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Reactive Arthritis

Reactive Arthritis

Condition Reactive

Reactive arthritis This booklet provides information and answers to your questions about this condition.

Arthritis Research UK produce and print our booklets entirely from charitable donations. What is ?

Reactive arthritis is a condition which can develop following any (usually a bowel or sexually transmitted infection), causing painful swelling of the . In this booklet we’ll explain more about the condition, some of the possible causes and what can be done to help.

At the back of this booklet you’ll find a brief glossary of medical words – we’ve underlined these when they’re first used.

www.arthritisresearchuk.org Arthritis Research UK Reactive arthritis

What’s inside?

2 Reactive arthritis at a glance 10 Self-help and daily living 4 What is reactive arthritis? – Rest and exercise – Diet 4 What are the symptoms – Complementary medicine of reactive arthritis? 11 Research and new 5 Who gets reactive arthritis? developments 6 What causes reactive arthritis? 11 Is reactive arthritis the same 7 What is the outlook? as viral-associated arthritis? 7 How is reactive arthritis 12 Glossary diagnosed? 14 Where can find out more? – What tests are there? 16 We’re here to help 8 What treatments are there for reactive arthritis? – Treating the infection – Treating the and swelling – Treating severe or ongoing arthritis At a glance Reactive arthritis Symptoms may last for up to six months but will usually disappear completely. What is reactive arthritis? Reactive arthritis is a relatively short- lived condition causing painful swelling of the joints. It develops shortly after an infection of the bowel or genitals, or, less commonly, after a viral or throat infection. Sometimes, the cause isn’t known. • a sore rash over the end of the penis.

What are the symptoms? What treatments are there? The most common symptoms of reactive Medical treatments for reactive arthritis arthritis are: fall into three groups: • painful and swollen joints, usually in the Treating the original infection: lower limbs (ankles or ) •  (usually taken by mouth) • swelling and tenderness of the tendons to help clear up the initial infection surrounding joints () if it doesn’t go away • sausage-like swelling of fingers or • eye drops to treat eye . toes () Treating : • inflamed, red eyes (). • non-steroidal anti-inflammatory drugs Other, less common symptoms (NSAIDs) – for example ibuprofen – may include: in mild to moderate cases. • scaly rashes over the hands or feet Tackling ongoing arthritis: • diarrhoea, which may start some time • disease-modifying anti-rheumatic before the arthritis drugs (DMARDs) • mouth ulcers • injections to remove fluid from the • inflammation of the the tube from joints (aspiration) the bladder (the ), known as • steroid injections into the joints – this can cause discharge or muscles. from the penis or female genital tract and/or stinging when passing 2 Arthritis Research UK Reactive arthritis

What causes it? What tests are there? Unlike , which is caused There’s no specific test for reactive by an active infection within a joint, arthritis, but the following may be used reactive arthritis is a reaction to an to confirm a diagnosis or rule out other infection elsewhere in your body. causes of the symptoms: This original infection may be: • a stool sample or swabs taken from • a gut infection, such as food the throat, penis or vagina, which can poisoning or dysentery, usually be tested for signs of inflammation involving diarrhoea or infection • an infection of the genital tract, • blood tests to check for levels of sometimes caused by sexually inflammation and sometimes to test for transmitted infections (STIs) a specific gene that can make you more • a throat infection, usually caused likely to get reactive arthritis (known as by a called HLA-B27). • an unknown viral or bacterial infection of another kind. How can I help myself? You might find the following help ease How is it diagnosed? some of the symptoms: Reactive arthritis can usually be told • plenty of bed rest, which may be apart from other arthritic conditions helpful in the short term because of the link to an earlier infection. • ice packs and heat pads Your doctor will therefore probably ask • wrist resting splints, and heel and shoe about your recent health and sexual pads for support and comfort activity if they think you may have reactive arthritis. • painkillers ().

3 What is reactive arthritis? What are the symptoms The term reactive arthritis is used of reactive arthritis? to describe joint inflammation (heat, Pain and swelling, usually in the lower pain and swelling) that can develop after limbs (knees, ankles or toes), are often an infection of the bowel or genitals. the first signs of reactive arthritis. Often reactive arthritis only causes joint Swelling may happen suddenly inflammation, but sometimes there may or develop over a few days after the be other symptoms. affected joints become stiff. Other Reactive arthritis is usually a relatively joints, including the fingers, wrists, short-lived condition that may last for and the joints at the base of up to six months and in most cases the spine (sacroiliac joints), can also disappears completely, causing no become inflamed. problems in the future.

Figure 1 Eye inflammation Symptoms of reactive arthritis

Lower back pain

Note: You may Scaly skin Diarrhoea only have some of patches on these symptoms. genitalia

Swelling in , heel or ball of foot ‘Sausage’ toes Flaky skin patches on sole

Photography used with kind permission of Elsevier. © Elsevier 2011. Taken from Practical , third edition. Edited by Marc C Hochberg, Alan J Silman, Josef S Smolen, Michael E Weinblatt and Michael H Weisman. 4 Arthritis Research UK Reactive arthritis

Reactive arthritis can also cause a particular gene, HLA-B27, you may be inflammation of the tendons around the more likely to develop the condition. joints, such as the Achilles tendon at the This gene is carried by about 1 in 14 (7%) back of the ankle. If both the tendons and of the general population. Having the joints of one finger or toe are affected HLA-B27 gene may also make you more at the same time, it can cause that finger likely to have further episodes of reactive or toe to become swollen like a sausage. arthritis in the future. This is called a sausage digit or dactylitis (see Figure 1). See Arthritis Research UK booklets Often joint pain and swelling are the only ; ; symptoms of reactive arthritis; however, What is arthritis? as Figure 1 shows, other possible symptoms include: • inflamed, red eyes (conjunctivitis) • scaly rashes over the hands or feet (known as keratoderma blenorrhagica) • diarrhoea, which may start some time before the arthritis • mouth ulcers • inflammation of the genitals, which produces a discharge from the vagina or penis • a sore rash over the end of the penis • weight loss and .

Who gets reactive arthritis? People of all ages, including children, can get reactive arthritis. It generally affects a younger average age group than rheumatoid arthritis or osteoarthritis. Although there isn’t a family tendency to develop reactive arthritis, if you have

5 What causes reactive arthritis even when there’s no reactive arthritis? definite history of infection. Unlike septic arthritis, reactive arthritis It isn’t known exactly why this isn’t caused by an active infection within happens. One theory is that once the joints. With reactive arthritis the your immune system has dealt with inflammation of the joints is a reaction the original infection, fragments of to an infection elsewhere in your body. bacteria may be carried through your Reactive arthritis is diagnosed if you bloodstream and deposited in the lining suddenly develop arthritis, especially in of your joints. This could trigger an your knees or ankles, just after suffering inflammatory reaction. an infection. Sometimes the infection The most common cause in the UK is may have been so mild that you didn’t an infection of the gut, such as food notice it, so doctors often diagnose poisoning or dysentery. Between 1 and 2% of people involved in any outbreak of food poisoning may suffer joint inflammation afterwards. Reactive arthritis is often reported following a stomach upset or diarrhoea. Less commonly, reactive arthritis may follow a sexually transmitted infection (STI), such as . You’re at risk from STIs if you have sex (including oral sex) without a condom or another form of barrier contraception. As many STIs don’t always have obvious symptoms, you should visit your doctor or local STI clinic for testing if you’ve had unprotected sex. Arthritis Research UK Reactive arthritis

Chlamydia, the most common STI in When this happens it’s described as the UK, can trigger bouts of reactive recurrent. If you’re affected in this way arthritis. It often doesn’t have any you should be especially careful to avoid symptoms (especially in women), exposure to food poisoning and to avoid but it may cause pain on passing urine the risk of STIs. or discharge from the vagina or penis. If you experience these symptoms, or have had unprotected sex and are How is reactive worried, see your GP or visit a sexual arthritis diagnosed? health clinic. There are several other conditions which can cause similar inflammation Sometimes reactive arthritis can follow of the joints. These include rheumatoid a throat infection (usually caused by arthritis, , Behçet’s bacteria called streptococcus). syndrome and .

What is the outlook? See Arthritis Research UK booklets For most people, reactive arthritis Behçet’s syndrome; Gout; disappears completely within six months. Psoriatic arthritis. During this time you may have good and bad days. Gradually, as the arthritis goes away, you’ll find there are more good days than bad. In 10–20% of people, the symptoms last for longer than six months, but only a small number of people go on to develop an ongoing arthritis that needs longer-term treatment. Some people, especially those who have the HLA-B27 gene, may have bouts of reactive arthritis which come Usually when back at intervals of months or years reactive arthritis in response to further infections. disappears the joints make a full recovery and there are no long-term problems as a result.

7 A short course of antibiotics will help to clear up your • a urine sample, which can also test for original infection. signs of infection • blood tests to check for levels of inflammation and sometimes to test for the HLA-B27 gene. Blood tests can also be used to test for antibodies linked with other forms of arthritis (including rheumatoid factor and anti-nuclear antibody (ANA).

Doctors usually diagnose reactive arthritis If your eyes are sore and red you may if one or more of the following are true: be examined by an eye specialist (ophthalmologist) in order to check • you suddenly develop arthritis, that it isn’t a serious inflammation of especially in the knees or ankles, the eye, known as iritis. This is different just after suffering an infection – but from conjunctivitis, which is the most the infection may have been so mild common cause of a painful red eye. Iritis that you didn’t notice it is inflammation of the coloured part of • all tests for other forms of arthritis (such the eye (the iris), whereas conjunctivitis is as rheumatoid arthritis) are negative inflammation of the white of the eye. • the arthritis is accompanied by symptoms very typical of reactive arthritis, such as rash over the palms What treatments are there or soles or red painful eyes. for reactive arthritis? Treatments for reactive arthritis fall into What tests are there? three groups: There isn’t a specific test for reactive • antibiotics to treat the initial infection arthritis, and it may be difficult to link if it doesn’t go away your symptoms to a previous infection. Tests may therefore be used to either • treatments to help the joint pain confirm a diagnosis of reactive arthritis and swelling or to rule out other possible conditions. • drugs to tackle ongoing arthritis. Tests may include: • a stool sample or swabs taken from Treating the infection the throat, penis or vagina, which can If you’re found to have a bowel or be tested for signs of inflammation genital tract infection, you’ll probably or infection be given antibiotics by mouth (oral

8 Arthritis Research UK Reactive arthritis

antibiotics). These will help to get rid of NSAIDs can cause digestive problems the organism that’s causing the infection. (stomach upsets, indigestion, or damage But antibiotics aren’t generally given over to the lining of the stomach) so in most a long period of time because research cases NSAIDs will be prescribed along has shown that this doesn’t help to clear with a drug called a proton pump up the joint inflammation in reactive inhibitor (PPI), which will help to protect arthritis. Conjunctivitis is often treated the stomach. with eye drops or ointment. More severe NSAIDs also carry an increased risk eye inflammation, such as iritis, may need of heart attack or stroke. Although the steroid eye drops. increased risk is small, your doctor will be cautious about prescribing NSAIDs Treating the joint pain if there are other factors that may increase and swelling your overall risk – for example, smoking, Joint inflammation is treated according circulation problems, high blood pressure, to severity. Mild to moderate arthritis high cholesterol or . may be eased with non-steroidal anti- inflammatory drugs (NSAIDs) such as See Arthritis Research UK ibuprofen or naproxen. Like all drugs, drug leaflets Drugs and arthritis; NSAIDs can sometimes have side-effects, Non-steroidal anti-inflammatory but your doctor will take precautions to drugs (NSAIDs). reduce the risk of these side-effects – for example, by prescribing the lowest effective dose for the shortest possible As well as drug treatments, you might find period of time. wrist resting splints, heel and shoe pads, and sometimes bed rest helpful in the short term. Ice packs and heat pads can also help to ease joint pain and swelling.

9 A pack of frozen peas or a hot-water short courses of low-dose steroid tablets. bottle can be used, but you shouldn’t Steroid treatments given in these ways apply them directly to your skin. are often very effective in the short term. If the treatments described above don’t See Arthritis Research UK booklets quickly allow good control of the disease, Looking after your joints when you have you may be given disease-modifying arthritis; Splints for arthritis of the wrist anti-rheumatic drugs (DMARDs) such as and hand. or methotrexate.

Treating severe or ongoing See Arthritis Research UK arthritis drug leaflets Local steroid injections; Methotrexate; Steroid tablets; If you have more severe symptoms, you Sulfasalazine. may need an injection to remove fluid from the affected joint (this is called aspiration) and to put steroid into it. This is often used to ease . Where a Self-help and daily living tendon is painful, it’s sometimes possible Rest and exercise to inject steroid near to that tendon to If your joints are inflamed, you may feel reduce the inflammation. Occasionally, tired and generally unwell. Plenty of rest severe arthritis may need treatment and sleep can play an important role with injections of steroids into a muscle in recovery during the early stages of (so that it spreads through the body) or reactive arthritis, but it’s also important that you try to keep your joints moving and maintain muscle strength. You may be advised by a physiotherapist or occupational therapist to do particular exercises, but you should avoid activities that might put too much strain on inflamed joints.

See Arthritis Research UK booklets Fatigue and arthritis; Keep moving; Occupational therapy and arthritis; Physiotherapy and arthritis; Sleep and arthritis. Arthritis Research UK Reactive arthritis

Diet See Arthritis Research UK booklet There are no diets that are proven to help Complementary and alternative reactive arthritis, although some people medicine for arthritis. find that rose extract and fish oils reduce the need for anti-inflammatory drugs. You’ll need to make sure that you take fish body oil (made from tissues of Research and new fatty fish like sardines, sprat, salmon, and mackerel) and not fish liver oil (made by developments pressing the cooked liver of halibut, shark Arthritis Research UK continue to support or, most commonly, cod) because it can research into reactive arthritis. As a result, be dangerous to take fish liver oil in the we now have a better understanding large doses recommended for arthritis. of how infections can trigger reactive A well-balanced diet is important for your arthritis by overstimulating the immune general health and well-being. system. Many studies have shown the presence of particles of bacteria and See Arthritis Research UK booklet within the inflamed joints. Further Diet and arthritis. work is being done to find out whether these germs are present in a live or dead form in the joints. Learning more about Complementary medicine the causes of reactive arthritis could mean Complementary and alternative medicine that even more effective treatments can may have a role to play in the control of be developed in the future. individual joint symptoms. These may include acupuncture, herbal medicine, massage and dietary supplements. Is reactive arthritis the There are some risks associated with same as viral-associated specific therapies, but in many cases the arthritis? risks associated with them are more to No, viral-associated or post-viral arthritis do with the therapist than the therapy. is different to reactive arthritis. In this This is why it’s important to go to a legally condition joint develop at the same registered therapist or one who has a set time that a person is suffering from a ethical code and is fully insured. infection or following vaccination against If you decide to try therapies or a virus. Viral-associated arthritis usually supplements, you should be critical of clears up within a few weeks, whereas what they’re doing for you, and base your reactive arthritis can last for several decision to continue on whether you months. One of the common causes of notice any improvement. viral-associated arthritis is parvovirus

11 infection. In children, parvovirus may Anti-nuclear antibodies (ANA) – cause an outbreak of slapped cheek antibodies which are often found in the syndrome (fever and rash on the cheeks) blood of people with forms of arthritis that can be easily spread through a school other than reactive arthritis. A test for and doesn’t usually cause joint problems anti-nuclear antibodies is sometimes in the children. Adults who’ve been in carried out to rule out other conditions contact with the children suffering from which can mimic reactive arthritis. parvovirus, such as teachers, may develop Behçet’s syndrome – a condition that parvovirus arthritis. causes a number of symptoms, including The most important thing to remember mouth ulcers, genital ulcers and eye about viral-associated arthritis is that it inflammation. It’s named after Professor usually only lasts a few days or weeks Hulusi Behçet, the skin specialist who first and doesn’t return or cause long- suggested that the symptoms might all term problems. However, viruses can be linked to a single disease. It’s not linked sometimes result in reactive arthritis. to an infection. Chlamydia – the most common sexually transmitted infection (STI) in the UK. It’s Glossary caused by bacteria that can remain hidden Acupuncture – a method of pain relief for many years and is a major cause of that originated in China. Very fine needles infertility. It usually has no symptoms. are inserted, virtually painlessly, at a number of sites on your skin (meridians) Disease-modifying anti-rheumatic but not necessarily at the painful area. drugs (DMARDs) – drugs used in This interferes with pain signals to your rheumatoid arthritis and some other brain and causes the release of natural rheumatic diseases to suppress the painkillers (endorphins). disease and reduce inflammation. Unlike painkillers and non-steroidal anti- Analgesics – painkillers. As well as dulling inflammatory drugs (NSAIDs), DMARDs pain they lower raised body temperature, treat the disease itself rather than just and many of them reduce inflammation. reducing the pain and stiffness caused Antibodies – blood proteins which are by the disease. Examples of DMARDs formed in response to germs, viruses or are methotrexate, sulfasalazine, gold, any other substances which the body infliximab, etanercept and adalimumab. sees as foreign or dangerous. The role of Dysentery – an infection of the antibodies is to attack foreign substances intestines. It causes diarrhoea containing and make them harmless. blood or mucus, stomach cramps, nausea and vomiting.

12 Arthritis Research UK Reactive arthritis

Gout – an caused Osteoarthritis – the most common by a reaction to the formation of urate form of arthritis (mainly affecting the crystals in the joint. Gout comes and joints in the fingers, knees, ), causing goes in severe flare-ups at first, but if cartilage thinning and bony overgrowths not treated it can eventually lead to joint () and resulting in pain, damage. It often affects the big toe. swelling and stiffness. HLA-B27 – Parvovirus – the cause of a common B27. People who have this gene are childhood illness known as fifth disease more likely to have conditions such as or slapped cheek syndrome. Adults in reactive arthritis, psoriatic arthritis or contact with children who have this . infection may pick up a mild infection Inflammation – a normal reaction to without realising it. This virus can also injury or infection of living tissues. The trigger reactive arthritis. flow of blood increases, resulting in Physiotherapist – a trained specialist heat and redness in the affected tissues, who helps to keep your joints and and fluid and cells leak into the tissue, muscles moving, helps ease pain and causing swelling. keeps you mobile. Non-steroidal anti-inflammatory Proton pump inhibitor (PPI) – a drug drugs (NSAIDs) – a large family of drugs that acts on the stomach to reduce the prescribed for different kinds of arthritis amount of acid it produces. They’re often that reduce inflammation and control prescribed along with non-steroidal anti- pain, swelling and stiffness. Common inflammatory drugs (NSAIDs) to reduce examples include ibuprofen, naproxen side-effects from the NSAIDs. and diclofenac. Psoriatic arthritis – an inflammatory Occupational therapist – a trained arthritis linked to the skin condition specialist who uses a range of strategies . and specialist equipment to help people Rheumatoid arthritis – an inflammatory to reach their goals and maintain their disease affecting the joints, particularly independence by giving practical the lining of the joint. It most commonly advice on equipment, adaptations or by starts in the smaller joints in a changing the way you do things (such symmetrical pattern – that is, for example, as learning to dress using one-handed in both hands or both wrists at once. methods following hand ).

13 Rheumatoid factor – a blood protein Where can I find out more? produced by a reaction in the immune If you’ve found this information useful system. About 80% of people with you might be interested in these other rheumatoid arthritis test positive for titles from our range: this protein. However the presence of rheumatoid factor cannot definitely Conditions confirm the diagnosis. • Behçet’s syndrome Septic arthritis – also known as infective • Gout arthritis, this is very different from reactive arthritis. It occurs when there’s • Osteoarthritis an active infection within a joint or joints, • Psoriatic arthritis usually only one joint initially. It can • Rheumatoid arthritis happen as a complication of an artificial or arthritis. Septic • What is arthritis? arthritis is a medical emergency requiring Therapies hospital treatment. • Occupational therapy and arthritis Sexually transmitted infections (STIs) • Physiotherapy and arthritis – diseases passed through unprotected sex (sex without a condom) or sometimes Self-help and daily living through genital contact. The most • Complementary and alternative medicine common STI in the UK is chlamydia. for arthritis Tendon – a strong, fibrous band or cord • Diet and arthritis that anchors muscle to . • Fatigue and arthritis • Keep moving • Looking after your joints when you have arthritis • Pain and arthritis • Sleep and arthritis • Splints for arthritis of the wrist and hand

14 Arthritis Research UK Reactive arthritis

Drug leaflets NHS Sexual Health Helplines • Drugs and arthritis Sexual Health Line (freephone): 0800 567123 • Local steroid injections www.nhs.uk/Livewell/Talkingaboutsex/ • Methotrexate Pages/Whocanhelp • Non-steroidal anti-inflammatory Provides information and helpline drugs (NSAIDs) services on sexually transmitted • Steroid tablets infections and sexual health in general. The website includes a search facility to • Sulfasalazine help you find local sexual health clinics. You can download all of our booklets Links to sites and resources provided and leaflets from our website or order by third parties are provided for your them by contacting: general information only. We have no Arthritis Research UK control over the contents of those sites Copeman House or resources and we give no warranty St Mary’s Court about their accuracy or suitability. St Mary’s Gate, Chesterfield You should always consult with your Derbyshire S41 7TD GP or other medical professional. Phone: 0300 790 0400 www.arthritisresearchuk.org

Related organisations The following organisations may be able to provide additional advice and information: Arthritis Care Floor 4, Linen Court 10 East Road London N1 6AD Phone: 020 7380 6500 Helpline: 0808 800 4050 Email: [email protected] www.arthritiscare.org.uk Offers self-help support, a helpline service (on both numbers above), and a range of leaflets on arthritis.

15 We’re here to help Arthritis Research UK is the charity with current research and education leading the fight against arthritis. news, highlighting key projects that we’re We’re the UK’s fourth largest medical funding and giving insight into the latest research charity and fund scientific and treatment and self-help available. medical research into all types of arthritis We often feature case studies and and musculoskeletal conditions. have regular columns for questions We’re working to take the pain away and answers, as well as readers’ hints for sufferers with all forms of arthritis and tips for managing arthritis. and helping people to remain active. We’ll do this by funding high-quality research, providing information Tell us what you think and campaigning. Please send your views to: Everything we do is underpinned [email protected] by research. or write to us at: We publish over 60 information booklets Arthritis Research UK, Copeman which help people affected by arthritis House, St Mary’s Court, St Mary’s Gate, to understand more about the condition, Chesterfield, Derbyshire S41 7TD its treatment, therapies and how to help themselves. We also produce a range of separate A team of people contributed to this booklet. leaflets on many of the drugs used The original text was written by Dr Ron for arthritis and related conditions. Hughes, who has expertise in the subject. It We recommend that you read the was assessed at draft stage by GP Dr Lisa le relevant leaflet for more detailed Roux. An Arthritis Research UK editor revised information about your . the text to make it easy to read, and a non- medical panel, including interested societies, Please also let us know if you’d like checked it for understanding. An Arthritis to receive our quarterly magazine, Research UK medical advisor, Dr Fraser Birrell, Arthritis Today, which keeps you up to date is responsible for the content overall.

16 Get involved You can help to take the pain away from millions of people in the UK by:

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To get more actively involved, please call us on 0300 790 0400, email us at [email protected] or go to www.arthritisresearchuk.org Arthritis Research UK Copeman House St Mary’s Court St Mary’s Gate, Chesterfield Derbyshire S41 7TD Tel 0300 790 0400 calls charged at standard rate www.arthritisresearchuk.org

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