Mycophenolate mofetil as an immunomodulatory agent in the treatment of chronic ocular inflammatory disorders

Current therapeutic approaches to autoimmune chronic uveitis in children

Uveitis is an inflammatory disorder involving inflammation of the uveal tract. It is classified as anterior, intermediate, posterior or panuveitis, depending on the part of eye affected by the inflammatory process. In children, non-infectious, chronic uveitis is a relatively uncommon but serious disease, with the potential for significant long-term complications and possible blindness. Although frequently associated with an underlying systemic disease, e.g. juvenile idiopathic arthritis (JIA), a significant number of cases in children show no associated signs or symptoms, and are labelled as idiopathic. Taking into account this evidence, an anti-inflammatory therapy based on an immuno-modulatory approach seems a reasonable strategy for non-infectious chronic uveitis, in children as well as in adults. Due to a lack of controlled studies regarding uveitis in children, immunosuppressive drugs are supported only at evidence level III. The aim of this review is to report currently available medical strategies for treatment of childhood sight-threatening chronic uveitis; in addition, a step-by-step approach to the use of immunosuppressants in this context is suggested.

[Ocular side effects of steroids and other immunosuppressive agents]

The increasing use of immunosuppressive (IS) drugs in transplants or in systemic diseases, implies a long period of treatment and to be aware of possible side effects. These drugs can be used alone or in combination with steroids. This review deals with the issue of ocular side effects of the most used IS drugs, including steroids. Data were collected from Medline using Pubmed software. We first describe specific complication of each drug and then conclude on major common toxicity represented by opportunistic infections and induced cancers.

Scleritis and systemic disease association in a community-based referral practice

PURPOSE

To evaluate the association between scleritis and systemic disease in a non-university, non-tertiary referral practice and to describe our experience with scleritis treatment.

DESIGN

Retrospective chart review.

METHODS

The medical records of patients with scleritis between 2001 and 2007 were reviewed for associated systemic disease.

RESULTS

In our series of 86 patients with scleritis, 55 patients (64.0%) had isolated scleritis while 31 patients (36.0%) had associated systemic-disease. Twenty-six patients (83.9%) with systemic disease had diagnosed systemic disease at the time of initial scleritis presentation, while 5 patients (16.1%) were diagnosed following systemic work-up. Those diagnosed after systemic work-up were more likely to have systemic vasculitic disease as opposed to a rheumatic or infectious disease. Patients with and without associated systemic disease were likely to require systemic therapy at similar rates (93.5% and 92.7%, respectively). Five patients with steroid-refractory scleritis were treated with infliximab (Remicade; Centocor Inc, Horsham, Pennsylvania, USA) and all responded without evidence of adverse effect. Seven patients were treated with mycophenolate mofetil (CellCept; Roche Laboratories, Nutley, New Jersey, USA), of which three improved.

CONCLUSIONS

The association between scleritis and systemic disease in a community-based referral practice may be lower than in tertiary referral or university-based centers. Although thorough systemic disease evaluation is warranted in scleritis patients, most patients with associated systemic disease will have such a diagnosis prior to the development of scleritis. The need to institute aggressive systemic therapy cannot be predicted by the presence of an associated systemic disease. Infliximab and mycophenolate mofetil are useful additions to the scleritis practitioner's armamentarium for steroid-refractory scleritis.

Mycophenolate mofetil as a treatment of steroid dependent Cogan's syndrome in childhood

Cogan's syndrome is a rare chronic inflammatory disorder which typically associates an ophthalmological and vestibulocochlear involvement, with a risk of systemic symptoms in 50-70% of cases. Autoimmune origin has been consolidated by the recent discoveries of Lunardi as a result of the dysregulation of the response of B and T lymphocytes. We report here a pediatric case of Cogan's syndrome, with long term follow-up and complete vestibulocochlear and ophthalmologic examination. During the acute phase, early steroids treatment (prednisone 1mg/kg per day) was effective on ocular lesions and hearing loss. The patient required high steroid doses to maintain remission, suggesting the necessity for steroid sparing immunosuppressive agents. We introduced mycophenolate mofetil (MMF), an immunosuppressive agent mainly used in solid organ transplantation. After steroid withdrawal the patient remained in complete remission on MMF. This is the first report of MMF treatment in Cogan's syndrome. MMF produces a targeted inhibition of the proliferation of B and T lymphocytes, particularly interesting in Cogan's syndrome. Low long term toxicity and overall good tolerance make MMF a new treatment option in steroid dependent Cogan's syndrome.

Non-infectious pediatric uveitis: an update on immunomodulatory management

Pediatric non-infectious uveitis remains a rare but potentially sight-threatening group of diseases. However, early screening and treatment can improve outcomes. No single agent has proven to be efficacious in all cases. A wide variety of long-term immunomodulatory treatments are available; these agents differ in both their potency and side effect profiles. Corticosteroids remain an extremely valuable form of treatment in the short-term management of uveitis. Other major groups of immunomodulatory treatments include the calcineurin inhibitors and antimetabolites such as methotrexate, which is frequently used as the first-line agent. The biologics, including anti-tumor necrosis factor agents and interferons, are newer and potentially very useful therapies although side effects limit their use. Successful outcomes may be achieved with appropriate immunosuppressant therapy given early in the disease, although clinical trials are required to define the true efficacy of this strategy.

Mycophenolate mofetil for the treatment of uveitis

PURPOSE

To evaluate the efficacy and tolerance of mycophenolate mofetil (MMF) for the treatment of noninfectious uveitis using the methods of analysis advocated by the Standardization of Uveitis Nomenclature (SUN) Working Group, and to compare this with other SUN-compliant reports of immunosuppression in ocular inflammation.

DESIGN

Retrospective case series. MEDHODS: A predefined data set was retrospectively obtained from the case notes of 100 consecutive uveitis patients treated with MMF at a single academic referral center between April 1, 2000 and August 1, 2006. These data were then analyzed in accordance with SUN recommendations. The main outcome measures were: 1) rate of tapering oral prednisone to 10 mg daily, 2) requirement for alternative second-line immunosuppressive therapy, and 3) rate of MMF dose discontinuation because of side effects.

RESULTS

In this large cohort with noninfectious persistent, chronic, or recurrent uveitis, there was an 84.6% probability of achieving a prednisone dose of < or =10 mg daily after one year of MMF treatment. Alternative second-line immunosuppressive therapy was introduced at a rate of 0.18 per patient-year (PY) and MMF was discontinued because of intolerance at a rate of 0.09/PY, predominantly because of gastrointestinal upset. This corroborates the findings of the only previous SUN-compliant study of MMF in ocular inflammation and is comparable to the rates of treatment success and intolerance we have recently reported for tacrolimus.

CONCLUSION

This data generates concordant evidence with other SUN-compliant studies supporting the use of MMF in uveitis.

Uses and safety profile of ciclosporin in ophthalmology

Ciclosporin is a calcineurin inhibitor that acts by primarily inhibiting the action of T cells. Clinical trials in the early 1980s demonstrated that systemic ciclosporin was a promising steroid-sparing agent and was also effective in patients who are refractory to treatment with corticosteroids. However, recent years have witnessed the emergence of safer immunosuppressive agents due to the poor side-effect profile of systemic ciclosporin. Topical ciclosporin, however, has a much improved safety profile and is still used to treat a variety of ocular surface disorders including dry eye syndrome, vernal and atopic keratoconjunctivitis, severe blepharitis and high-risk corneal graft patients. This article reviews the uses and safety profile of systemic and topical ciclosporin in ophthalmology, as well as discussing alternative therapeutic agents available.

Pediatric rheumatology for the adult rheumatologist II: uveitis in juvenile idiopathic arthritis

Uveitis is an important and frequent extra-articular manifestation of juvenile idiopathic arthritis (JIA) that may result in poor visual outcome. Without early detection and aggressive therapy, the uveitis and topical steroid therapy used to treat it may result in cataracts, glaucoma, and even blindness. Fortunately, a variety of systemically administered anti-inflammatory agents have been found useful for the treatment of JIA associated uveitis. Methotrexate is often the first line disease modifying systemic agent used to help wean topical corticosteroids, but when this is not sufficiently effective there are a variety of other systemic medicines available. In particular, one of the tumor necrosis factor-alpha inhibitors, infliximab, has shown some promising results in difficult to treat JIA associated uveitis. With early screening and detection combined with aggressive therapy in difficult to treat cases, the morbidity associated with uveitis as part of JIA is on the decline.

Orbital inflammatory disease: a diagnostic and therapeutic challenge

The spectrum of orbital inflammatory disease (OID) ranges broadly from specific disease diagnoses, for example, Wegener's granulomatosis or sarcoidosis, to nonspecific inflammation which may involve one or multiple structures of the orbit. Mimics of idiopathic OID must be considered in a comprehensive differential diagnosis and include malignancies, congenital mass lesions, infectious diseases, and occult or distant trauma. Idiopathic OID may be secondary to an underlying systemic inflammatory disease, which must be diagnosed in order to develop a comprehensive therapeutic plan, or may represent localized pathologic processes without systemic involvement. Evaluation of the patient with suspected OID must include a careful history, physical examination, directed laboratory, and radiologic studies, and may sometimes require tissue for diagnostic studies. Therapeutic options for inflammatory diseases are expanding as biologically targeted agents become available that act on specific segments of the inflammatory cascades. The purpose of this paper is to provide a framework for the evaluation and management of patients with the spectrum of diseases known as OID and to discuss some of the new advances in immunologic monitoring and targeted immune therapies that will likely play an increasingly important role in the care of these patients.

Biological response modifier therapy for refractory childhood uveitis

PURPOSE

To evaluate the use of biological response modifiers (BRM) in the treatment of refractory childhood uveitis.

DESIGN

Retrospective non-comparative case series of pediatric patients with uveitis treated with BRM.

PARTICIPANTS

23 pediatric patients.

METHODS

All children (18 years or younger) who received a BRM were assessed for visual changes, time to control inflammation, and any associated adverse side effects. Thirteen patients were treated with infliximab, five with adalimumab, and five with daclizumab. All patients had bilateral eye involvement. Diagnoses of the participants included juvenile idiopathic arthritis, keratouveitis, sarcoid panuveitis, Adamantiades-Behcets disease, and idiopathic panuveitis.

MAIN OUTCOME MEASURES

Inflammation and visual acuity.

RESULTS

In the infliximab group 16 of 26 eyes (62%), and 10 of 13 patients (77%) demonstrated an improvement in visual acuity. Twenty of 26 eyes (77%) demonstrated an improvement in the degree of inflammation. In the adalimumab group, four of 10 eyes (40%) demonstrated an improvement in visual acuity, with five of 10 eyes (50%) demonstrating an improvement in inflammation. Four of 10 eyes (40%) in the daclizumab group demonstrated an improvement in vision with eight of 10 eyes (80%) demonstrating an improvement in inflammation.

CONCLUSION

BRM appear to be safe to use in children, and represent a useful therapeutic adjunctive drug group for treating recalcitrant childhood uveitis.

Long-term Efficacy and Tolerance of Tacrolimus for the Treatment of Uveitis

PURPOSE

To evaluate the long-term efficacy and tolerance of tacrolimus for the treatment of uveitis.

DESIGN

Retrospective case series.

PARTICIPANTS

Sixty-two consecutive patients with noninfectious uveitis treated with tacrolimus at a single academic referral center between April 2000 and April 2004.

METHODS

A standard data set was obtained from patients' medical records and analyzed according to the recommendations of the Standardization of Uveitis Nomenclature Working Group.

MAIN OUTCOME MEASURES

(1) Rate of tapering oral prednisone to 10 mg daily, (2) requirement for alternative second-line immunosuppressive therapy, and (3) rate of tacrolimus dose reduction or discontinuation due to side effects.

RESULTS

In this cohort with well-established ocular inflammation, patients successfully tapered their oral prednisone to 10 mg daily at an average rate of 1.62 per patient-year (PY), with an 85% probability of achieving < or =10 mg after 1 year 2 months of treatment. Tacrolimus was discontinued due to intolerance at a rate of 0.13/PY. This was predominantly due to noncardiovascular adverse events, and rates of introducing or increasing concomitant treatment for hypertension, hypercholesterolemia, and diabetes mellitus were all below 0.05/PY. Creatinine rises of > or =30% were also notably uncommon (0.05/PY).

CONCLUSION

Tacrolimus's efficacy for the treatment of uveitis is maintained long-term, and its cardiovascular risk profile is excellent.

[Interferon and retinal vasculitis]

The treatment of noninfectious posterior uveitis can lead to severe vision loss, and the first-line conventional treatment includes systemic steroids. When the prednisone doses necessary to control intraocular inflammation are above 0.3mg/day, a therapeutic association is proposed in order to lower the daily prednisone dose. The combined drugs are immunosuppressive or immunomodulative. The side effects of immunosuppressive drugs are oncogenic, infectious, and hematological, and can involve reproductive troubles, associated with specific toxic effects depending on the drug used. Recently adding polyclonal or monoclonal antibodies and the interferons to immunomodulative drugs has been suggested. Interferon alpha has been shown to be effective in Behçet's disease. The efficacy of interferon needs to be evaluated in other etiologies of retinal vasculitis through randomized studies.

Mycophenolate mofetil as an immunosuppressive agent in refractory inflammatory eye disease

PURPOSE

The aim of this study was to assess the role of mycophenolate mofetil (MMF) in refractory inflammatory eye disease.

METHODS

Retrospective, noncomparative, interventional case series of all patients commenced on MMF between 1999 and 2005 for refractory inflammatory eye disease at St Paul's Eye Unit (Liverpool, UK). Main outcome measures noted were control of inflammation, steroid-sparing effect, and adverse effects of MMF therapy.

RESULTS

Ten (10) patients (2 with sarcoid, 2 with intermediate uveitis, 1 with Vogt-Koyanagi Harada (VKH) syndrome, 1 with ankylosing spondylitis, 1 with juvenile chronic arthritis (JCA), and 3 with scleritis) who were unresponsive or intolerant to previous therapy and/or as a steroid-sparing agent, received 2-3 g of MMF per day for a mean period of 40.5 months (range, 3-67). Nine (9) patients had a favorable response, with diarrhea and insomnia being the main side-effects. MMF had to be withdrawn in 1 patient because of side-effects and in another because of active arthropathy (with stable uveitis). Average number of relapses was reduced from 3.1 per patient per year to 0.8 per patient per year (P < 0.005). A steroid-sparing effect was achieved in all patients. Visual acuity improved in 8 patients.

CONCLUSIONS

MMF appears to be a safe and effective second- or third-line adjunct/alternative immunosuppressant in these difficult cases and works well in combination with cyclosporin A, tacrolimus, and antitumor necrosis factor (TNF) agents. It has potential as a firstor second-line agent and can be considered at a dose of 3 g/day in refractory cases.

[Therapy of chronic non infectious uveitis]

PURPOSE

Chronic non infectious uveitis represents two-thirds of the causes of chronic uveitis referred in tertiary referral ophthalmology centre. One case out of 5 may evolve towards blindness. Therapy should be discussed on the basis of the uveitis severity and the diagnosis; it uses topics or systemic drugs, mainly corticosteroids and immunosuppressors.

CURRENT KNOWLEDGE AND KEY POINTS

Besides corticosteroids and ciclosporin, use of immunosuppressors and biotherapy in chronic non infectious uveitis is not an indication of the Autorisation de Mise sur le Marché. However, immunosuppressors and biotherapy were the subjects of several studies, although controlled studies are scarce. Controlled studies concerned cyclosporine, azathioprine and intravenous cyclophosphamide in Behçet's disease, ciclosporine and tacrolimus in uveitis of various causes. Therapy of chronic non infectious uveitis was recently enriched by new drugs: mycophenolate mofetil, initially used in transplantation, has its indications extended to systemic diseases; TNF inhibitors initially used in therapy of systemic diseases; interferon efficacy revealed in Behçet's disease is now used in uveitis due to other causes.

FUTURE PROSPECTS AND PROJECTS

Controlled studies are suitable in order to determinate the respective part of immunosuppressors and biotherapies in the treatment of chronic non infectious uveitis.

Mycophenolate mofetil in the treatment of uveitis in children

BACKGROUND

Mycophenolate mofetil (MMF) is a new immunosuppressive agent that effectively controls the intraocular inflammation in adults.

PURPOSE

To assess the efficacy of MMF in uveitis in children and to analyse the possible side effects.

PARTICIPANTS AND METHODS

A retrospective analysis was carried out on 17 children (32 eyes) with intraocular inflammation treated with MMF and followed up at the University Eye Hospital Tuebingen, Tuebingen, Germany, between 2000 and 2005. All children had chronic non-infectious uveitis and received MMF for at least 6 months. All patients were given steroids or other immunosuppressive agents before initiating treatment with MMF.

RESULTS

17 children (10 boys and 7 girls) with a mean age of 8 (range 2-13) years at the onset of uveitis were examined. The average duration of follow-up after initiation of MMF was 3 (range 2-5) years. A steroid-sparing effect was achieved in 88% of the patients. The oral prednisolone was successfully discontinued in 41% children and reduced to a daily dose of < or =5 mg in 47% of the children. 24% of the patients remained relapse-free during the treatment, but a reduction in the relapse rate was observed in all other patients except one. Visual acuity was increased or maintained in 13 children (76%). Mild side effects (headache, rash, gastrointestinal discomfort) occurred in 7 patients (41%) and were the cause of discontinuation of MMF in 1 patient.

CONCLUSION

The results of our study are encouraging and suggest that MMF is an effective agent also in the treatment for uveitis in children, with marked steroid-sparing potential and an acceptable side effect profile.

Uveitis

Uveitis is a prevalent disease that mainly affects young people. It leads to a significant number of visual losses. Acute anterior uveitis is the most prevalent form, and it is often associated with spondyloarthritides in which uveitis can be the first manifestation of disease. Precise patterns of uveitis are frequently associated with systemic diseases. Thus, the close collaboration between ophthalmologists and rheumatologists avoids unnecessary diagnostic tests and is essential for the correct assessment and treatment of these patients. Acute anterior uveitis usually has a good prognosis compared with other forms of uveitis. However, it is a cause of disability when flares are frequent. Small prospective studies conducted with sulphasalazine have demonstrated a reduction in the number of flares. Other patterns of uveitis have a worse prognosis, and systemic corticosteroids and/or immunosuppressive drugs are usually required. Infliximab is a promising therapeutic option in selected patients.

Favorable response to high-dose infliximab for refractory childhood uveitis

OBJECTIVE

Uveitis in children most commonly is associated with juvenile idiopathic arthritis. In addition to topical glucocorticoids, treatment may include systemic immunosuppressive agents. Tumor necrosis factor alpha (TNF-alpha) has been implicated in the pathogenesis of uveitis; therefore, TNF-alpha blockade seems to be a reasonable therapeutic option to investigate. We report successful treatment of children with uveitis using infliximab.

STUDY DESIGN

A retrospective study of our complete experience using infliximab for the treatment of childhood uveitis was conducted.

PARTICIPANTS

Seventeen children (14 females, 3 males) with chronic uveitis were administered high-dose infliximab (10-20 mg/kg/dose).

MAIN OUTCOME MEASURES

Our main outcome measure was the ability to eliminate all signs of intraocular inflammation.

RESULTS

All 17 patients demonstrated a dramatic, rapid response, with no observed inflammation in 13 patients after the second infusion, and 4 patients requiring 3 to 7 infusions to achieve disease quiescence. Additional immunosuppressives and topical glucocorticoids were tapered when patients achieved no intraocular inflammation.

CONCLUSIONS

In this series, high-dose infliximab was a rapidly effective, well-tolerated therapeutic agent for the treatment of chronic, medically refractory, noninfectious uveitis.

Immunomodulatory therapy for ocular inflammatory disease: a basic manual and review of the literature

Corticosteroids are used as first-line treatment for many ocular inflammatory conditions. The risk of adverse effects, however, necessitates conversion to steroid-sparing immunomodulatory therapy (IMT) for disease that is recurrent, chronic, or poorly responsive to treatment. Combination drug treatments with multiple agent 'recipes' are also considered. Immunomodulatory agents include the broad categories of antimetabolites (azathioprine, methotrexate, mycophenolate mofetil), alkylating agents (cyclophosphamide, chlorambucil), T-cell inhibitors (cyclosporine, tacrolimus), and cytokines (interferon alfa). This article reviews and summarizes the evidence for IMT agent use in the treatment of various forms of ocular inflammation.

Tumour necrosis factor alpha inhibitors in the treatment of childhood uveitis

OBJECTIVE

To describe the efficacy of anti-TNF-alpha agents in the treatment of childhood uveitis.

METHODS

We performed a retrospective chart review of all children with uveitis treated with TNF-alpha blockers at The Hospital for Sick Children, Toronto.

RESULTS

Twenty-one children with uveitis were treated with the anti-TNF-alpha agents etanercept (11 patients) and infliximab (13 patients), resulting in 24 treatment courses. All patients had persistently active uveitis despite treatment with at least one standard immunosuppressive drug before the start of anti-TNF-alpha therapy. Six of 21 patients (29%) had idiopathic uveitis. In the other 15 patients, the underlying disease was juvenile idiopathic arthritis in 12 (57%), Behçet disease in two (9%) and sarcoidosis in one (5%). Response to etanercept treatment was good in 27%, moderate in 27% and poor in 45% of patients. Response to infliximab treatment was good in 38%, moderate in 54% and poor in 8% of patients. The difference in the percentage of patients with a moderate or good response was statistically significant (P = 0.0481). We also observed a lower rate of complications, such as new-onset or worsening glaucoma or cataract in the infliximab-treated group.

CONCLUSION

Anti-TNF-alpha treatment was beneficial in a high percentage of patients with childhood uveitis refractory to standard immunosuppressive treatment. Infliximab resulted in better clinical responses with less ocular complications than etanercept.

Mycophenolate mofetil is a highly effective and safe immunosuppressive agent for the treatment of uveitis : a retrospective analysis of 106 patients

BACKGROUND

We evaluated the outcomes of patients with different forms of chronic uveitis treated with mycophenolate mofetil (MMF) as an immunomodulatory and steroid-sparing agent. The multi-system side effects that arise after long-term treatment with corticosteroids and other immunosuppressants prompted us to use MMF. MMF is a selective inhibitor of inosine monophosphate dehydrogenase, thus blocking purine synthesis via the de novo pathway preferentially used by T and B lymphocytes.

METHODS

Between 1998 and 2003, 106 patients were treated for uveitis (anterior n=26, intermediate n=51, posterior n=23, panuveitis n=6) with MMF at a dose of 1g twice daily. Treatment duration was at least 6 months (n=10), in most cases greater than 12 months (n=77) and in 25 cases between 24 months and 41 months, when the present retrospective evaluation was undertaken. Patient charts were analysed according to a standardized evaluation protocol.

RESULTS

In 95 patients MMF was combined with prednisolone at a dosage of 2.5-10 mg per day. In 8 patients MMF was used as a monotherapy, and in 3 cases one further systemic immunosuppressant was required. The number of recurrences during MMF treatment was none or one in 92 patients, two in 6 cases and three or more in 8 patients. In none of the patients had MMF been stopped at the time of data analysis. The most frequently observed side effects were gastrointestinal upset (15%), followed by headache (9.3%), fatigue (5.7%), eczema (5%), and hair loss (3.5%). Other side effects were sporadic. Most of these phenomena were transitory. Forty-two patients experienced no side effects at all. In 4 patients MMF was judged ineffective due to failure to reduce the number of recurrences of severe inflammation compared with the previous therapeutic regime, or indeed occurrence of persistent macular oedema.

CONCLUSIONS

Our results show that MMF is an effective immunosuppressant in patients with uveitis. We provide evidence that MMF controls the disease in the majority of patients with an acceptable profile of side effects.

Systemic mycophenolate mofetil avoids immune reactions in penetrating high-risk keratoplasty: preliminary results of an ongoing prospectively randomized multicentre study

Recently, in a monocentre study mycophenolate mofetil (MMF) was demonstrated to be efficacious and safe in penetrating high-risk keratoplasty. Here, preliminary results of a randomized multicentre trial are presented. To date, 86 of 140 scheduled patients undergoing high-risk penetrating keratoplasty have already been randomized into the two study groups: 48 into the MMF group and 38 into the control group. All 86 patients received fluocortolon 1 mg/kg body weight/day, tapered within 3 weeks, and topical prednisolone acetate 1% tapered within 5 months. MMF was administered at a daily oral dose of 2 x 1000 mg for the first 6 postoperative months. Thereafter, MMF was tapered within 2 weeks. The proportion of grafts with immune reactions and side-effects were the main outcome measures. Within an average follow up of 9.2 +/- 6.6 months two patients developed reversible endothelial immune reactions in the MMF group after cessation of MMF application. In the control group, five reversible and three irreversible immune reactions were observed within an average follow up of 10.1 +/- 7.6 months. According to Kaplan and Meier analysis, the ratio of grafts without immune reactions was estimated 89% 1 year postoperatively in the MMF group, in contrast to only 67% in the control group (P = 0.03; log-rank test). Fifteen patients experienced side-effects, especially gastroenterotoxicity, tachycardia, arthralgia or systemic infections. All attributable side-effects were reversible. Systemic MMF may be an effective and safe immune modulating drug in the prophylaxis of immune reactions after penetrating high-risk keratoplasty.

Mycophenolate Mofetil Therapy for Inflammatory Eye Disease

PURPOSE

To evaluate treatment outcomes with mycophenolate mofetil in patients with inflammatory eye disease.

DESIGN

Retrospective case series.

PARTICIPANTS

Eighty-four consecutive patients with inflammatory eye disease treated with mycophenolate mofetil at an academic referral center.

METHODS

Medical records were reviewed for treatment with mycophenolate mofetil. Dose of mycophenolate mofetil, response to therapy, dose of prednisone, use of other immunosuppressive drugs, and side effects associated with the use of mycophenolate mofetil were recorded.

MAIN OUTCOME MEASURES

Ability to control ocular inflammation with mycophenolate mofetil and to taper prednisone to < or =10 mg daily, and incidence of treatment-related side effects.

RESULTS

Of the 84 patients treated with mycophenolate mofetil, 61% had uveitis, 17% had scleritis, 11% had mucous membrane pemphigoid, and 11% had orbital or other inflammatory disease. Forty-three percent of patients treated with mycophenolate mofetil had been treated with at least one other immunosuppressive drug previously. The median dose of prednisone at the start of mycophenolate mofetil therapy was 40 mg, and 82% of the patients were considered a treatment success, as judged by the ability to control the inflammation and taper prednisone to < or =10 mg daily. Median time to treatment success was 3.5 months. Mycophenolate mofetil therapy was discontinued due to insufficient efficacy at a rate of 0.10 per person-year (PY) and due to side effects at a rate of 0.08/PY. The most frequent side effect was gastrointestinal upset, with a rate of 0.19/PY.

CONCLUSIONS

These data suggest that mycophenolate mofetil may be an effective corticosteroid-sparing agent in the treatment of inflammatory eye disease with a manageable side effect profile.

Management of extraintestinal manifestations and other complications of inflammatory bowel disease

The past 18 months have seen many studies of the prevalence, pathogenesis, and treatment of the extraintestinal manifestations of inflammatory bowel disease (IBD). Inhibitors of tumor necrosis factor alpha have shown effectiveness in randomized trials for the treatment of spondyloarthropathies and ocular manifestations. Open-label studies suggest that these agents may be effective for pyoderma gangrenosum as well. The epidemiology of primary sclerosing cholangitis (PSC), and its relationship to IBD, is becoming clearer. Colorectal neoplasia in PSC remains an important clinical problem. Osteoporosis occurs more commonly in IBD, but the relative importance of corticosteroid use versus underlying chronic bowel inflammation as risk factors remains controversial. Chromoendoscopy may be an important means to improve detection of colorectal neoplasia in IBD. Observational studies suggest that prolonged use of aminosalicylates is associated with decreased risk of neoplasia, but data are conflicting. A randomized trial of ursodeoxycholic acid in PSC showed decreased risk of colorectal neoplasia in patients receiving the drug relative to those on placebo.

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.

Retinal vasculitis

Retinal vasculitis represents a group of diseases characterized by inflammation affecting the retinal vasculature. It is an uncommon disorder that may occur as an isolated disease or more commonly in association with other ocular diseases or a variety of systemic diseases. With a wide variety of disease associations, a search for an underlying etiology should be undertaken based on a meticulous history, review of systems, and physical examination. The laboratory evaluation of patients with retinal vasculitis is an essential component of the work-up to facilitate detection of any underlying disease or to establish a limited differential diagnosis. The management of infectious causes of retinal vasculitis consists of antimicrobial therapy while noninfectious retinal vasculitis is managed with corticosteroids and/or immunosuppressive agents. Because retinal vasculitis is an uncommon disease, there are only a limited number of publications over the past year related to this topic.

Monitoring trough plasma concentrations of mycophenolate mofetil in patients with uveitis

BACKGROUND

Mycophenolate mofetil (MMF) has been used successfully in patients with various forms of uveitis not responsive to other immunosuppressants. Nevertheless, for these patients neither recommendations for optimal dosage of MMF nor data concerning drug exposure of MMF are available.

OBJECTIVE

To describe the results of the therapeutic drug monitoring (TDM) of MMF trough concentrations in a cohort of patients with uveitis, with the aim of optimizing the dosage of this drug, by maintaining a target concentration to achieve adequate immunosuppression with a minimal risk of therapeutic failure or toxicity.

PATIENTS AND METHODS

This study describes the results of monitoring trough plasma concentrations of MMF in 12 patients with uveitis during a mean period of 21.4 months. Patients included one with Stevens-Johnson syndrome, one with Graves-Basedow's disease, one with Behcet's disease, one with idiopathic thrombocytopenic purpura and the rest with idiopathic uveitis. All patients were treated with steroids and additional therapy prior to treatment with MMF.

RESULTS

Pharmacokinetic monitoring of mycophenolic acid (MPA) was performed with 108 trough plasma samples using an EMIT assay. Mean daily MMF dose was 24.5 +/- 6.3 mg/kg and mean trough MPA concentration was 2.9 +/- 1.9 microg/mL. Therapy was effective in 10 patients (83%). There were few side-effects: diarrhoea, excitement, agitation and cough that disappeared with daily dose reduction of MMF.

CONCLUSIONS

MMF was effective in the majority of patients with uveitis with an acceptable profile of side-effects. TDM of MMF in patients with uveitis is clinically practicable and may help to optimize individual immunosuppressive therapy. We estimated that MMF dosages in the range of 0.5-1.5 g/day might be sufficient for treating uveitis and we recommend an initial target range of 2-4 microg/mL, which included 50% of our results. Randomized controlled trials are essential to confirm the efficacy of MMF in uveitis.

Novel therapies in pediatric rheumatic diseases

PURPOSE OF REVIEW

Better understanding of the etiology of autoimmune diseases and their progression has brought about numerous novel therapies used in the treatment of pediatric rheumatic diseases. The introduction of biologic agents such as tumor necrosis factor inhibitors has changed how we approach and manage autoimmune diseases. This has led to a proliferation of other therapies targeting specific inflammatory processes evident in many rheumatic illnesses, with hopes of improving efficacy and decreasing adverse effects from treatment.

RECENT FINDINGS

Clinical studies demonstrate safety and efficacy of these newer medications in both adults and children. Although most of the novel therapies have been studied primarily in the adult rheumatic population, many are being evaluated in children in randomized controlled and open label trials as well. Long-term results are being collected regarding these newer regimens in both adults and children.

SUMMARY

This review looks at the risks and benefits of the variety of novel therapies including the new biologics, immunosuppressives, and stem cell transplantation currently being used in rheumatic conditions. Using these new therapies along with traditional antirheumatic medications, pediatric rheumatologists intervene to control disease early and more effectively to prevent long-term damage and complications.

Use of immunosuppressive agents in uveitis

PURPOSE OF REVIEW

This review summarizes current patterns in the use of immunosuppressive agents in patients with uveitis.

RECENT FINDINGS

A number of immunosuppressive agents are currently available for the treatment of uveitis. Reports of safety and efficacy, although numerous, have been largely nonrandomized and performed without controls, limiting, to some extent, the strength and generalizability of their conclusions. Nonetheless, the volume of case reports and case series provides compelling evidence that immunosuppressive agents are effective at providing long-term control in patients with moderate to severe chronic or recurrent uveitis. The choice of immunosuppressive agent is complex, and depends on the cause and severity of the patient's underlying inflammation, the presence or absence of associated systemic inflammation, and the patient's prior response to immunosuppressive treatments.

SUMMARY

Although corticosteroids remain the primary initial treatment for patients with uveitis, use of noncorticosteroid immunosuppressive agents in selected patients with uveitis allows for improved control and decreased risk of corticosteroid-induced side effects.

Clinical trials in pediatric uveitis

Uveitis associated with juvenile rheumatoid arthritis is the most common form of ocular inflammation in children. Prevention of permanent visual damage by this silent disease requires heightened awareness from pediatric rheumatologists and ophthalmologists. Early prediction of severity and prognosis will aid in the identification of those patients requiring more aggressive management. Generally, reports using immunosuppressives in this population are small, uncontrolled, and retrospective. Large-scale collaborative studies have been proposed and are underway. Hopefully, collaborations between pediatricians, pediatric rheumatologists, and ophthalmologists will allow the development of straightforward treatment guidelines for children suffering from chronic uveitis and its related complications.