ANTIBIOTICS.

Antibiotic therapy may be indicated in certain individuals with reactive arthritis or Reiter's syndrome. Patients with culture-proven infectious diarrhea (e.g.,Shigella, Salmonella, Yersinia) may benefit from appropriate antibiotic therapy. If chlamydial-induced arthritis is documented by serology, culture, or DNA probe, prolonged (e.g., 3 months) antibiotic therapy with doxycycline or lymecycline should be initiated. Studies have shown disappointing results with short-term tetracycline therapy.

SLOW-ACTING ANTIRHEUMATIC DRUGS.

Slow-acting antirheumatic drugs (e.g., sulfasalazine, methotrexate) should be considered, when chronic NSAID-unresponsive peripheral arthritis, enthesitis, or spondylitis exists. These agents have a delayed onset of action (2 to 6 months), and their efficacy in the spondyloarthropathies is based on limited numbers of controlled trials and numerous anecdotal reports.

Placebo-controlled trials of sulfasalazine indicate that efficacy is greatest in patients with peripheral arthropathy and enthesopathy. Equivocal results have been observed in patients with long-standing disease and evidence of severe radiographic destruction or spinal ankylosis. At a dose of 2 to 4 g/day, it is most effective in patients with Reiter's syndrome, reactive arthritis, and enteropathic arthritis. The value of sulfasalazine in treating inflammatory axial disease has not been established but warrants consideration in poorly controlled spondylitis patients.

Methotrexate (7.5 to 20 mg/week) may also be effective in many patients with spondyloarthopathy. It is particularly effective for treating both cutaneous and articular disease in psoriasis, but higher doses and prolonged use may be associated with unacceptable hepatotoxicity. Azathioprine (1 to 2 mg/kg/day) should be reserved for those unresponsive to or intolerant of other slow-acting antirheumatic drugs.

Additional therapeutic options exist for patients with psoriatic arthritis. Both methotrexate and sulfasalazine may be effective for managing articular and skin disease associated with psoriasis. Other patients may benefit from therapy with gold salts, antimalarials, etretinate, or cyclosporine. Newer agents (e.g., leflunomide) and proinflammatory cytokine inhibitors (e.g., etanercept, infliximab) have not been studied in spondyloarthropathy patients. Although immunosuppressive regimens should be avoided in HIV-associated arthritis, agents such as sulfasalazine or etretinate may be considered.

SURGERY.

Surgery should be considered when pain and immobility markedly interfere with patient lifestyle. Total joint replacement is commonly performed in the hip or knee. The success of arthroplasty may be limited by postoperative heterotopic bone formation. Surgical correction of spinal deformities and/or fractures should be undertaken with extreme caution.

Reference

Amor B, Dougados M, Khan MA: Management of refractory ankylosing spondylitis and related spondyloarthropathies. Rheum Dis Clin North Am 21:117, 1995.Review of the diagnosis and treatment of patients with refractory or severe spondyloarthropathy.

Bardin T, Enel C, Cornelis F, et al: Antibiotic treatment of venereal disease and Reiter's syndrome in aGreenlandpopulation.Arthritis Rheum35:190, 1992.Suggested guidelines and treatment outcomes of patients with Reiter's syndrome treated with antibiotics.

1507

Cush JJ,LipskyPE: Reiter's syndrome and reactive arthritis. In Koopman WJ (ed): Arthritis and Allied Conditions--A Textbook of Rheumatology, 13th ed. Baltimore, Williams & Wilkins, 1996, pp 1209-1227.A comprehensive overview of Reiter's syndrome and reactive arthropathies.

Hammer RE,MalkaSD, Richardson JA, et al: Spontaneous inflammatory disease in transgenic rats expressing HLA-B27 and human b2m: An animal model of HLA-B27-associated human disorders. Cell 63:1099, 1990.Describes the spectrum of clinicopathologic manifestations induced by introducing HLA-B27 into transgenic rats.

Kettering JM, Towers JD, Rubin DA: The seronegative spondyloarthropathies. Semin Arthritis Rheum 31:220, 1996.Review of the seronegative spondyloarthropathies with an emphasis on the clinical and radiographic features that distinguish these disorders from other arthritides.

LipskyPE, Alarcon GS, Bombardier C, et al: Algorithms for the diagnosis and management of musculoskeletal complaints. Am J Med 103 (Suppl. 6A): 49, 1997.Overview of the diagnosis and management of several musculoskeletal disorders, including the spondyloarthropathies.

Tay-Kearney ML, Schwam BL, Lowder C, et al: Clinical features and associated systemic diseases of HLA-B27 uveitis. Am J Ophthalmol 121:47, 1996.Retrospective review of HLA-B27-associated uveitis in clinical practice, its manifestations, and clinical associations.