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Baquet-Walscheid K, Rath T, Heiligenhaus A. Ocular Involvement in Selected Rheumatic Diseases - Clinical Manifestation in Adulthood. Klin Monbl Augenheilkd 2024; 241:626-632. [PMID: 38574680 DOI: 10.1055/a-2239-0412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Ocular manifestations of rheumatic diseases are common and contribute significantly to the morbidity and reduced quality of life of affected patients. Knowledge of typical clinical manifestations is important for the rheumatologist in order to support the reference of patients with corresponding symptoms for ophthalmological consultation at an early stage of disease, or to initiate regular screening examinations (e.g. in patients with Behçet's syndrome). Conversely, a (possibly urgent) rheumatological assessment is crucial for certain ophthalmological diseases, in order not to overlook a (possibly fatal) systemic associated disease. Patients with rheumatic or inflammatory ocular diseases should always be informed by the treating physician about possible symptoms of other organ manifestations, in order to avoid a delayed diagnosis. "Classic" associations for uveitis are (HLA-B27-associated) spondyloarthritis and acute anterior uveitis, as well as retinal vasculitis with or without panuveitis and Behçet's syndrome. In patients with rheumatoid arthritis or ANCA-associated vasculitis, however, scleritis (with or without peripheral ulcerative keratitis) typically occurs, but a variety of other findings are also possible. Close interdisciplinary collaboration, particularly regarding therapeutic decisions, is crucial to ensuring a good prognosis for the patient.
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Affiliation(s)
- Karoline Baquet-Walscheid
- Augenzentrum am St. Franziskus-Hospital Münster, Deutschland
- Medizinische Fakultät, Universität Duisburg-Essen, Essen, Deutschland
| | - Thomas Rath
- Rheumatologie, Fachklinik Bad Bentheim, Deutschland
| | - Arnd Heiligenhaus
- Augenzentrum am St. Franziskus-Hospital Münster, Deutschland
- Medizinische Fakultät, Universität Duisburg-Essen, Essen, Deutschland
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Chao YJ, Hung JH, Lin CP, Kuo HK, Chen SN, Hwang YS, Li KJ, Lin CJ, Hwang DK, Sheu SJ. Diagnosis, Treatment, and Prevention of Noninfectious Acute Anterior Uveitis with or without Human Leukocyte Antigen B27 in Adults - Expert Consensus in Taiwan. Ocul Immunol Inflamm 2024; 32:226-233. [PMID: 36701640 DOI: 10.1080/09273948.2023.2165113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 12/31/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Anterior uveitis is the most common anatomical type of uveitis. Patients with noninfectious anterior uveitis may develop various ocular complications and eventually visual impairment. Appropriately differentiating the etiologies can help clinicians to predict the outcome, arrange clinical follow-up, and decide the treatment or prevention strategy. Adequate treatment and effective prevention strategies can reduce the frequency of recurrence and the risk of developing complications. Human leukocyte antigen (HLA)-B27 is the most common positive finding in patients with noninfectious AAU in many countries including Taiwan. PURPOSE To report a consensus from experienced uveitis specialists and rheumatologists was made in Taiwan. METHODS A panel of nine ophthalmologists from nine different referral centers with expertise in the management of uveitis and an experienced rheumatologist was held on January 16, 2022. A comprehensive literature review was performed. Differential diagnoses for etiologies, general treatments, and prevention strategies were discussed. Each statement in the consensus was made only if more than 70% of the experts agreed. RESULTS A flow chart and seven statements regarding the differential diagnoses for etiologies, treatments and preventions, and co-management with rheumatologists were included in the consensus. CONCLUSIONS This article discusses the general diagnosis, treatment, and prevention of noninfectious acute anterior uveitis, with or without HLA-B27, in adults for general ophthalmologists to improve overall outcomes of these patients.
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Affiliation(s)
- Yu-Jang Chao
- Department of Ophthalmology, Cheng Hsin General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Jia-Horung Hung
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan, ROC
- Department of Ophthalmology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan, ROC
| | - Chang-Ping Lin
- Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan, ROC
| | - Hsi-Kung Kuo
- Department of Ophthalmology, Kaohsiung Chang-Gung Memorial Hospital, Kaohsiung, Taiwan, ROC
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan, ROC
| | - San-Ni Chen
- Department of Ophthalmology, China Medical University Hospital, China Medical University, Taichung, Taiwan, ROC
- Department of Medication, China Medical University, Taichung, Taiwan, ROC
| | - Yih-Shiou Hwang
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan, ROC
- Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan City, Taiwan, ROC
- Department of Ophthalmology, Chang Gung Memorial Hospital, Xiamen Branch, Xiamen, China
- Department of Ophthalmology, Jen-Ai Hospital Dali Branch, Taichung, Taiwan
| | - Ko-Jen Li
- Division of Rheumatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, ROC
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chun-Ju Lin
- Department of Ophthalmology, China Medical University Hospital, China Medical University, Taichung, Taiwan, ROC
- Department of Optometry, Asia University, Taichung, Taiwan, ROC
| | - De-Kuang Hwang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Shwu-Jiuan Sheu
- Department of Ophthalmology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Department of Ophthalmology, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Jacquot R, Kodjikian L, Chapurlat R, Sève P. Targeted therapies for uveitis in spondyloarthritis: A narrative review. Joint Bone Spine 2024; 91:105697. [PMID: 38309516 DOI: 10.1016/j.jbspin.2024.105697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 01/01/2024] [Accepted: 01/23/2024] [Indexed: 02/05/2024]
Abstract
Spondyloarthritis (SpA) encompasses a group of chronic inflammatory disorders of the joints frequently associated with uveitis in almost a quarter of cases. SpA-related uveitis typically affects the eye anterior chamber with sudden onset, causing pain, redness, photophobia, and blurred vision. Ophthalmologists will describe an acute anterior unilateral uveitis. Most patients present with episodic acute anterior non-granulomatous uveitis and retain excellent visual acuity. However, systemic treatments are recommended in the event of frequent relapses (2-3/year) or in rare cases of sight-threatening with ocular complications. The improved understanding of the pathogenesis of SpA has led to the management of this disease by biologics. Here, we review the main data regarding the opportunity to target specific components in inflammatory pathways for the treatment of SpA-related uveitis. These therapies are recommended for long-term control when uveitis relapses occur too frequently despite conventional systemic treatments. Significant benefits have been obtained with the tumor necrosis factor-α inhibitors (TNFis), particularly infliximab and adalimumab. Paradoxically, a high number of uveitis occurrences have been shown on etanercept. Mixed results have been demonstrated with interleukin-17 antagonists (secukinumab) and interleukin-12/interleukin-23 antagonists (ustekinumab) in cases of failure of TNFis. JAK inhibitors seem to be a valuable class of medications for these patients in the future. Although SpA-related uveitis is typically managed with conventional local and/or systemic treatments, these biological/targeted therapies may provide avenues to control both the underlying SpA and uveitis manifestations. Thus, a close collaboration between patients, rheumatologists, internists, and ophthalmologists is needed to optimally manage ocular inflammation in SpA.
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Affiliation(s)
- Robin Jacquot
- Department of Internal Medicine, Hospices Civils de Lyon, Hôpital Universitaire de la Croix-Rousse, University Claude-Bernard Lyon 1, Lyon, France; Inserm U1290, Research on Healthcare Performance (RESHAPE), University Claude-Bernard Lyon 1, Lyon, France.
| | - Laurent Kodjikian
- Department of Ophthalmology, Hospices Civils de Lyon, Hôpital Universitaire de la Croix-Rousse, University Claude-Bernard Lyon 1, Lyon, France; UMR5510 MATEIS, CNRS, INSA Lyon, University Claude-Bernard Lyon 1, Villeurbanne, France
| | - Roland Chapurlat
- Department of Rheumatology, Hospices Civils de Lyon, Hôpital Universitaire Édouard-Herriot, University Claude-Bernard Lyon 1, Lyon, France
| | - Pascal Sève
- Department of Internal Medicine, Hospices Civils de Lyon, Hôpital Universitaire de la Croix-Rousse, University Claude-Bernard Lyon 1, Lyon, France; Inserm U1290, Research on Healthcare Performance (RESHAPE), University Claude-Bernard Lyon 1, Lyon, France
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4
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Werkl P, Rademacher J, Pleyer U. HLA-B27-positive anterior uveitis : Clinical aspects, diagnostics, interdisciplinary management, and treatment. DIE OPHTHALMOLOGIE 2024; 121:12-22. [PMID: 38085287 DOI: 10.1007/s00347-023-01960-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/08/2023] [Indexed: 02/03/2024]
Abstract
Acute anterior uveitis (AAU) associated with human leukocyte antigen (HLA) B27 is the most common form of noninfectious intraocular inflammation and is considered to be a separate clinical entity. Young adults between the ages of 20 and 40 years are predominantly affected. The HLA-B27 positive AAU typically presents as a unilateral, fulminant disruption of the blood-aqueous humor barrier, which is accompanied by pronounced cellular infiltration and fibrinous exudation. Other characteristics are reduced intraocular pressure and a high tendency to relapse, which can also involve the partner eye. Patients with HLA-B27 positive AAU share a high risk for other genetically associated diseases, especially spondylarthritis, chronic inflammatory bowel diseases and psoriasis. As up to 40% of those affected have a systemic disease that has not yet been diagnosed, the ophthalmologist is of major importance for early detection.
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Affiliation(s)
- Peter Werkl
- Universitätsaugenklinik Graz-LKH-Universitätsklinikum Graz, Medizinische Universität Graz, Auenbruggerplatz 4, 8036, Graz, Austria
| | - Judith Rademacher
- Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Division of Gastroenterology, Infectious Diseases and Rheumatology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Hindenburgdamm 30, 12203, Berlin, Germany
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Uwe Pleyer
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
- Universitäts-Augenklinik, Charité, Campus Virchow Klinikum-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, und Berlin Institute of Health, 13355, Berlin, Germany.
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Pineda-Sierra JS, Cifuentes-González C, Rojas-Carabali W, Muñoz-Vargas PT, Henao-Posada A, de-la-Torre A. Clinical characterization of patients with HLA-B27-associated uveitis and evaluation of the impact of systemic treatment on the recurrence rate: a cross-sectional study. J Ophthalmic Inflamm Infect 2023; 13:38. [PMID: 37646883 PMCID: PMC10468442 DOI: 10.1186/s12348-023-00352-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 05/27/2023] [Indexed: 09/01/2023] Open
Abstract
INTRODUCTION Despite HLA-B27-associated uveitis is one of the most frequent etiologies of uveitis worldwide, there are scarce studies on the clinical spectrum of this disease and the implications of therapeutic strategies used in the Latin-American population, with none conducted in Colombia. Thus, this study aimed to describe the clinical characteristics of a cohort of patients with positive HLA-B27-associated uveitis in Colombia and evaluate the impact of systemic treatment on the recurrence rate. METHODS We retrospectively reviewed 490 clinical charts of patients with uveitis, searching for those with positive HLA-B27-associated uveitis over eight years in a referral center in Bogotá, Colombia. We used descriptive statistics to summarize demographic and clinical characteristics and conducted a Chi-square test, Fisher Exact test, Spearman correlation, and Mann-Whitney test to assess associations between treatment strategies and the recurrences rate. RESULTS We analyzed 39 patients (59% females) with positive HLA-B27-associated uveitis, with a median age at the first consultation of 44.5 years (Range: 2-80) and a mean follow-up time of 86.4 weeks (1.65 years). Most patients had unilateral uveitis (53.8%) and an anterior anatomical diagnosis (76.6%); two had anterior chamber fibrinous reaction, and only one had hypopyon. Most patients did not show associated systemic symptoms (66.7%). Topical corticosteroids, NSAIDs, methotrexate, mydriatics, and adalimumab were the most used treatments. The most common complications included cataracts, posterior synechiae, and macular edema. We identified that the rate of recurrences decreases over time (r = -0.6361, P = 0.002571), and this decrease seems to be associated with the initiation of disease-modifying antirheumatic drugs (DMARDs) in chronic and recurrent cases. CONCLUSION The clinical spectrum of HLA-B27-associated uveitis in Colombian patients is distinct from other latitudes. Notably, we found a female predominance, older age at presentation, higher frequency of bilateral and vitreous involvement, and lower frequency of concomitant systemic diseases. Additionally, our results suggest that DMARDs such as methotrexate and biologic agents are good therapeutic options to avoid recurrences in chronic and recurrent cases.
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Affiliation(s)
- Juan Sebastián Pineda-Sierra
- Neuroscience (NEUROS) Research Group, Institute of Translational Medicine (IMT), Neurovitae Research Center, Escuela de Medicina Y Ciencias de La Salud, Universidad del Rosario, Carrera 24 # 63C - 69, Bogotá, Colombia
- Ophthalmology Interest Group, Neuroscience (NEUROS) Research Group, Institute of Translational Medicine (IMT), Neurovitae Research Center, Escuela de Medicina Y Ciencias de La Salud, Universidad del Rosario, Carrera 24 # 63C - 69, Bogotá, Colombia
| | - Carlos Cifuentes-González
- Neuroscience (NEUROS) Research Group, Institute of Translational Medicine (IMT), Neurovitae Research Center, Escuela de Medicina Y Ciencias de La Salud, Universidad del Rosario, Carrera 24 # 63C - 69, Bogotá, Colombia
| | - William Rojas-Carabali
- Neuroscience (NEUROS) Research Group, Institute of Translational Medicine (IMT), Neurovitae Research Center, Escuela de Medicina Y Ciencias de La Salud, Universidad del Rosario, Carrera 24 # 63C - 69, Bogotá, Colombia
| | - Paula Tatiana Muñoz-Vargas
- Neuroscience (NEUROS) Research Group, Institute of Translational Medicine (IMT), Neurovitae Research Center, Escuela de Medicina Y Ciencias de La Salud, Universidad del Rosario, Carrera 24 # 63C - 69, Bogotá, Colombia
| | - Alejandro Henao-Posada
- Neuroscience (NEUROS) Research Group, Institute of Translational Medicine (IMT), Neurovitae Research Center, Escuela de Medicina Y Ciencias de La Salud, Universidad del Rosario, Carrera 24 # 63C - 69, Bogotá, Colombia
| | - Alejandra de-la-Torre
- Neuroscience (NEUROS) Research Group, Institute of Translational Medicine (IMT), Neurovitae Research Center, Escuela de Medicina Y Ciencias de La Salud, Universidad del Rosario, Carrera 24 # 63C - 69, Bogotá, Colombia.
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Queiro R, Loredo M, Braña I, Pardo E, Alonso S, Alperi M. Managing psoriatic arthritis in different clinical scenarios. Expert Rev Clin Immunol 2023; 19:1469-1484. [PMID: 37589128 DOI: 10.1080/1744666x.2023.2249235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 08/14/2023] [Indexed: 08/18/2023]
Abstract
INTRODUCTION Psoriatic arthritis (PsA) is a chronic, immune-mediated disease characterized by synovio-entheseal inflammation. It is estimated to affect around 30% of patients with psoriasis and significantly reduces patients' physical function and quality of life. There is a growing number of treatment options for PsA, but due to the heterogeneous clinical features of the disease and prevalence of comorbidities, managing PsA can be challenging. AREAS COVERED In this article, we review current understanding of the disease and available pharmacological options. Based on published treatment guidelines, emerging evidence and clinical experience, we provide our expert opinion on treatment strategies, taking into consideration the predominant disease domain and the presence of comorbidities, which can impact treatment decisions and clinical outcomes. EXPERT OPINION Biological and targeted synthetic disease-modifying agents are dramatically improving the lives of patients with PsA. Biosimilar TNF inhibitors offer a particularly versatile and cost-effective option, whilst newer biologics and targeted synthetic molecules that can be used to treat most domains of psoriatic disease are an attractive alternative to TNF inhibitors. Despite a lack of consensus on treatment sequencing and tapering, it is important that PsA patients, especially those with comorbidities, are looked after by a multidisciplinary team to optimize their care.
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Affiliation(s)
- Rubén Queiro
- Rheumatology & ISPA Translational Immunology Division, Central University Hospital of Asturias, Oviedo, Spain
- Department of Medicine, Oviedo University School of Medicine, Oviedo, Spain
| | - Marta Loredo
- Rheumatology Division, Central University Hospital of Asturias, Oviedo, Spain
| | - Ignacio Braña
- Rheumatology Division, Central University Hospital of Asturias, Oviedo, Spain
| | - Estefanía Pardo
- Rheumatology Division, Central University Hospital of Asturias, Oviedo, Spain
| | - Sara Alonso
- Rheumatology Division, Central University Hospital of Asturias, Oviedo, Spain
| | - Mercedes Alperi
- Rheumatology Division, Central University Hospital of Asturias, Oviedo, Spain
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Stübiger N, Farrokhi S, Gkanatsas Y, Deuter C, Kötter I. [Association of the different forms of uveitis with inflammatory rheumatic diseases and their treatment]. DIE OPHTHALMOLOGIE 2023; 120:223-236. [PMID: 36695880 DOI: 10.1007/s00347-023-01814-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
The etiology of uveitis greatly varies worldwide, whereby in industrial nations noninfectious causes occur relatively more frequently. In Germany, 44% of all cases of uveitis are due to systemic diseases. In rheumatology, uveitis or other kinds of ocular inflammation, such as scleritis or retinal vasculitis, most commonly occur in spondylarthritis, vasculitis and sarcoidosis. Vice versa, ophthalmologists often ask rheumatologists about an underlying rheumatic disease in patients with uveitis. It is of utmost importance to differentiate between the different forms of uveitis. This review article presents the associations with inflammatory rheumatic diseases as well as treatment options from the point of view of both ophthalmologists and rheumatologists.
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Affiliation(s)
- Nicole Stübiger
- Augenklinik, Universitätsklinikum Eppendorf (UKE), Martinistr. 52, 20251, Hamburg, Deutschland
| | - Sanaz Farrokhi
- Augenklinik, Universitätsklinikum Eppendorf (UKE), Martinistr. 52, 20251, Hamburg, Deutschland
| | - Yannik Gkanatsas
- Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Oskar-Alexander-Str. 26, 24576, Bad Bramstedt, Deutschland
| | - Christoph Deuter
- Department für Augenheilkunde, Universitätsklinikum Tübingen, Elfriede-Aulhrn-Str. 7, 72076, Tübingen, Deutschland
| | - Ina Kötter
- Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Oskar-Alexander-Str. 26, 24576, Bad Bramstedt, Deutschland.
- Sektion für Rheumatologie und Entzündliche Systemerkankungen, Universitätsklinikum Eppendorf (UKE), Martinistr. 52, 20251, Hamburg, Deutschland.
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Werkl P, Rademacher J, Pleyer U. [HLA-B27 positive anterior uveitis : Clinical aspects, diagnostics, interdisciplinary management and treatment]. DIE OPHTHALMOLOGIE 2023; 120:108-122. [PMID: 36633629 DOI: 10.1007/s00347-022-01793-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/08/2022] [Indexed: 01/13/2023]
Abstract
Acute anterior uveitis (AAU) associated with human leukocyte antigen (HLA) B27 is the most common form of noninfectious intraocular inflammation and is considered to be a separate clinical entity. Young adults between the ages of 20 and 40 years are predominantly affected. The HLA-B27 positive AAU typically presents as a unilateral, fulminant disruption of the blood-aqueous humor barrier, which is accompanied by pronounced cellular infiltration and fibrinous exudation. Other characteristics are reduced intraocular pressure and a high tendency to relapse, which can also involve the partner eye. Patients with HLA-B27 positive AAU share a high risk for other genetically associated diseases, especially spondylarthritis, chronic inflammatory bowel diseases and psoriasis. As up to 40% of those affected have a systemic disease that has not yet been diagnosed, the ophthalmologist is of major importance for early detection.
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Affiliation(s)
- Peter Werkl
- Universitätsaugenklinik Graz - LKH-Universitätsklinikum Graz, Medizinische Universität Graz, Auenbruggerplatz 4, 8036, Graz, Österreich
| | - Judith Rademacher
- Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Division of Gastroenterology, Infectious Diseases and Rheumatology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Hindenburgdamm 30, 12203, Berlin, Deutschland.,Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
| | - Uwe Pleyer
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland. .,Universitäts-Augenklinik, Charité, Campus Virchow Klinikum - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, und Berlin Institute of Health, Berlin, Deutschland.
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Stübiger N, Farrokhi S, Gkanatsas Y, Deuter C, Kötter I. [Association of the different forms of uveitis with inflammatory rheumatic diseases and their treatment]. Z Rheumatol 2022; 81:667-681. [PMID: 36040536 DOI: 10.1007/s00393-022-01244-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2022] [Indexed: 11/26/2022]
Abstract
The etiology of uveitis greatly varies worldwide, whereby in industrial nations noninfectious causes occur relatively more frequently. In Germany, 44% of all cases of uveitis are due to systemic diseases. In rheumatology, uveitis or other kinds of ocular inflammation, such as scleritis or retinal vasculitis, most commonly occur in spondylarthritis, vasculitis and sarcoidosis. Vice versa, ophthalmologists often ask rheumatologists about an underlying rheumatic disease in patients with uveitis. It is of utmost importance to differentiate between the different forms of uveitis. This review article presents the associations with inflammatory rheumatic diseases as well as treatment options from the point of view of both ophthalmologists and rheumatologists.
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Affiliation(s)
- Nicole Stübiger
- Augenklinik, Universitätsklinikum Eppendorf (UKE), Martinistr. 52, 20251, Hamburg, Deutschland
| | - Sanaz Farrokhi
- Augenklinik, Universitätsklinikum Eppendorf (UKE), Martinistr. 52, 20251, Hamburg, Deutschland
| | - Yannik Gkanatsas
- Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Oskar-Alexander-Str. 26, 24576, Bad Bramstedt, Deutschland
| | - Christoph Deuter
- Department für Augenheilkunde, Universitätsklinikum Tübingen, Elfriede-Aulhrn-Str. 7, 72076, Tübingen, Deutschland
| | - Ina Kötter
- Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Oskar-Alexander-Str. 26, 24576, Bad Bramstedt, Deutschland.
- Sektion für Rheumatologie und Entzündliche Systemerkankungen, Universitätsklinikum Eppendorf (UKE), Martinistr. 52, 20251, Hamburg, Deutschland.
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Cassinotti A, Batticciotto A, Parravicini M, Lombardo M, Radice P, Cortelezzi CC, Segato S, Zanzi F, Cappelli A, Segato S. Evidence-based efficacy of methotrexate in adult Crohn's disease in different intestinal and extraintestinal indications. Therap Adv Gastroenterol 2022; 15:17562848221085889. [PMID: 35340755 PMCID: PMC8949794 DOI: 10.1177/17562848221085889] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 02/18/2022] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Methotrexate (MTX) is included in the therapeutic armamentarium of Crohn's disease (CD), although its positioning is currently uncertain in an era in which many effective biological drugs are available. No systematic reviews or meta-analysis have stratified the clinical outcomes of MTX according to the specific clinical scenarios of its use. METHODS Medline, PubMed and Scopus were used to extract eligible studies, from database inception to May 2021. A total of 163 studies were included. A systematic review was performed by stratifying the outcomes of MTX according to formulation, clinical indication and criteria of efficacy. RESULTS The use of MTX is supported by randomized clinical trials only in steroid-dependent CD, with similar outcomes to thiopurines. The use of MTX in patients with steroid-refractoriness, failure of thiopurines or in combination with biologics is not supported by high levels of evidence. Combination therapy with biologics can optimize the immunogenic profile of the biological drug, but the impact on long-term clinical outcomes is described only in small series with anti-TNFα. Other off-label uses, such as fistulizing disease, mucosal healing, postoperative prevention and extraintestinal manifestations, are described in small uncontrolled series. The best performance in most indications was shown by parenteral MTX, favouring higher doses (25 mg/week) in the induction phase. DISCUSSION Evidence from high-quality studies in favour of MTX is scarce and limited to the steroid-dependent disease, in which other drugs are the leading players today. Many limitations on study design have been found, such as the prevalence of retrospective underpowered studies and the lack of stratification of outcomes according to specific types of patients and formulations of MTX. CONCLUSION MTX is a valid option as steroid-sparing agent in steroid-dependent CD. Numerous other clinical scenarios require well-designed clinical studies in terms of patient profile, drug formulation and dosage, and criteria of efficacy.
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Affiliation(s)
| | | | | | | | - Paolo Radice
- Ophtalmology Unit, ASST Sette Laghi, Varese, Italy
| | | | - Simone Segato
- Gastroenterology Unit, ASST Sette Laghi, Varese, Italy
| | | | | | - Sergio Segato
- Gastroenterology Unit, ASST Sette Laghi, Varese, Italy
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Psoriatic Arthritis: The Influence of Co-morbidities on Drug Choice. Rheumatol Ther 2021; 9:49-71. [PMID: 34797530 PMCID: PMC8814223 DOI: 10.1007/s40744-021-00397-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 09/28/2021] [Indexed: 12/20/2022] Open
Abstract
Psoriatic arthritis (PsA) is associated with a higher burden of co-morbidities such as obesity, cardiovascular disease, non-alcoholic fatty liver disease, inflammatory eye disease, inflammatory bowel disease, skin cancer and depression compared to the general population. In the last 20 years, the therapeutic options for PsA have increased exponentially with the availability of tumor necrosis factor-alpha (TNF) inhibitors, interleukin (IL)-17 inhibitors, IL-12/23 inhibitors and Janus kinases/signal transducer and activator of transcription proteins (JAK/STAT) inhibitors. The articular and extra-articular manifestations of PsA usually dictate the treatment choice but important consideration must be given to the corresponding co-morbidities while deciding the drug therapy due to associated safety profile, effect on disease activity, etc. This review provides a comprehensive review of common co-morbidities in PsA and how they can influence treatment choices.
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El Jammal T, Loria O, Jamilloux Y, Gerfaud-Valentin M, Kodjikian L, Sève P. Uveitis as an Open Window to Systemic Inflammatory Diseases. J Clin Med 2021; 10:E281. [PMID: 33466638 PMCID: PMC7828680 DOI: 10.3390/jcm10020281] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/06/2021] [Accepted: 01/11/2021] [Indexed: 12/11/2022] Open
Abstract
Spondyloarthritis (Spa), Behçet's disease (BD) and sarcoidosis are major systemic inflammatory diseases worldwide. They are all multisystem pathologies and share a possible ocular involvement, especially uveitis. We hereby describe selected cases who were referred by ophthalmologists to our internal medicine department for unexplained uveitis. Physical examination and/or the use of laboratory and imaging investigations allowed to make a diagnosis of a systemic inflammatory disease in a large proportion of patients. In our tertiary referral center, 75 patients have been diagnosed with Spa (n = 20), BD (n = 9), or sarcoidosis (n = 46) in the last two years. There was a significant delay in the diagnosis of Spa-associated uveitis. Screening strategies using Human Leukocyte Antigen (HLA)-B27 determination and sacroiliac magnetic resonance imaging in patients suffering from chronic low back pain and/or psoriasis helped in the diagnosis. BD's uveitis affects young people from both sexes and all origins and usually presents with panuveitis and retinal vasculitis. The high proportion of sarcoidosis in our population is explained by the use of chest computed tomography (CT) and 18F-fluorodeoxyglucose positron emission tomography CT that helped to identify smaller hilar or mediastinal involvement and allowed to further investigate those patients, especially in the elderly. Our results confirm how in these sight- and potentially life-threatening diseases a prompt diagnosis is mandatory and benefits from a multidisciplinary approach.
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Affiliation(s)
- Thomas El Jammal
- Department of Internal Medicine, Hôpital de la Croix-Rousse, Université Claude Bernard Lyon I, 69004 Lyon, France; (T.E.J.); (Y.J.); (M.G.-V.)
| | - Olivier Loria
- Department of Ophthalmology, Hôpital de la Croix-Rousse, Université Claude Bernard Lyon I, 69004 Lyon, France; (O.L.); (L.K.)
- Laboratoire UMR-CNRS 5510 Matéis, 69004 Villeurbane, France
| | - Yvan Jamilloux
- Department of Internal Medicine, Hôpital de la Croix-Rousse, Université Claude Bernard Lyon I, 69004 Lyon, France; (T.E.J.); (Y.J.); (M.G.-V.)
| | - Mathieu Gerfaud-Valentin
- Department of Internal Medicine, Hôpital de la Croix-Rousse, Université Claude Bernard Lyon I, 69004 Lyon, France; (T.E.J.); (Y.J.); (M.G.-V.)
| | - Laurent Kodjikian
- Department of Ophthalmology, Hôpital de la Croix-Rousse, Université Claude Bernard Lyon I, 69004 Lyon, France; (O.L.); (L.K.)
- Laboratoire UMR-CNRS 5510 Matéis, 69004 Villeurbane, France
| | - Pascal Sève
- Department of Internal Medicine, Hôpital de la Croix-Rousse, Université Claude Bernard Lyon I, 69004 Lyon, France; (T.E.J.); (Y.J.); (M.G.-V.)
- IMER Department, Hospices Civils de Lyon, 69424 Lyon, France
- Department of Formation and Research in Human Biology, Université Claude Bernard Lyon 1, HESPER EA 7425, 69008 Lyon, France
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Wakefield D, Clarke D, McCluskey P. Recent Developments in HLA B27 Anterior Uveitis. Front Immunol 2021; 11:608134. [PMID: 33469457 PMCID: PMC7813675 DOI: 10.3389/fimmu.2020.608134] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 11/23/2020] [Indexed: 02/03/2023] Open
Abstract
There has been steady progress in understanding the pathogenesis, clinical features, and effective treatment of acute anterior uveitis (AU) over the past 5 years. Large gene wide association studies have confirmed that AU is a polygenic disease, with overlaps with the seronegative arthropathies and inflammatory bowel diseases, associations that have been repeatedly confirmed in clinical studies. The role of the microbiome in AU has received increased research attention, with recent evidence indicating that human leukocyte antigen B27 (HLA B27) may influence the composition of the gut microbiome in experimental animals. Extensive clinical investigations have confirmed the typical features of acute AU (AAU) and its response to topical, regional and systemic immunosuppressive treatment. Increased understanding of the role of cytokines has resulted in studies confirming the value of anti-cytokine therapy [anti-tumor necrosis factor (anti-TNF) and interleukin 6 (IL-6) therapy] in severe and recurrent cases of AAU, particularly in subjects with an associated spondyloarthopathy (SpA) and in juvenile idiopathic arthritis (JIA)-associated AAU.
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Affiliation(s)
- Denis Wakefield
- Faculty of Medicine, University of NSW Sydney, Kensington, NSW, Australia
- NSW Health Pathology and South Eastern Sydney, LHD, Sydney, NSW, Australia
| | - Daniel Clarke
- Department of Medicine, South Eastern Sydney, LHD, Sydney, NSW, Australia
| | - Peter McCluskey
- Save Sight Institute, The University of Sydney, Sydney, NSW, Australia
- Discipline of Clinical Ophthalmology and Eye Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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Rademacher J, Poddubnyy D, Pleyer U. Uveitis in spondyloarthritis. Ther Adv Musculoskelet Dis 2020; 12:1759720X20951733. [PMID: 32963592 PMCID: PMC7488890 DOI: 10.1177/1759720x20951733] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 07/30/2020] [Indexed: 12/17/2022] Open
Abstract
Uveitis is the most frequent extra-articular manifestation of axial spondyloarthritis (SpA), occurring in up to one-third of the patients. In the majority of patients, uveitis is acute, anterior and unilateral and presents with photosensitivity, sudden onset of pain and blurred vision. Topical steroids are an effective treatment; however, recurrent or refractory cases may need conventional disease-modifying antirheumatic drugs or biological treatment with monoclonal tumor necrosis factor (TNF) inhibitors, thus also influencing treatment strategy of the underlying SpA. Though the exact pathogenesis of SpA and uveitis remains unknown, both seem to result from the interaction of a specific, mostly shared genetical background (among other HLA-B27 positivity), external influences such as microbiome, bacterial infection or mechanical stress and activation of the immune system resulting in inflammation. Up to 40% of patients presenting with acute anterior uveitis (AAU) have an undiagnosed SpA. Therefore, an effective referral strategy for AAU patients is needed to shorten the diagnostic delay of SpA and enable an early effective treatment. Further, the risk for ophthalmological manifestations increases with the disease duration in SpA; and patients presenting with ocular symptoms should be referred to an ophthalmologist. Thus, a close collaboration between patient, rheumatologist and ophthalmologist is needed to optimally manage ocular inflammation in SpA.
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Affiliation(s)
- Judith Rademacher
- Department of Gastroenterology, Infectiology and Rheumatology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Hindenburgdamm 30, Berlin, 10117, Germany
| | - Denis Poddubnyy
- Department of Gastroenterology, Infectiology and Rheumatology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Uwe Pleyer
- Department of Ophthalmology, Campus Virchow, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
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Ben Nessib D, Ferjani H, Maatallah K, Rahmouni S, Kaffel D, Hamdi W. Update on therapeutic management of spondyloarthritis associated with inflammatory bowel disease. Clin Rheumatol 2020; 39:3543-3553. [PMID: 32424656 DOI: 10.1007/s10067-020-05136-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/21/2020] [Accepted: 05/01/2020] [Indexed: 02/06/2023]
Abstract
Management of spondyloarthritis (SpA) in patients with inflammatory bowel disease (IBD) remains a challenging task that requires multidisciplinary collaboration. Separate guidelines for each disease are well-established. However, the management of SpA co-occurring with Crohn's disease (CD) or ulcerative colitis (UC) has hardly been studied. There are few specific reports that focus on this therapeutic area. The main issue is that some therapeutic options used to treat one disease can negatively influence the other disease course. This study aims to evaluate the therapeutic alternatives that would allow for the appropriate management of patients with both SpA and IBD. Key Points • Collaboration between gastroenterologists and rheumatologists is recommended to improve the management of patients with spondyloarthritis (SpA) and inflammatory bowel disease (IBD). • When treating SpA occurring simultaneously with IBD, it would be appropriate to give priority to the active disease. • Considering its well-proven efficacy in both conditions, anti-tumor necrosis factor (TNF) therapy remains the corner stone in the treatment of these patients. • Other therapeutic options such as Janus kinases (JAK) inhibitors, interleukin (IL)-23 and IL-12 inhibitors, and vedolizumab are still under investigation.
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Affiliation(s)
- Dorra Ben Nessib
- Rheumatology Department, Kassab Orthopedics Institute, Mannouba, Tunisia. .,Faculty of Medicine of Tunis, University Tunis el Manar, Tunis, Tunisia. .,Research Unit UR17SP04, Ksar Said, 2010, Tunis, Tunisia.
| | - Hanene Ferjani
- Rheumatology Department, Kassab Orthopedics Institute, Mannouba, Tunisia.,Faculty of Medicine of Tunis, University Tunis el Manar, Tunis, Tunisia.,Research Unit UR17SP04, Ksar Said, 2010, Tunis, Tunisia
| | - Kaouther Maatallah
- Rheumatology Department, Kassab Orthopedics Institute, Mannouba, Tunisia.,Faculty of Medicine of Tunis, University Tunis el Manar, Tunis, Tunisia.,Research Unit UR17SP04, Ksar Said, 2010, Tunis, Tunisia
| | - Safa Rahmouni
- Rheumatology Department, Kassab Orthopedics Institute, Mannouba, Tunisia.,Faculty of Medicine of Tunis, University Tunis el Manar, Tunis, Tunisia.,Research Unit UR17SP04, Ksar Said, 2010, Tunis, Tunisia
| | - Dhia Kaffel
- Rheumatology Department, Kassab Orthopedics Institute, Mannouba, Tunisia.,Faculty of Medicine of Tunis, University Tunis el Manar, Tunis, Tunisia.,Research Unit UR17SP04, Ksar Said, 2010, Tunis, Tunisia
| | - Wafa Hamdi
- Rheumatology Department, Kassab Orthopedics Institute, Mannouba, Tunisia.,Faculty of Medicine of Tunis, University Tunis el Manar, Tunis, Tunisia.,Research Unit UR17SP04, Ksar Said, 2010, Tunis, Tunisia
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van Bentum RE, van der Horst-Bruinsma IE. Axial Spondyloarthritis in the Era of Precision Medicine. Rheum Dis Clin North Am 2020; 46:367-378. [DOI: 10.1016/j.rdc.2020.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Bouzid N, Jamilloux Y, Chapurlat R, Pradat P, De Parisot A, Kodjikian L, Sève P. Impact of systemic treatments on the course of HLA-B27-associated uveitis: A retrospective study of 101 patients. PLoS One 2020; 15:e0230560. [PMID: 32231384 PMCID: PMC7108732 DOI: 10.1371/journal.pone.0230560] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 03/04/2020] [Indexed: 12/17/2022] Open
Abstract
PURPOSE To investigate the efficacy and tolerance of systemic treatments for the prevention of HLA-B27-associated acute uveitis (AU) recurrence. METHODS Retrospective review of patients with HLA-B27-associated uveitis followed in our tertiary center over a 15-year period. Systemic treatments were prescribed to patients with frequent (more than 2 flares per year) or severe uveitis, according to a step-up strategy. RESULTS 101 patients (51.5% of men, 88.1% of white Europeans) with a median age of 37 years. AU was mostly recurrent (68.3%) and associated with spondyloarthritis (60.4%). After a median follow-up duration of 22 months (3-73), 37.6% of the patients have received systemic treatment. 88.5% of the patients have been treated with sulfasalazine (SSZ) for ophthalmologic purposes (23/26). Methotrexate (MTX) and anti-TNFα agents have been initiated for a rheumatologic indication in 81.8% (9/11) and 100% of the patients (13/13), respectively. The annual uveitis relapse rate significantly decreased on SSZ (0.37 recurrences/year versus baseline 2.46 recurrences/year; p<0.001) and MTX (1.54 recurrences/year versus 4.17/year; p = 0.008). Patients under ADA for ophthalmologic purposes (n = 2) did not experience any recurrence. CONCLUSION We report an open-label strategy to prevent the recurrences of HLA-B27-associated AU. First-line sulfasalazine reduced uveitis relapses. The use of anti-TNFα agents for ophthalmologic purposes was unnecessary with rare exceptions.
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Affiliation(s)
- Nabil Bouzid
- Service de Médecine Interne, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard-Lyon 1, Lyon, France
| | - Yvan Jamilloux
- Service de Médecine Interne, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard-Lyon 1, Lyon, France
| | - Roland Chapurlat
- Service de Rhumatologie, Hôpital Édouard Herriot, Hospices Civils de Lyon, INSERM UMR 1033, Université de Lyon, Lyon, France
| | - Pierre Pradat
- Centre de Recherche Clinique, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard-Lyon 1, Lyon, France
| | - Audrey De Parisot
- Service de Médecine Interne, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard-Lyon 1, Lyon, France
| | - Laurent Kodjikian
- Service d’Ophtalmologie, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard-Lyon 1, Lyon, France
| | - Pascal Sève
- Service de Médecine Interne, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard-Lyon 1, Lyon, France
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