Arthritis and uveitis in children. A pediatric rheumatology perspective

Etanercept and uveitis in patients with juvenile idiopathic arthritis

OBJECTIVES

Etanercept has been shown to be effective for the treatment of juvenile idiopathic arthritis (JIA). The therapeutic efficacy of etanercept for chronic uveitis, a major complication of JIA, has not been evaluated so far. Therefore, the appearance of chronic anterior uveitis and associated complications in JIA patients treated with etanercept was evaluated.

METHODS

Questionnaires were sent to paediatric rheumatologists treating a total of 310 JIA patients with etanercept.

RESULTS

Two hundred and twenty-nine questionnaires (74%) were returned. Before institution of etanercept, 31 patients (13.5%) had a history of uveitis with a total of 102 flares. Twenty-eight patients belonged to the high-risk groups of the oligoarticular and seronegative polyarticular subtypes. Upon commencing etanercept, 32 courses of uveitis occurred in 19 patients and in two further patients (1%) in whom uveitis occurred for the first time. Twenty of them belonged to the high-risk group. Uveitis during etanercept therapy occurred in 12 of 15 patients (80%) with more than one course of uveitis, and in seven of 16 patients (44%) with only one course before etanercept therapy. Complications were noted in 12 patients before and in eight during etanercept treatment. In 87% of the uveitis patients, arthritis demonstrated a significant or complete response.

CONCLUSION

During treatment with etanercept, there were both relapses and first courses of uveitis. In addition, the frequency and severity of uveitis seemed not to be influenced by etanercept. In particular, patients with relapsing uveitis before institution of etanercept treatment remain at high risk of the development of uveitis flares despite etanercept treatment.

Ocular manifestations of juvenile rheumatoid arthritis in Olmsted County, Minnesota: a population-based study

BACKGROUND

Juvenile rheumatoid arthritis (JRA) is the most common systemic cause of uveitis in Europe and North America. The cumulative incidence of uveitis in JRA has been reported at between 8.5% and 25% in series from referral centers in the USA. There have been no population-based studies of the cumulative incidence of uveitis in JRA in the USA.

METHODS

We performed a population-based, retrospective cohort study of patients residing in Olmsted County, Minnesota between 1 January 1960 and 31 December 2000 who met American College of Rheumatology diagnostic criteria for JRA. The patients were identified using the Rochester Epidemiology Project (REP), a surveillance and medical records-linkage system which provides access to medical records of residents of Olmsted County. Patient histories were reviewed and information regarding rheumatic and ocular disease was extracted and analyzed. The main outcome measures were: cumulative incidence of uveitis, of complications of uveitis, of keratoconjunctivitis sicca (KCS) and of adverse visual outcome.

RESULTS

Of the 88 patients identified, three patients developed uncomplicated uveitis [3.4%; 95% confidence intervals [CI] 0.7-9.6%), all with pauciarticular onset JRA. Two patients developed KCS (2.3%; 95% CI 0.3-8.0%). The visual acuity of these five patients at last follow-up (mean length of follow-up 22.6 years, range 8-36 years) was 20/20. There were no patients with visual loss attributable to JRA.

CONCLUSIONS

In a population-based study of JRA in the United States, uveitis occurred at a lower frequency than expected. In the limited number of cases in this cohort with JRA-associated ophthalmologic complications there was no resulting loss of visual acuity.

Review of immunosuppressive drug therapy in uveitis

PURPOSE OF REVIEW

Uveitis is an important cause of functional visual loss and blindness in the developed world. Immunosuppressive drugs may be required to treat severe noninfectious uveitis successfully, but the efficacy and safety of such treatments are often limited by the small numbers of patients enrolled in clinical trials or studied retrospectively, the absence of control participants, and the variable natural course of some types of uveitis. This review was undertaken to highlight recent clinical advances in the treatment of severe noninfectious uveitis.

RECENT FINDINGS

A literature search emphasizing the research published since 2001 was undertaken. The role of previously available immunosuppressives such as antimetabolites, calcineurin inhibitors, and alkylating agents continues to develop. In recent years, more specific drugs, collectively known as biologics, have been used in the treatment of uveitis. A persistent limitation of the published literature remains the general lack of randomized, controlled clinical trials. The long-term risks of most immunosuppressive drugs and the risk of relapse after discontinuation of therapy are also not well established. Tumor necrosis factor-alpha antagonists are promising but extremely expensive, and they may be more effective for rheumatologic and nonocular autoimmune disorders than for uveitis.

SUMMARY

The number of options available for the treatment of severe noninfectious uveitis has expanded in the past few years. While promising, the new drugs are expensive, and their long-term efficacy and safety are not known; consequently, older immunosuppressive drugs still play an important role in the treatment of uveitis.

Advances in paediatric rheumatology: beyond NSAIDs and joint replacement

Over the previous three decades there have been a number of dramatic changes in our understanding of both the pathogenesis and epidemiology of the rheumatic diseases of childhood. Improvements in the classification of paediatric-onset arthritides and international collaboration in terms of multicentre research have led to the development of new therapeutic agents and better methods of outcome assessment for these chronic and often disabling conditions. Fortunately for children with paediatric rheumatic diseases treatment regimes are now available that provide excellent disease control for many and remission induction for some. Challenges include clearer definition of the genetics and pathogenesis of the diseases, delineation of reliable biological markers for diagnosis and monitoring of disease activity. The future should also herald early identification of those with a poorer prognosis, together with the design of more powerful, safer and cheaper remission-inducing agents, given to the right patients at the right time.

Special considerations in the evaluation and management of uveitis in children

PURPOSE

To review issues related to the diagnosis, examination, and treatment of children with uveitis that are important for ophthalmologists.

DESIGN

Literature review.

METHOD

A review was made of pertinent reports from the medical literature, with commentary based on the authors' experiences and on discussions at an international workshop.

RESULTS

There are differences between children and adults in the differential diagnosis and manifestations of uveitis that should be considered during evaluation. There may be a higher risk of some ocular complications such as uveitic glaucoma, and the presence of other unique complications, such as amblyopia, in young patients during follow-up. With regard to treatment, children with uveitis may have unique dosing requirements and drug-associated risks such as growth retardation with systemic corticosteroids that must be considered. Examination and treatment may also be more difficult with children because of problems with patient cooperation.

CONCLUSIONS

There are unique patient care issues associated with uveitis in children that must be considered by care providers. Attention to these issues will improve the well-being of this patient population.