Combination therapy - is it time to start using? - A case-based review

Background: This case-based review presents a Reactive arthritis (ReA) refractory to conventional therapies with excellent response to the combination of ustekinumab and tofacitinib. This is the first case report of ReA with combination therapy with a bDMARD and a tsDMARD. Although not a consensus, combination therapy is already used especially in psoriasis, psoriatic arthritis and inflammatory bowel diseases, motivating this choice since in monotherapy the last two drugs achieved the best responses in different domains, justifying the possibility of blocking several pathophysiological mechanisms of immune-mediated arthritis. Case presentation: A man with peripheral and axial arthritis, conjunctivitis, balanoposthitis, keratoderma blenorrhagicum and urethral discharge preceded by diarrhea, treated with antibiotics, then methotrexate and prednisone were introduced for ReA. Along the years he received three different anti-TNF drugs with no response. Same as IL-17a monoclonal antibody with primary failure. Treatment was changed to ustekinumab with resolution of cutaneous involvement, but not articular. Then, tofacitinib was tried and arthritis improved but skin relapsed. Since severity and refractoriness of the case, combination of ustekinumab and tofacitinib was considered, achieving remission in both domains Conclusions ReA has a difficult diagnosis and treatment, anti-TNF, anti-IL 17, anti-IL 12/23, and JAK inhibitors may be used based on limited data and clinical experience, specially adapted from other spondyloarthritis. This case had poor disease control with all such bDMARD used separately, but achieved low disease activity and resolution of skin lesions with combination of JAK inhibitor and anti-IL 12/23 with no severe adverse effects during follow-up.