What is the best approach to manage a patient with uveitis, arthritis, and urethritis syndrome, likely reactive arthritis or Reiter's syndrome?

Management of Reactive Arthritis (Reiter's Syndrome)

For a patient presenting with the triad of uveitis, arthritis, and urethritis, initiate topical prednisolone acetate 1% four times daily for the uveitis while simultaneously treating the underlying infection with antibiotics (typically doxycycline for Chlamydia), and add NSAIDs for joint symptoms. 1, 2

Immediate Assessment and Initial Treatment

Ocular Management

• Start prednisolone acetate 1% topical drops immediately as first-line therapy for anterior uveitis, dosing at 2 drops four times daily in the affected eye(s) 1, 2
• Initial dosing may require more than 1-2 drops/eye/day for severe inflammation, though this increases complication risk 1
• Arrange ophthalmology evaluation within 2-6 weeks to assess intraocular pressure, degree of inflammation, and presence of complications 1

Infectious Workup and Treatment

• Test for Chlamydia trachomatis via PCR from urethral swab, as this is the most common trigger 3, 4
• Initiate doxycycline or azithromycin immediately if Chlamydia is suspected or confirmed 5
• Consider HLA-B27 testing, as 60-80% of reactive arthritis patients are positive, though HLA-B51 has also been associated 4, 5

Musculoskeletal Management

• Start NSAIDs at full anti-inflammatory doses for arthritis and enthesitis 3
• Continue rest and physiotherapy as indicated 6

Escalation to Systemic Therapy

Indications for Systemic Immunosuppression

Add methotrexate if topical corticosteroids cannot be tapered to ≤2 drops/day within 3 months, or if poor prognostic factors are present at first visit. 1

First-Line Systemic Agent

• Methotrexate is the first-choice systemic immunosuppressant, with subcutaneous administration preferred over oral 1, 6
• Methotrexate has been successfully used in combination therapy for reactive arthritis with persistent symptoms 5
• Sulfasalazine may be added as an alternative DMARD 5

Second-Line Biologic Therapy

• For methotrexate failure or intolerance, adalimumab is the preferred anti-TNF agent over infliximab and golimumab 1
• Monoclonal antibody TNF inhibitors (adalimumab, infliximab) are preferred over etanercept for uveitis 7

Monitoring Protocol

Ophthalmologic Surveillance

• Monitor every 2-6 weeks while on frequent topical corticosteroids based on inflammation severity and intraocular pressure 1
• Once stable on therapy, monitor every 3 months 7, 1
• Within 1 month after each change in topical corticosteroid dosing 7
• Within 2 months after any change in systemic therapy 7

Treatment Goals and Tapering

• Limit topical corticosteroids to ≤3 months due to glaucoma and cataract risk 7, 1, 2
• Goal is inactive disease defined as grade <1+ anterior chamber cells (6-15 cells per field) without new inflammatory complications 8
• Taper topical corticosteroids first before reducing systemic therapy 7

Critical Pitfalls to Avoid

Do Not Discontinue Therapy Prematurely

• Reactive arthritis requires comprehensive evaluation and multidisciplinary management 3
• If signs and symptoms fail to improve after 2 days of topical therapy, reevaluate the patient 2
• In chronic conditions, withdraw treatment gradually by decreasing frequency of applications 2

Exclude Masquerade Syndromes

• Before escalating immunosuppression, exclude infection and malignancy through appropriate sampling 8
• This is particularly critical in immunosuppressed patients 8

Monitor for Complications

• Watch for ocular complications including cataracts, glaucoma/elevated intraocular pressure, peripheral anterior synechiae, posterior synechiae, and cystoid macular edema 7, 8
• Monitor for systemic side effects of methotrexate including hepatotoxicity, bone marrow suppression, and pulmonary toxicity 6

Patient Education

Educate patients on warning signs of acute anterior uveitis (eye pain, photophobia, blurred vision, redness) to decrease delay in treatment and prevent complications. 7, 1