, and feature arthritis symptoms that tend to focus on large joints. Doctors may investigate each of these features if they suspect a diagnosis of ReA.
Common Tests for ReA
Looking for inflammation: ReA is an inflammatory arthritis so these tests are expected to have abnormal results. Common tests include a Complete Blood Count (CBC), Erythrocyte Sedimentation Rate (ESR), and C-Reactive Protein (CRP).
Looking for a Genetic Marker: Over 75% of people with ReA will be positive for a gene called HLA-B27. However, as HLA-B27 is also present in about 6% of this population, so doctors and patients need to be careful interpreting the results of this test. A positive HLA-B27 test does not mean there is ReA. The result of this test must be taken in context of other test results.
Blood tests and urine tests looking for sexually transmitted diseases: Since ReA is often associated with a recent infection, STI tests for Chlamydia, gonorrhea, syphilis, and HIV are commonly ordered.
Urine tests that look for signs of infection: Urinalysis and urine culture tests look for signs of infections of the urinary tract.
Stool culture test looking for signs of infection: A stool culture looks for the types of bacteria often associated with an infection in the bowels.
Reactive arthritis (ReA) typically occurs after an infection of the bowels, urinary tract, or following a sexually transmitted infection (STI). For some reason, the infection seems to trigger the immune system to begin attacking its own tissues, creating an arthritis reaction.
Oftentimes the trigger infection has been cured or is in remission (dormant) by the time a person experiences symptoms of ReA. The arthritis symptoms usually occur 1 to 4 weeks after the infection, most likely around the 2 week mark (10-14 days).
The most common triggers are intestinal infections that cause food poisoning and/or diarrhea such as Salmonella, Shigella, Campylobacter, Yersinia, and Clostridium difficile; and sexually transmitted infections (STI’s) such as chlamydia.
Scientists aren’t sure exactly why the immune system causes an arthritic reaction, but it seems that there is a genetic component to the disease. About 75% of people who get ReA have a gene called HLA-B27. This suggests that people with this gene have a genetic predisposition to developing the disease after an infection.
The first step in treating reactive arthritis (ReA) is to treat the infection if it hasn’t already been cleared. Bowel and urinary tract infections are usually treated with antibiotics. Other types of medications may be required for sexually transmitted infections (STI’s).
Medications for Treating Arthritis Symptoms in ReA
Corticosteroids (Prednisone, Cortisone)
For acute (sudden and severe) attacks of reactive arthritis, corticosteroids can be very effective to control inflammation and to reduce pain and swelling. These can be taken orally as pills (prednisone) or sometimes as cortisone injections directly into a joint.
Corticosteroids provide the quickest relief of any treatment. It can take up to 24 or 48 hours to feel the effects. The effects can last for a few days up to a few months, depending on the individual person and the joint.
Corticosteroid injections are usually limited to 2 or 3 in a single joint per year.
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
NSAIDs can also reduce the inflammation of joints caused by acute reactive arthritis. They also help to reduce pain. They can take a little longer to work than corticosteroids.
Disease Modifying Anti-Rheumatic Drugs (DMARDs)
Anti-TNF biologics can be an extremely effective group of medications that help relieve the joint pain and stiffness caused by ReA that aren’t relieved by anti-inflammatory drugs or DMARDs.
Medications for Treating Eye Symptoms in ReA
If a skin rash or oral ulcers are present, a topical (applied to the surface) steroid such as cortisone is used. Eye drops that contain cortisone are usually used to treat conjunctivitis.
Living with ReA
The pain and stiffness caused by ReA can sometimes limit people’s normal activities, including work. There are many things people can do to lessen the impact of ReA on their work and daily routine.
We recommend adjusting features of the workplace to help make working with ReA easier. For example, people that sit for much of the day can adjust the position of chairs and desks for proper posture. Vehicle seats can be adjusted to make driving more comfortable and reduce stress on joints and affected tissues.
Those who find out they have ReA while they’re still young can consider choosing work that isn’t physically demanding on their joints and back.
Exercise is important to overall health. It also helps keep the joints moving properly, and helps protect them by strengthening the muscles around them.
The level and amount of exercise people with ReA can do depends on the activity of their disease.
A trained arthritis physiotherapist is the best person to help design an exercise program tailored to the needs of patients with ReA.
The following are some useful articles on exercising with arthritis:
Exercise and Arthritis: An article by arthritis physiotherapist Marlene Thompson
Exercising in a Flare: Another excellent article by Marlene Thompson on how to cope with flares through your exercise routine.
Alcoholic beverages are not an effective treatment for ReA, and they can interact with many medications.
People with ReA that plan on drinking should ask their doctor about possible negative interactions with the medications they take.
Some examples of medication that mixes poorly with alcohol includes, and is not limited to: the DMARDs methotrexate, Arava (leflunomide), and Imuran (azathioprine).
Smoking is not healthy for people with ReA. It can make symptoms worse and harder to treat.
Research has shown that some arthritis medications do not work as well in people who smoke.
We recommend that smokers quit immediately to reduce the impact of their symptoms, improve the effectiveness of their medications, and improve their overall health.
Smoking significantly increases the risk of cardiovascular disease. The chronic (long-term) inflammation caused by rheumatic diseases like ReA already increases this risk without a big extra boost from smoking.
Travel is still possible when you have ReA.
It is best for people with this disease to get organized well in advance of a trip to ensure a smooth, comfortable, and enjoyable time.
Check out our Travel Checklist page.
Though ReA does not particularly cause a loss of sex drive, it can cause pain, fatigue and emotional hardships. These hardships risk creating barriers to sexual needs, ability, and satisfaction.
People with ReA can take comfort knowing that sex and intimacy can be maintained. In many cases, it can help draw partners closer together, especially through improved communication.
For more information on intimacy and arthritis, a great book is: Rheumatoid Arthritis: Plan to Win by Cheryl Koehn, Taysha Palmer and John Esdaile.
Reactive Arthritis (ReA) has no effect on fertility. The chances of getting pregnant for people with ReA are the same as with people that don’t have it. ReA also has no known effects on the developing fetus or the newborn.
The two main issues doctors worry about with ReA and pregnancy are:
Patients with ReA might be treated with a number of medications that can affect pregancies including NSAIDs, anti-TNF biologics, and occasionally DMARDs. It is important for people with ReA who want to become pregnant to discuss their medications with their doctor and create a pre-pregnancy plan. A plan is important for a number of reasons. For example, discontinuing a particular medication for safety of the newborn might cause ReA to flare, so its wise to have a plan in place to handle these possibilities.
Any type of arthritis that affects the pelvis or the hips can make vaginal delivery difficult. It is important for those planning pregnancy to discuss delivery options with an obstetrician.
Following the basics of healthy eating can help improve health and well-being in everyone, including those with ReA. Keeping a healthy weight helps reduce the load on weight-bearing joints including the spine, hips, and knees, making it easier to live with the disease.
Unfortuantely, no special diet has ever been proven to significantly alter the course of ReA or any other types of arthritis.
In addition, no known natural remedies or complementary therapies have been proven to help ReA in any significant way.
People with ReA should consult with their doctor to make sure that any supplements or alternative therapies they consume will not negatively interact with their medications.
Its very important for people with ReA to attend regularly scheduled appointments with their rheumatologist, and promptly get any tests that are ordered by their doctors.
It is often very important that medications are taken exactly as prescribed. Patients should always talk to their doctor about any issues they experience, or if they would like to change anything.
Reactive Arthritis is a chronic disease and a rheumatologist is the best partner in helping patients achieve the best quality of life possible.