What is the management approach for reactive arthritis in the eye?

Management of Reactive Arthritis in the Eye

Topical corticosteroids (preferably prednisolone acetate 1%) are the first-line treatment for reactive arthritis-associated anterior uveitis, with systemic immunosuppression indicated when topical therapy is insufficient or requires prolonged use. 1, 2

Initial Management

• Immediate treatment is required for active uveitis in reactive arthritis to prevent vision loss and complications 1
• Prednisolone acetate 1% topical drops are the preferred first-line treatment due to better corneal penetration compared to other topical corticosteroids 1, 2
• Initial dosing may require more than 1-2 drops/eye/day, but this increases the risk of ocular complications 1
• Topical corticosteroids should be used as short-term therapy (≤3 months) due to risks of glaucoma and cataract formation 1, 3

Monitoring

• For patients with active uveitis, ophthalmologic examinations should occur at 2-6 week intervals based on:
  • Frequency of topical glucocorticoid administration
  • Intraocular pressure
  • Degree of inflammation
  • Presence of complications 1
• For patients with controlled uveitis on stable medication, monitoring should occur every 3 months 1, 2
• When tapering or discontinuing topical glucocorticoids, monitoring should occur within 1 month after each change 1, 2
• When tapering or discontinuing systemic therapy, monitoring should occur within 2 months of the change 1, 2

Systemic Therapy Indications

• Systemic immunosuppression is recommended if:
  • Topical corticosteroids cannot be tapered to ≤2 drops/day within 3 months 1
  • Poor prognostic factors are present at first visit (posterior synechiae, male gender, band keratopathy, glaucoma, cataract, poor initial vision, hypotony, macular edema) 1
  • Sight-threatening complications are present 2

Systemic Therapy Options

• Methotrexate is the first-choice systemic immunosuppressant 1, 2
  • Subcutaneous administration is preferred over oral administration 1, 2
• For methotrexate inefficacy or intolerance, anti-TNF agents are recommended 1
  • Adalimumab is preferred over infliximab and golimumab 1, 2
  • Etanercept should not be used for uveitis associated with reactive arthritis 1
• For patients failing methotrexate and two monoclonal TNF inhibitors, consider:
  • Abatacept or tocilizumab as biologic options
  • Mycophenolate, leflunomide, or cyclosporine as non-biologic alternatives 1, 2
• Azathioprine may be particularly effective for intermediate uveitis 4

Treatment Escalation Algorithm

1. Start with topical prednisolone acetate 1% (frequency based on severity)
2. If unable to taper to ≤2 drops/day within 3 months, add methotrexate (preferably subcutaneous) 1, 2
3. If inadequate response to methotrexate, add or switch to adalimumab 1, 2
4. If inadequate response to standard-dose adalimumab, escalate dose/frequency before switching to another TNF inhibitor 2
5. If failure of first TNF inhibitor at above-standard dose, change to another monoclonal antibody TNF inhibitor 1, 2
6. For failure of multiple TNF inhibitors, consider abatacept, tocilizumab, mycophenolate, leflunomide, or cyclosporine 1, 2

Special Considerations

• NSAIDs have no demonstrable effect as monotherapy but may be used as additional therapy 1, 5
• Systemic corticosteroids can be used as short-term bridging therapy in complicated cases 1
• Patient education regarding warning signs of acute anterior uveitis is strongly recommended to decrease delay in treatment and complications 1
• For isolated short-lived episodes of anterior uveitis in patients well-controlled on systemic therapy, treat with topical glucocorticoids first before changing systemic therapy 2

Common Pitfalls and Caveats

• Long-term topical corticosteroid use increases risk of cataract formation and glaucoma, independent of active uveitis or presence of posterior synechiae 1, 3
• Low doses of topical corticosteroids (≤3 drops daily) may be used over moderate periods with a lower risk of developing cataracts 1
• Monitoring for ocular glucocorticoid complications (cataracts, glaucoma, infection) is essential 2
• Non-reversible changes (cataract, glaucoma/elevated intraocular pressure, hypotony, sequelae of keratic precipitates) should not be indications to change treatment in the absence of active inflammation 1
• The goal of treatment should be no cells in the anterior chamber, but the presence of macular/disk edema, ocular hypotony, or rubeosis iridis may require anti-inflammatory treatment even without anterior chamber cells 1