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Maccora I, Soldovieri S, Oliverio T, de Masi S, Marrani E, Pagnini I, Mastrolia MV, Simonini G. To switch or to swap? Evidence from a meta-analysis for the best treatment approach in childhood chronic uveitis resistant to the I anti-TNF. J Transl Autoimmun 2024; 9:100247. [PMID: 39027719 PMCID: PMC11254593 DOI: 10.1016/j.jtauto.2024.100247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 06/20/2024] [Accepted: 06/22/2024] [Indexed: 07/20/2024] Open
Abstract
Objective Since adalimumab approval in childhood chronic non-infectious uveitis (cNIU), the prognosis has been dramatically changed, but the 25 % failed to achieve inactivity. There is not accordance if it is better to switch to another anti-TNF or to swap to another category of biologic. Thus, we aim to summarize evidence regarding the best treatment of cNIU refractory to the first anti-TNF. Methods A systematic literature review and meta-analysis, according to PRISMA Guidelines, was performed(Jan2000-Aug2023). Studies investigating the efficacy of treatment in cNIU refractory to the first anti-TNF were considered for inclusion. The primary outcome was the improvement of intraocular inflammation according to SUN. A combined estimation of the proportion of children responding to switch or swap and for each drug was performed. Results 23 articles were eligible, reporting 150 children of whom 109 switched anti-TNF (45 adalimumab, 49 infliximab, 9 golimumab) and 41 swapped to another biologics (31 abatacept, 8 tocilizumab and 1 rituximab). The proportion of responding children was 46 %(95 % CI 23-70) for switch and 38 %(95 % CI 8-73) for swap (χ20.02, p = 0.86). Instead analysing for each drug, the proportion of responding children was the 24 %(95 % CI 2-55) for adalimumab, 43 %(95 % CI 2-80) for abatacept, 79 %(95 % CI 61-93) for infliximab, 56 %(95 % CI 14-95) for golimumab and 96 %(95 % CI 58-100) for tocilizumab. We evaluated a superiority of tocilizumab and infliximab compared to the other drugs(χ2 27.5 p < 0.0001). Conclusion Although non-conclusive, this meta-analysis suggests that, after the first anti-TNF failure, tocilizumab and infliximab are the best available treatment for the management of cNIU.
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Affiliation(s)
- Ilaria Maccora
- Rheumatology Unit, ERN ReCONNET Centre, Meyer Children's Hospital IRCCS, Florence, Italy
- NeuroFARBA Department, University of Florence, Florence, Italy
| | - Sara Soldovieri
- Rheumatology Unit, ERN ReCONNET Centre, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Teodoro Oliverio
- Rheumatology Unit, ERN ReCONNET Centre, Meyer Children's Hospital IRCCS, Florence, Italy
| | | | - Edoardo Marrani
- Rheumatology Unit, ERN ReCONNET Centre, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Ilaria Pagnini
- Rheumatology Unit, ERN ReCONNET Centre, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Maria Vincenza Mastrolia
- Rheumatology Unit, ERN ReCONNET Centre, Meyer Children's Hospital IRCCS, Florence, Italy
- NeuroFARBA Department, University of Florence, Florence, Italy
| | - Gabriele Simonini
- Rheumatology Unit, ERN ReCONNET Centre, Meyer Children's Hospital IRCCS, Florence, Italy
- NeuroFARBA Department, University of Florence, Florence, Italy
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2
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Maccora I, Simonini G, Guly CM, Ramanan AV. Management of JIA associated uveitis. Best Pract Res Clin Rheumatol 2024:101979. [PMID: 39048481 DOI: 10.1016/j.berh.2024.101979] [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: 03/07/2024] [Revised: 05/14/2024] [Accepted: 07/17/2024] [Indexed: 07/27/2024]
Abstract
Juvenile Idiopathic Arthritis (JIA) is the most common chronic rheumatic disease in childhood, and is associated with uveitis in up to 20-25% of cases. Typically, the uveitis is chronic, asymptomatic, non-granulomatous and anterior. For this reason, screening for uveitis is recommended to identify uveitis early and allow treatment to prevent sight-threatening complications. The management of JIA associated uveitis requires a multidisciplinary approach and a close collaboration between paediatric rheumatologist and ophthalmologist. Starting the appropriate treatment to control uveitis activity and prevent ocular complications is crucial. Current international recommendations advise a step-wise approach, starting with methotrexate and moving on to adalimumab if methotrexate alone is not sufficient to control the disease. If the uveitis remains active despite standard treatment other therapeutic options may be considered including anti-IL6 or other anti-TNF agents such as infliximab, although the evidence for these agents is limited.
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Affiliation(s)
- Ilaria Maccora
- NeuroFARBA Department, University of Florence, Florence, Italy; Rheumatology Unit, ERN ReCONNET Center, Meyer Children's Hospital IRCCS, Florence, Italy.
| | - Gabriele Simonini
- NeuroFARBA Department, University of Florence, Florence, Italy; Rheumatology Unit, ERN ReCONNET Center, Meyer Children's Hospital IRCCS, Florence, Italy.
| | - Catherine M Guly
- Bristol Eye Hospital, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK.
| | - Athimalaipet V Ramanan
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK; Translational Health Science, University of Bristol, Bristol, UK.
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3
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Leal I, Steeples LR, Wong SW, Giuffrè C, Pockar S, Sharma V, Green EKY, Payne J, Jones NP, Chieng ASE, Ashworth J. Update on the systemic management of noninfectious uveitis in children and adolescents. Surv Ophthalmol 2024; 69:103-121. [PMID: 36682467 DOI: 10.1016/j.survophthal.2023.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 12/22/2022] [Accepted: 01/13/2023] [Indexed: 01/20/2023]
Abstract
Noninfectious uveitis (NIU) in children and adolescents is a rare but treatable cause of visual impairment in children. Treatments for pediatric NIU and their side effects, along with the risks of vision loss and the need for long-term disease monitoring, pose significant challenges for young patients and their families. Treatment includes local and systemic approaches and this review will focus on systemic therapies that encompass corticosteroids, conventional synthetic disease-modifying antirheumatic drugs (csDMARD), and biological disease-modifying antirheumatic drugs (bDMARD). Treatment is generally planned in a stepwise approach. Methotrexate is well-established as the preferential csDMARD in pediatric NIU. Adalimumab, an antitumor necrosis factor (TNF) agent, is the only bDMARD formally approved for pediatric NIU and has a good safety and efficacy profile. Biosimilars are gaining increasing visibility in the treatment of pediatric NIU. Other bDMARD with some evidence in literature for the treatment of pediatric NIU include infliximab, tocilizumab, abatacept, rituximab and, more recently, Janus kinase inhibitors. Important aspects of managing children on these systemic therapies include vaccination issues, risk of infection, and psychological distress. Also, strategies need to address regarding primary nonresponse/secondary loss of response to anti-TNF treatment, biological switching, and monitoring regimens for these drugs. Optimal management of pediatric uveitis involves a multidisciplinary team, including specialist pediatric uveitis and rheumatology nurses, pediatric rheumatologists, psychological support, orthoptic and optometry support, and play specialists.
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Affiliation(s)
- Inês Leal
- Ophthalmology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal; Visual Sciences Study Centre, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.
| | - Laura R Steeples
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK; Academic Health Science Centre, Manchester, UK
| | - Shiao Wei Wong
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Chiara Giuffrè
- Centro Europeo di Oftalmologia, Palermo, Italy; Ophthalmology Department, San Raffaele Scientific Institute, University Vita-Salute, Milan, Italy
| | - Sasa Pockar
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Vinod Sharma
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Elspeth K Y Green
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Janine Payne
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Nicholas P Jones
- School of Biological Sciences, University of Manchester, Manchester, UK
| | | | - Jane Ashworth
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK; Division of Evolution & Genomic Sciences, University of Manchester, Manchester, UK
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4
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Li B, Li H, Huang Q, Zheng Y. Shaping the Future of Behçet's Uveitis Management: A Comprehensive Review of Efficacy, Challenges, and Prospects of Biologic Therapies. Ophthalmol Ther 2023; 12:2295-2321. [PMID: 37477857 PMCID: PMC10442050 DOI: 10.1007/s40123-023-00767-0] [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: 05/03/2023] [Accepted: 06/29/2023] [Indexed: 07/22/2023] Open
Abstract
Behçet's uveitis (BU), a vision-threatening manifestation of Behçet's disease, poses substantial management challenges due to its chronic, relapsing nature and potential for vision loss. This review explores the role of biologic therapies in the treatment of BU, providing a comprehensive overview of their effectiveness, drawbacks, and future possibilities. Traditionally, management has relied heavily on corticosteroids and conventional immunosuppressants. However, their long-term use is frequently associated with systemic side effects and insufficient control of ocular inflammation. Biologic therapies, particularly TNF-alpha inhibitors like infliximab and adalimumab, have emerged as effective alternatives, offering better disease control and a more favorable safety profile. We critically evaluated these agents, noting their clinical efficacy in reducing inflammatory flares and preserving visual acuity. Despite their benefits, several issues remain. Accessibility, cost, and lack of long-term safety data limit their widespread use. Additionally, individual variability in treatment response necessitates personalized therapeutic strategies. Recent research has shown promise in addressing these challenges, with the emergence of novel biologic agents and personalized medicine approaches. In summary, biologic therapies represent a paradigm shift in BU management, contributing to better patient outcomes. Yet, there are significant challenges to be overcome. As we move forward, continued research, development of novel biologic agents, and a precision medicine approach will shape the future landscape of BU treatment.
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Affiliation(s)
- Biao Li
- Department of Ophthalmology, Affiliated Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Haoran Li
- Department of Ophthalmology, Affiliated Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Qun Huang
- Department of Ophthalmology, Affiliated Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Yanlin Zheng
- Department of Ophthalmology, Affiliated Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China.
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5
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van Bilsen K, Vergouwen DPC, van Velthoven MEJ, Missotten TOAR, Rombach SM, van Zelm MC, Berkowska MA, van Hagen PM, Kuijpers RWAM, van Laar JAM. Long-Term Follow-Up of Patients with Scleritis After Rituximab Treatment Including B Cell Monitoring. Ocul Immunol Inflamm 2023:1-6. [PMID: 37437135 DOI: 10.1080/09273948.2023.2229900] [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: 01/04/2023] [Revised: 03/28/2023] [Accepted: 06/21/2023] [Indexed: 07/14/2023]
Abstract
PURPOSE We report the long-term effect of rituximab (RTX) in scleritis and determine the value of B-cell monitoring for the prediction of relapses. METHODS We retrospectively studied 10 patients with scleritis, who were treated with RTX. Clinical characteristics were collected, and blood B-cell counts were measured before the start of RTX, and at various time points after treatment. RESULTS Clinical activity of scleritis decreased after RTX treatment in all patients within a median time of 8 weeks (range 3-13), and all reached remission. The median follow-up was 101 months (range 9-138). Relapses occurred in 6 out of 10 patients. All relapses, where B-cell counts were measured (11 out of 19), were heralded by returning B cells. However, B cells also returned in patients with long-term remissions. CONCLUSIONS RTX is a promising therapeutic option for scleritis. Recurrence of B cells after initial depletion does not always predict relapse of scleritis.
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Affiliation(s)
- Kiki van Bilsen
- Department of Internal Medicine, Section Clinical Immunology Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Daphne P C Vergouwen
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Ophthalmology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | | | - Tom O A R Missotten
- Centrum Medical Retinal and Uveitis, The Rotterdam Eye Hospital, Rotterdam, The Netherlands
| | - Saskia M Rombach
- Department of Internal Medicine, Section Clinical Immunology Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Menno C van Zelm
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Immunology and Pathology, Central Clinical School, Monash University and Alfred Hospital, Melbourne, Australia
| | - Magdalena A Berkowska
- Department of Internal Medicine, Section Clinical Immunology Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - P Martin van Hagen
- Department of Internal Medicine, Section Clinical Immunology Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Robert W A M Kuijpers
- Department of Ophthalmology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Ophthalmology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
- Department of Ophthalmology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Jan A M van Laar
- Department of Internal Medicine, Section Clinical Immunology Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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Ahmed AR, Aksoy M, Kinane TB. Pemphigoid of the pulmonary system (POPS): A review of a less recognized feature. Clin Exp Rheumatol 2022; 21:103180. [PMID: 35981700 DOI: 10.1016/j.autrev.2022.103180] [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: 08/04/2022] [Accepted: 08/11/2022] [Indexed: 11/02/2022]
Abstract
This review of Pemphigoid of the Pulmonary System (POPS) is a comprehensive description of pulmonary involvement in patients with mucous membrane pemphigoid (MMP), which is an orphan autoimmune blistering disease. The objective of the review was to analyze clinical features of pulmonary involvement in MMP. This POPS review is a case series in which multiple search engines were utilized from inception to June 2022 for cases of MMP with biopsy and immunopathology proven tracheal and bronchial pemphigoid. Clinical profiles prior to pulmonary involvement, bronchoscopy findings, clinical course and therapy were recorded and cause of death was analyzed. Patients with documented MMP who developed tracheal, bronchial and pulmonary involvement were included in the POPS review. Histology and immunopathology documentation were essential diagnostic criteria. Comparison groups were not possible. Patients were treated with immunosuppressive therapy. Some required surgical interventions. Six of the 11 patients attained complete or partial remission on or off therapy. Five patients died from pulmonary complications. The POPS review had six females and five males. The mean age at onset was 20 years (range 4-76), while 80% of the patients were under 40 years. All had severe widespread MMP involving three to five mucosal tissues. 100% had oral, 82% had ocular and cutaneous involvement. Pulmonary involvement occurred at 24 mo (range 2-372) after the onset of MMP. Bronchoscopy revealed acute inflammation during active disease and scarring of the trachea and bronchi in the later stages. Systemic infections occurred in 45%, while pulmonary infection occurred in 36%. Mortality due to respiratory failure, at the median age of 20 years (range 18-76), occurred in 45% of the patients, and was considered disease related. In spite of the young age, while there are some similarities in the clinical profile and response to systemic therapy, there are definitive differences from other patients with MMP. Early diagnosis with appropriate management could produce better clinical outcomes and prevent mortality in this orphan disease. Consequently, there is a critical need for early identification and diagnosis of POPS.
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Affiliation(s)
- A Razzaque Ahmed
- Center for Blistering Diseases, Department of Dermatology, Tufts University School of Medicine, Boston, MA, USA.
| | - Merve Aksoy
- Center for Blistering Diseases, Department of Dermatology, Tufts University School of Medicine, Boston, MA, USA
| | - T Bernard Kinane
- Chief Pediatric Pulmonary Medicine, Mass General Hospital, Harvard Medical School, Boston, MA, USA
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7
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Farooq MM, Miloslavsky EM, Konikov N, Ahmed AR. Use of rituximab in the treatment of mucous membrane pemphigoid: An analytic review. Autoimmun Rev 2022; 21:103119. [PMID: 35688385 DOI: 10.1016/j.autrev.2022.103119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 05/15/2022] [Indexed: 11/26/2022]
Abstract
Mucous Membrane Pemphigoid (MMP) is a potentially fatal mucocutaneous autoimmune blistering disease. Autoantibodies are produced against various components of the dermo-epidermal or mucosal-submucosal junction are referred to as basement membrane zone (BMZ). The hallmark is deposition of of Ig and C3 on the perilesional tissues and in some patients detection of anti-BMZ autoantibodies. A unique characteristic of MMP is that as the blisters or erosions heal, they leave irreversible scarring. This scarring results in serious and catastrophic sequelae that affect the quality of life. Conventional therapy consists of anti-inflammatory and immunosuppressive agents (ISA). In patients who fail conventional therapy or develop significant side effects to them, rituximab (RTX) has been used off label. In this review, the clinical outcomes of patients with MMP treated with RTX were studied. 124 patients were identified, 47.58% being male. 72 patients were treated by the Lymphoma Protocol and 51 by Rheumatoid Arthritis (RA) protocol. Follow up for the entire cohort was 36 months (range 0.5-72). On follow-up 64 patients (51.61%) achieved complete clinical remission (CR) off therapy, 25 patients (20.16%) were in CR on therapy, 5 patients (4.03%) were non-responders, and 9 patients (7.25%) were failures. 52 patients (41.93%) experienced a relapse, after 36 months follow-up. Duration between last RTX infusion and relapse was 10.5 months (range 1-30). Most patients with relapses were treated with additional RTX. A statistically significant better outcome was observed in patients treated with RTX as monotherapy compared to those who received RTX with ISA. Clinical outcomes in patients treated with Lymphoma protocol were better than RA protocol at a statistically significant level. Data on CD20+ B cell depletion and repopulation was limited. Interestingly relapses were seen in patients with CD20+ B cell depletion and after repopulation. In the final analysis, 89 patients (71.77%) were in complete remission. Data in this review indicated that RTX was a useful agent to treat MMP. While a randomized control trial may not be practically possible, better and disease specific protocols need to be developed. When publishing, authors should attempt to provide complete and detailed information. In doing so, they will benefit their colleagues and the patients with MMP they treat with RTX.
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Affiliation(s)
| | - Eli M Miloslavsky
- Massachusetts General Hospital, Department of Medicine, Division of Rheumatology, Boston, MA 02114, USA; Harvard Medical School, Boston, MA 02215, USA
| | - Nellie Konikov
- Boston VA health Care System, Jamaica Plain, Boston, MA 02130, USA
| | - A Razzaque Ahmed
- Center for Blistering Diseases, Boston, MA 02135, USA; Department of Dermatology, Tufts University School of Medicine, Boston, MA 02111, USA.
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8
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Systemic Immunosuppression for the Treatment of Pediatric Uveitis. Int Ophthalmol Clin 2022; 62:155-175. [PMID: 34965233 DOI: 10.1097/iio.0000000000000402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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9
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IMMUNOGLOBULIN G4-RELATED OPHTHALMIC DISEASE MIMICKING INTRAOCULAR LYMPHOMA: A CASE REPORT. Retin Cases Brief Rep 2022; 16:32-35. [PMID: 33181803 DOI: 10.1097/icb.0000000000001087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE To describe a case of immunoglobulin G4-related choroiditis mimicking intraocular lymphoma. METHODS The patient underwent a complete ophthalmological evaluation including multimodal imaging, with structural optical coherence tomography, fluorescein angiography, indocyanine green angiography, ultra-widefield color, and autofluorescent fundus photographies to assess the ocular involvement. RESULTS Patient's best-corrected visual acuity was of 20/25 in the right eye and 20/20 in the left eye. Fundus appearance showed abnormal yellowish choroidal lesions and moderate vitritis in both eyes. Fluorescein angiography was within normal limits, whereas indocyanine green angiography showed areas of choroiditis in both eyes, and structural optical coherence tomography scans disclosed retinal small roundish lesions in the corresponding regions. Laboratory examinations and lymph node biopsy led to the final diagnosis of immunoglobulin G4-related disease. CONCLUSION We describe a case of immunoglobulin G4-related choroiditis mimicking intraocular lymphoma. The proper use of multimodal imaging associated with laboratory investigations was helpful to reach the correct diagnosis.
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10
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Maleki A, Anesi SD, Look-Why S, Manhapra A, Foster CS. Pediatric uveitis: A comprehensive review. Surv Ophthalmol 2021; 67:510-529. [PMID: 34181974 DOI: 10.1016/j.survophthal.2021.06.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 06/15/2021] [Accepted: 06/21/2021] [Indexed: 12/14/2022]
Abstract
Pediatric uveitis accounts for 5-10% of all uveitis. Uveitis in children differs from adult uveitis in that it is commonly asymptomatic and can become chronic and cause damage to ocular structures. The diagnosis might be delayed for multiple reasons, including the preverbal age and difficulties in examining young children. Pediatric uveitis may be infectious or noninfectious in etiology. The etiology of noninfectious uveitis is presumed to be autoimmune or autoinflammatory. The most common causes of uveitis in this age group are idiopathic and juvenile idiopathic arthritis-associated uveitis. The stepladder approach for the treatment of pediatric uveitis is based on expert opinion and algorithms proposed by multidisciplinary panels. Uveitis morbidities in pediatric patients include cataract, glaucoma, and amblyopia. Pediatric patients with uveitis should be frequently examined until remission is achieved. Once in remission, the interval between follow-up visits can be extended; however, it is recommended that even after remission the child should be seen every 8-12 weeks depending on the history of uveitis and the medications used. Close follow up is also necessary as uveitis can flare up during immunomodulatory therapy. It is crucial to measure the impact of uveitis, its treatment, and its complications on the child and the child's family. Visual acuity can be considered as an acceptable criterion for assessing visual function. Additionally, the number of cells in the anterior chamber can be a measure of disease activity. We review different aspects of pediatric uveitis. We discuss the mechanisms of noninfectious uveitis, including autoimmune and autoinflammatory etiologies, and the risks of developing uveitis in children with systemic rheumatologic diseases. We address the risk factors for developing morbidities, the Standardization of Uveitis Nomenclature (SUN) criteria for timing and anatomical classifications, and describe a stepladder approach in the treatment of pediatric uveitis based on expert opinion and algorithms proposed by multi-disciplinary panels. In this review article, We describe the most common entities for each type of anatomical classification and complications of uveitis for the pediatric population. Additionally, we address monitoring of children with uveitis and evaluation of Quality of Life.
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Affiliation(s)
- Arash Maleki
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA; The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
| | - Stephen D Anesi
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA; The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
| | - Sydney Look-Why
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA; The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
| | - Ambika Manhapra
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA; The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
| | - C Stephen Foster
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA; The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA; Harvard Medical School, Department of Ophthalmology, Boston, MA, USA.
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11
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Murthy SI, Shah S, Bagga B, Dudam R. Rituximab therapy combined with methotrexate for severe necrotizing scleritis in a case of granulomatosis with polyangiitis. Indian J Ophthalmol 2021; 68:1981-1983. [PMID: 32823449 PMCID: PMC7690469 DOI: 10.4103/ijo.ijo_2249_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A 19-year-old girl presented with severe pain and redness in her right eye and also with nasal congestion and epistaxis since the past 5 months. The patient was systemically investigated and tested positive for proteinase 3 anti-neutrophil cytoplasmic antibody (PR-3 ANCA) with raised erythrocyte sedimentation rate (ESR). The provisional diagnosis of granulomatosis with polyangiitis (GPA) was made, and she was started on systemic steroids and azathioprine after consultation with the rheumatologist. However on steroid taper, she developed severe reactivation of the scleritis and the corneal involvement was noted in the form of peripheral ulcerative keratitis. Instead of starting another course of high dose oral cortico-steroids or pulse cyclophosphomide, she was started on rituximab infusion (two doses), and oral methotrexate was added, leading to the successful remission of the disease.
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Affiliation(s)
- Somasheila I Murthy
- Department of Cornea, The Cornea Institute, L.V. Prasad Eye Institute, Kallam Anji Reddy Campus, L.V. Prasad Marg, Banjara Hills, Hyderabad, India
| | - Sahil Shah
- Department of Cornea, The Cornea Institute, L.V. Prasad Eye Institute, Kallam Anji Reddy Campus, L.V. Prasad Marg, Banjara Hills, Hyderabad, India
| | - Bhupesh Bagga
- Department of Cornea, The Cornea Institute, L.V. Prasad Eye Institute, Kallam Anji Reddy Campus, L.V. Prasad Marg, Banjara Hills, Hyderabad, India
| | - Rajkiran Dudam
- Department of Rheumatology, Hyderabad Rheumatology Center, Prakash Nagar, Begumpet, Hyderabad, India
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12
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Ponti R, Mastrolia MV, Simonini G. Non-infectious Chronic Uveitis in Childhood: Assessment and Treatment in the Biological Era. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2021. [DOI: 10.1007/s40674-020-00166-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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Dominguez-Casas LC, Sánchez-Bilbao L, Calvo-Río V, Maíz O, Blanco A, Beltrán E, Martínez-Costa L, Demetrío-Pablo R, del Buergo MÁ, Rubio-Romero E, Díaz-Valle D, Lopez-Gonzalez R, García-Aparicio ÁM, Mas AJ, Vegas-Revenga N, Castañeda S, Hernández JL, González-Gay MA, Blanco R. Biologic therapy in severe and refractory peripheral ulcerative keratitis (PUK). Multicenter study of 34 patients. Semin Arthritis Rheum 2020; 50:608-615. [DOI: 10.1016/j.semarthrit.2020.03.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 03/26/2020] [Accepted: 03/30/2020] [Indexed: 12/17/2022]
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Non-Infectious Chronic Uveitis in Childhood: Assessment and Treatment in the Biological Era. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2020. [DOI: 10.1007/s40674-020-00151-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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15
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16
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Innate and Adaptive Cell Populations Driving Inflammation in Dry Eye Disease. Mediators Inflamm 2018; 2018:2532314. [PMID: 30158831 PMCID: PMC6109495 DOI: 10.1155/2018/2532314] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 06/15/2018] [Accepted: 06/28/2018] [Indexed: 12/19/2022] Open
Abstract
Dry eye disease (DED) is the most common ocular disease and affects millions of individuals worldwide. DED encompasses a heterogeneous group of diseases that can be generally divided into two forms including aqueous-deficient and evaporative DED. Evidence suggests that these conditions arise from either failure of lacrimal gland secretion or low tear film quality. In its secondary form, DED is often associated with autoimmune diseases such as Sjögren's syndrome and rheumatoid arthritis. Current treatment strategies for DED are limited to anti-inflammatory medications that target the immune system as the source of deleterious inflammation and tissue injury. However, there is a lack of understanding of the underlying pathogenesis of DED, and subsequently, there are very few effective treatment strategies. The gap in our knowledge of the etiology of primary DED is in part because the majority of research in DED focused on secondary autoimmune causes. This review focuses on what is currently understood about the contribution of innate and adaptive immune cell populations in the pathogenesis of DED and highlights the need to continue investigating the central role of immunity driving DED.
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Dogra M, Bajgai P, Kumar A, Sharma A. Progressive outer retinal necrosis after rituximab and cyclophosphamide therapy. Indian J Ophthalmol 2018; 66:591-593. [PMID: 29582832 PMCID: PMC5892074 DOI: 10.4103/ijo.ijo_811_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
We report a case of progressive outer retinal necrosis (PORN) in a patient of microscopic polyangitis (MPA), being treated with immunosuppressive drugs such as cyclophosphamide and rituximab. Her aqueous tap was positive for Varicella Zoster virus and she was treated with oral and intravitreal antivirals, along with discontinuation of one of the immunosuppressive agents, i.e. rituximab, which might have led to reactivation of the virus causing necrotizing retinitis lesions. Rituximab and cyclophosphamide are extremely potent drugs, which are necessary to manage immunological disorders such as MPA. However, they may predispose the patient to serious complications like viral infections, including PORN.
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Affiliation(s)
- Mohit Dogra
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Priya Bajgai
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashok Kumar
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Sharma
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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LONG-TERM OUTCOMES OF RITUXIMAB THERAPY IN PATIENTS WITH NONINFECTIOUS POSTERIOR UVEITIS REFRACTORY TO CONVENTIONAL IMMUNOSUPPRESSIVE THERAPY. Retina 2018; 38:395-402. [PMID: 28225369 DOI: 10.1097/iae.0000000000001563] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE To assess long-term effectiveness of rituximab therapy for refractory noninfectious uveitis affecting the posterior segment. METHODS Retrospective case series. Patients diagnosed with recalcitrant noninfectious posterior uveitis who were treated with rituximab intravenous infusions between 2010 and 2015 were included. Patients underwent best-corrected visual acuity testing and fluorescein angiography evidence of disk or vascular staining at 6, 12, 18, and 24 months. Patients had at least 24 months of follow-up. RESULTS Eleven patients (21 eyes) with refractory posterior uveitis treated with intravenous rituximab were included. Nine (81.8%) patients were female. Mean follow-up was 29.3 ± 7.8 months. rituximab was administered as complementary therapy because of previous inefficacy of other therapies in 7 (63.7%) patients, and it was the only treatment in four (36.3%) patients who did not tolerate other drugs. Inflammation signs by fluorescein angiography were controlled in nine (81.8%) patients at the end of follow-up. Baseline best-corrected visual acuity was 20/80 (logarithm of the minimal angle of resolution 0.6 ± 0.4), and final best-corrected visual acuity was 20/40 (0.3 ± 0.5) (P = 0.005). No significant side effects were reported. CONCLUSION Rituximab therapy was associated with stability and remission of recalcitrant noninfectious posterior uveitis in patients who did not tolerate or did not respond to other therapies.
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Khan ZH, Ilyas K, Ghazanfar H, Khan HH, Hussain Q, Hammad S, Munir A, Asim R. Fatal Fulminant Hepatitis from Rituximab-induced Hepatitis B Reactivation in a Patient with Follicular Lymphoma: A Case Report and a Brief Review of Literature. Cureus 2018; 10:e2257. [PMID: 29725560 PMCID: PMC5931408 DOI: 10.7759/cureus.2257] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The objective of our study was to recognize hepatitis B reactivation as a complication of rituximab chemotherapy and to realize the importance of screening for prior Hepatitis B virus (HBV) exposure in all patients with hematologic malignancies who will receive rituximab as part of their therapy. Rituximab is a monoclonal antibody targeting CD 20 receptors on the membrane of B cells. In this case report, we described a 79-year-old man who presented to our department with nausea, fatigue, and jaundice. Two months ago, he had received the last dose of the chemotherapy regimen containing rituximab for follicular B cell lymphoma. Ultrasound and computed tomography (CT) scan of abdomen did not show any focal lesions. Liver function tests showed worsening hepatic failure and viral serology demonstrated active HBV infection. Antiviral therapy with entecavir and tenofovir disoproxil fumarate failed to improve his symptoms, and he died of fulminant hepatic failure. Rituximab targets CD 20 receptors positive B cells. It can destroy both cancerous and normal B cells. A decline in immune function can activate occult HBV infection. Prior to initiation of rituximab therapy, screening should be conducted in all cases for HBV associated serological markers. Patients with active or occult HBV infection must be started on appropriate antiviral therapy to prevent any severe outcomes with rituximab-containing regimens.
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Affiliation(s)
- Zarak H Khan
- Department of Medicine, Shifa International Hospital, Islamabad, Pakistan
| | - Kamran Ilyas
- Internal Medicine, Shifa College of Medicine, Islamabad, Pakistan
| | - Haider Ghazanfar
- Internal Medicine, Shifa College of Medicine, Islamabad, Pakistan
| | - Hamza H Khan
- Graduate, Shifa International Hospital, Islamabad, Pakistan
| | - Qulsoom Hussain
- Internal Medicine, Shifa College of Medicine, Islamabad, Pakistan
| | - Sahla Hammad
- Internal Medicine, Shifa International Hospital, Islamabad, Pakistan
| | - Ahmed Munir
- Department of Medicine, Services Hospital, Services Institute of Medical Sciences, Lahore, Pakistan
| | - Rizwan Asim
- Internal Medicine, Texas Tech University (perian Basin)
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Efficacy of rituximab in non-paraneoplastic autoimmune retinopathy. Orphanet J Rare Dis 2017; 12:129. [PMID: 28709429 PMCID: PMC5512938 DOI: 10.1186/s13023-017-0680-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Accepted: 07/05/2017] [Indexed: 12/27/2022] Open
Abstract
Background Autoimmune retinopathy (AIR) is a rare but potentially blinding condition that is often underdiagnosed. Common features in AIR presentation include rapidly progressive vision loss with abnormal electrophysiological responses of the retina associated with positive anti-retinal antibodies. AIR is also challenging to treat, and thus, the introduction of new potential therapeutic agents is welcomed. The goal of this communication is to assess the effects of rituximab infusions on electroretinogram (ERG) responses and visual function outcomes in patients with non-paraneoplastic autoimmune retinopathy (npAIR). Results Following infusion(s), three out of five patients showed no evidence of disease progression or improved, while two patients continued to progress on ERG. One patient demonstrated improvement in visual acuity (2 lines) in both eyes. ERG responses provided objective monitoring of patients’ visual function and response to immunosuppression over time. Conclusions These findings suggest that patients with npAIR unresponsive to other immunosuppression therapies may benefit from rituximab infusion, although stabilization rather than improvement was more frequently the outcome in our case series. Furthermore, regularly scheduled ERG follow-up examinations are recommended for monitoring patients’ progression during treatment.
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Sood AB, Angeles-Han ST. An Update on Treatment of Pediatric Chronic Non-Infectious Uveitis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2017; 3:1-16. [PMID: 28944162 PMCID: PMC5604477 DOI: 10.1007/s40674-017-0057-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
There are no standardized treatment protocols for pediatric non-infectious uveitis. Topical corticosteroids are the typical first-line agent, although systemic corticosteroids are used in intermediate, posterior and panuveitic uveitis. Corticosteroids are not considered to be long-term therapy due to potential ocular and systemic side effects. In children with severe and/or refractory uveitis, timely management with higher dose disease-modifying antirheumatic drugs (DMARDs) and biologic agents is important. Increased doses earlier in the disease course may lead to improved disease control and better visual outcomes. In general, methotrexate is the usual first-line steroid-sparing agent and given as a subcutaneous weekly injection at >0.5 mg/kg/dose or 10-15 mg/m2 due to better bioavailability. Other DMARDs, for instance mycophenolate, azathioprine, and cyclosporine are less common treatments for pediatric uveitis. Anti-tumor necrosis factor-alpha agents, primarily infliximab and adalimumab are used as second line agents in children refractory to methotrexate, or as first-line treatment in those with severe complicated disease at presentation. Infliximab may be given at a minimum of 7.5 mg/kg/dose every 4 weeks after loading doses, up to 20 mg/kg/dose. Adalimumab may be given up to 20 or 40 mg weekly. In children who fail anti-tumor necrosis factor-alpha agents, develop anti-tumor necrosis factor-alpha antibodies, experience adverse effects, or have difficulty with tolerance, there is less data available regarding subsequent treatment. Promising results have been noted with tocilizumab infusions every 2-4 weeks, abatacept monthly infusions and rituximab.
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Calvo-Río V, Santos-Gómez M, Calvo I, González-Fernández MI, López-Montesinos B, Mesquida M, Adán A, Hernández MV, Maíz O, Atanes A, Bravo B, Modesto C, Díaz-Cordovés G, Palmou-Fontana N, Loricera J, González-Vela MC, Demetrio-Pablo R, Hernández JL, González-Gay MA, Blanco R. Anti-Interleukin-6 Receptor Tocilizumab for Severe Juvenile Idiopathic Arthritis-Associated Uveitis Refractory to Anti-Tumor Necrosis Factor Therapy: A Multicenter Study of Twenty-Five Patients. Arthritis Rheumatol 2017; 69:668-675. [DOI: 10.1002/art.39940] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 09/20/2016] [Indexed: 11/08/2022]
Affiliation(s)
- Vanesa Calvo-Río
- Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Marqués de Valdecilla (IDIVAL), and University of Cantabria; Santander Spain
| | - Montserrat Santos-Gómez
- Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Marqués de Valdecilla (IDIVAL), and University of Cantabria; Santander Spain
| | | | | | | | | | | | | | - Olga Maíz
- Hospital Universitario Donostia; San Sebastian Spain
| | | | - Beatriz Bravo
- Hospitalario Universitario Virgen de las Nieves; Granada Spain
| | | | | | - Natalia Palmou-Fontana
- Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Marqués de Valdecilla (IDIVAL), and University of Cantabria; Santander Spain
| | - Javier Loricera
- Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Marqués de Valdecilla (IDIVAL), and University of Cantabria; Santander Spain
| | - M. C. González-Vela
- Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Marqués de Valdecilla (IDIVAL), and University of Cantabria; Santander Spain
| | - Rosalía Demetrio-Pablo
- Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Marqués de Valdecilla (IDIVAL), and University of Cantabria; Santander Spain
| | - J. L. Hernández
- Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Marqués de Valdecilla (IDIVAL), and University of Cantabria; Santander Spain
| | - Miguel A. González-Gay
- Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Marqués de Valdecilla (IDIVAL), and University of Cantabria; Santander Spain
| | - Ricardo Blanco
- Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Marqués de Valdecilla (IDIVAL), and University of Cantabria; Santander Spain
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Altaweel MM, Gangaputra SS, Thorne JE, Dunn JP, Elner SG, Jaffe GJ, Kim RY, Rao PK, Reed SB, Kempen JH. Morphological assessment of the retina in uveitis. J Ophthalmic Inflamm Infect 2016; 6:33. [PMID: 27613274 PMCID: PMC5017967 DOI: 10.1186/s12348-016-0103-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 08/29/2016] [Indexed: 11/21/2022] Open
Abstract
Background The objective of this study is to describe a system for color photograph evaluation in uveitis and report baseline morphologic findings for the Multicenter Uveitis Steroid Treatment (MUST) Trial. Four-hundred seventy-nine eyes of 255 subjects with intermediate, posterior, and panuveitis had stereoscopic color fundus photographs obtained by certified photographers and evaluated by certified graders using standardized procedures to evaluate morphologic characteristics of uveitis. The posterior pole was evaluated for macular edema, vitreoretinal interface abnormalities, and macular pigment disturbance/atrophy; the optic disk was assessed for edema, pallor, or glaucomatous changes. The presence of neovascularization, vascular occlusion, vascular sheathing, and tractional retinal changes was determined. A random subset of 77 images was re-graded to determine the percentage agreement with the original grading on a categorical scale. Results At baseline, 437/479 eyes had images available to grade. Fifty-three eyes were completely ungradable due to media opacity. Common features of intermediate and posterior/panuveitis were epiretinal membrane (134 eyes, 35 %), and chorioretinal lesions (140 eyes, 36 %). Macular edema was seen in 16 %. Optic nerve head and vascular abnormalities were rare. Reproducibility evaluation found exact agreement for the presence of chorioretinal lesions was 78 %, the presence and location of macular edema was 71 %, and the presence of epiretinal membrane was 71 %. Vertical cup-to-disk ratio measurement had intra-class correlation of 0.75. Conclusions The MUST system for evaluating stereoscopic color fundus photographs describes the morphology of uveitis and its sequelae, in a standardized manner, is highly reproducible, and allows monitoring of treatment effect and safety evaluation regarding these outcomes in clinical trials. Electronic supplementary material The online version of this article (doi:10.1186/s12348-016-0103-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michael M Altaweel
- Fundus Photograph Reading Center, Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, USA. .,Department of Ophthalmology and Visual Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, 2870 University Ave. Suite 206, Madison, WI, 53705, USA.
| | - Sapna S Gangaputra
- Fundus Photograph Reading Center, Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, USA
| | - Jennifer E Thorne
- Department of Ophthalmology, The Johns Hopkins University, Baltimore, MD, USA.,Department of Epidemiology, The Johns Hopkins University, Baltimore, MD, USA
| | - James P Dunn
- Wills Eye Hospital, Thomas Jefferson University, Philadelphia, USA
| | | | | | - Rosa Y Kim
- Retina Consultants of Houston, Houston, TX, USA
| | - P Kumar Rao
- Department of Ophthalmology and Visual Sciences, Washington University, St. Louis, MO, USA
| | - Susan B Reed
- Fundus Photograph Reading Center, Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, USA
| | - John H Kempen
- Departments of Ophthalmology and Biostatistics & Epidemiology and the Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, USA
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Dithmer M, Hattermann K, Pomarius P, Aboul Naga SH, Meyer T, Mentlein R, Roider J, Klettner A. The role of Fc-receptors in the uptake and transport of therapeutic antibodies in the retinal pigment epithelium. Exp Eye Res 2016; 145:187-205. [PMID: 26773870 DOI: 10.1016/j.exer.2015.12.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 11/11/2015] [Accepted: 12/31/2015] [Indexed: 10/22/2022]
Abstract
In the ophthalmological clinic, intravitreally applied antibodies or Fc-containing fusion proteins are frequently used, but the biology and pharmacokinetics of these therapeutics in the retina are not well understood. We have previously shown intracellular uptake of Fc-containing molecules in RPE cells. In this study, we investigated the involvement of Fc-receptors, both Fcγ-receptors and the neonatal Fc-receptor (FcRn) in the uptake and intracellular trafficking of the VEGF-antagonists bevacizumab, aflibercept and the anti-CD20 antibody rituximab in three different model systems, primary porcine RPE cells, ARPE-19 cells and porcine RPE/choroid explants. The expression of Fcγ-receptors was tested in primary porcine RPE cells, and the expression of Fcγ-receptors I and II could be shown in RT-PCR and qRT-PCR, while the expression of FcRn was additionally confirmed in Western blot and immunocytochemistry. All three compounds, bevacizumab, rituximab and aflibercept, were taken up into the cells and displayed a characteristic time-dependent pattern, as shown in Western blot and immunohistochemistry. The uptake was not altered by the inhibition of Fcγ-receptors using different inhibitors (TruStain FcX, genistein, R406). However, the inhibition of FcRn with an antagonistic antibody reduced intracellular IgG in porcine RPE cells (rituximab) and ARPE-19 cells (bevacizumab, rituximab). Colocalisations between the tested compounds and myosin7a could be found. In addition, limited colocalization with FcRn and the tested compounds, as well as triple localization between compound, FcRn and myosin7a could be detected, indicating a role of myosin7a in FcRn mediated transport. However, the colocalizations are restricted to small fractions of the Fc-containing compounds. Furthermore, the FcRn is mainly found in the membrane section, where only minute amounts of the Fc-containing compounds are seen, suggesting a limited interaction. An apical to choroidal transport of IgG through the RPE/choroid can be found in RPE/choroid explants. Inhibition of FcRn increases the amount of bevacizumab found on the choroidal side, suggesting a role of FcRn in the recycling of bevacizumab. In conclusion, our data indicate a role for FcRn, but not Fcγ-receptors, in the uptake and transport of Fc-containing molecules in the RPE and indicate a recycling function of FcRn in the retina.
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Affiliation(s)
- Michaela Dithmer
- University of Kiel, University Medical Center, Department of Ophthalmology, Kiel, Germany
| | | | - Prasti Pomarius
- University of Kiel, University Medical Center, Department of Ophthalmology, Kiel, Germany
| | - Shereen Hassan Aboul Naga
- University of Kiel, University Medical Center, Department of Ophthalmology, Kiel, Germany; University of Cairo, Kasr Al-Aini Faculty of Medicine, Cairo, Egypt
| | - Tim Meyer
- Department of Gastroenterology, Charite University Clinic, Berlin, Germany
| | - Rolf Mentlein
- University of Kiel, Department of Anatomy, Kiel, Germany
| | - Johann Roider
- University of Kiel, University Medical Center, Department of Ophthalmology, Kiel, Germany
| | - Alexa Klettner
- University of Kiel, University Medical Center, Department of Ophthalmology, Kiel, Germany.
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Amin RM, Miserocchi E, Thorne JE, Hornbeak D, Jabs DA, Zierhut M. Treatment Options for Juvenile Idiopathic Arthritis (JIA) Associated Uveitis. Ocul Immunol Inflamm 2015; 24:81-90. [DOI: 10.3109/09273948.2015.1077976] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Rowayda M. Amin
- Department of Ophthalmology, Alexandria University, Alexandria, Egypt
| | - Elisabetta Miserocchi
- Department of Ophthalmology, University Vita-Salute, San Raffaele Scientific Institute, Milan, Italy
| | - Jennifer E. Thorne
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Dana Hornbeak
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Douglas A. Jabs
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Ophthalmology, Mount Sinai School of Medicine, New York, New York, USA
| | - Manfred Zierhut
- Centre for Ophthalmology, University Tuebingen, Tuebingen, Germany
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Simonini G, Cimaz R, Jones GT, Macfarlane GJ. Non-anti-TNF biologic modifier drugs in non-infectious refractory chronic uveitis: The current evidence from a systematic review. Semin Arthritis Rheum 2015; 45:238-50. [DOI: 10.1016/j.semarthrit.2015.05.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Revised: 04/29/2015] [Accepted: 05/14/2015] [Indexed: 12/14/2022]
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Miserocchi E, Modorati G, Berchicci L, Pontikaki I, Meroni P, Gerloni V. Long-term treatment with rituximab in severe juvenile idiopathic arthritis-associated uveitis. Br J Ophthalmol 2015; 100:782-6. [DOI: 10.1136/bjophthalmol-2015-306790] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 09/08/2015] [Indexed: 11/04/2022]
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Umran RMR, Shukur ZYH. Rituximab for sight-threatening refractory pediatric Vogt-Koyanagi-Harada disease. Mod Rheumatol 2015; 28:197-199. [PMID: 26154298 DOI: 10.3109/14397595.2015.1071234] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Rituximab was trialed in a refractory Vogt-Koyanagi-Harada disease (VKH). A 10-year-old girl with panuveitis recalcitrant to treatment, including corticosteroids, was diagnosed with VKH 20 months later. Following rituximab at 0, 1, 6, and 18 months, response was favorable after the second dose, usual life activity resumed after the third dose (uveitis was inactivated and vision improved), and eyes stabilized 9 months after the fourth dose. Rituximab is effective in the treatment and long-term control of advanced, pediatric VKH.
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Affiliation(s)
- Raid M R Umran
- a Department of Pediatrics , University of Kufa, College of Medicine, Al- Zahraa Teaching Hospital , Najaf , Iraq
| | - Zaid Y H Shukur
- b Department of Physiology , University of Kufa, College of Medicine, Al Sader Teaching Hospital , Najaf , Iraq
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Abstract
Anterior uveitis (AU), inflammation of the iris, choroid or ciliary body, can cause significant eye morbidity, including visual loss. In the pediatric age group, the most common underlying diagnosis for AU is juvenile idiopathic associated uveitis and idiopathic AU, which are the focus of this paper. AU is often resistant to medications such as topical corticosteroids and methotrexate. In the past 15 years, biologic agents (biologics) have transformed treatment. In this review, we discuss those in widespread use and those with more theoretical applications for anterior uveitis. Tumor necrosis factor alpha inhibitors (anti-TNFα) have been available the longest and are used widely to treat pediatric uveitis. The effects of anti-TNFα in children are described mostly in small retrospective case series. Together, the literature suggests that the majority of children treated with anti-TNFα achieve decreased uveitis activity and reduced corticosteroid burden. However, many will have disease flares even on treatment. Only a few small studies directly compare outcomes between alternate anti-TNFα (infliximab and adalimumab). The use of different uveitis grading systems, inclusion criteria, and outcome measures makes cross-study comparisons difficult. Whether the achievement and maintenance of inactive disease occurs more frequently with certain anti-TNFα remains controversial. Newer biologics that modulate the immune system differently (e.g., interfere with Th17 activation through IL-17a and IL-6 blockade, limit T lymphocyte costimulation, and deplete B lymphocytes), have shown promise for uveitis. Studies of these agents are small and include mostly adults. Additional biologics are also being explored to treat uveitis. With their advent, we are hopeful that outcomes will ultimately be improved for children with AU. With many biologics available, much work remains to identify the optimal inflammatory pathway to target in AU.
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Affiliation(s)
- Melissa A Lerman
- Division of Rheumatology, The Children's Hospital of Philadelphia (CHOP), Abramson Research Center Suite 1102, 3615 Civic Center Boulevard, Philadelphia, PA, 19104, USA,
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Schuler S, Brunner M, Bernauer W. Rituximab and Acute Retinal Necrosis in a Patient with Scleromalacia and Rheumatoid Arthritis. Ocul Immunol Inflamm 2015; 24:96-8. [PMID: 25760911 DOI: 10.3109/09273948.2014.999377] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Rituximab is a widely used biologic agent, which has shown favourable results in the treatment of vasculitis. But immunosuppressive treatment also bears the risk of severe complications. METHODS A patient with rheumatoid arthritis, progressive scleromalacia, and acute retinal necrosis on therapy with rituximab is reported. RESULTS For the first time, a correlation between rituximab and acute retinal necrosis in a patient with progressive rheumatoid scleromalacia is shown. CONCLUSIONS Although rituximab is a promising biologic agent for the treatment of autoimmune diseases, it bears the risk of reactivation of viral infections, including the onset of acute retinal necrosis.
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Affiliation(s)
| | | | - Wolfgang Bernauer
- a ÓMMA Eye Center , Zurich , Switzerland and.,b University of Zurich , Zurich , Switzerland
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32
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Uvéites et biothérapies. Rev Med Interne 2015; 36:107-16. [DOI: 10.1016/j.revmed.2014.07.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Revised: 02/16/2014] [Accepted: 07/28/2014] [Indexed: 12/25/2022]
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Suhler EB, Lim LL, Beardsley RM, Giles TR, Pasadhika S, Lee ST, de Saint Sardos A, Butler NJ, Smith JR, Rosenbaum JT. Rituximab Therapy for Refractory Scleritis. Ophthalmology 2014; 121:1885-91. [DOI: 10.1016/j.ophtha.2014.04.044] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 03/05/2014] [Accepted: 04/29/2014] [Indexed: 02/04/2023] Open
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Agrawal R, Lee C, Phatak S, Pavesio C. Immunopharmacotherapy of non-infectious uveitis: where do we stand? Expert Opin Biol Ther 2014; 14:1719-22. [PMID: 25244075 DOI: 10.1517/14712598.2014.963049] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
With ever-evolving concept of personalised medicine backed up with specific biomarkers for ocular inflammatory disease, there is a sudden surge of using biologics in non-infectious recalcitrant posterior uveitis. Have we understood these biologic agents enough to embark on this long enduring journey with the patient to optimise control of intraocular inflammation? On the other hand, there is still a strong inhibition of using these novel agents in management of uveitis even at tertiary referral centres. Immunopharmacotherapy of non-infectious uveitis poses a significant conundrum for both physicians and patients as it is like a two-edged sword effective to control inflammation but at the same time potentially toxic, suspected of causing long-term adverse effects. Systemic immunosuppressive therapy is used in a substantial number of most vision-threatening ocular inflammatory diseases. There is lack of randomised control trials establishing the safety of this therapy and our current practice pattern is based on retrospective studies and personal experience in using this treatment modality. This overview will highlight on the current dilemma faced by the clinicians in opting for steroid-sparing immunosuppressive therapy.
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Affiliation(s)
- Rupesh Agrawal
- Moorfields Eye Hospital, NHS Foundation Trust , London , UK
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Pleyer U, Stübiger N. New pharmacotherapy options for noninfectious posterior uveitis. Expert Opin Biol Ther 2014; 14:1783-99. [DOI: 10.1517/14712598.2014.956074] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Lee K, Bajwa A, Freitas-Neto CA, Metzinger JL, Wentworth BA, Foster CS. A comprehensive review and update on the biologic treatment of adult noninfectious uveitis: part II. Expert Opin Biol Ther 2014; 14:1651-66. [PMID: 25226284 DOI: 10.1517/14712598.2014.947957] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Treatment of adult, noninfectious uveitis remains a major challenge for ophthalmologists around the world, especially in regard to recalcitrant cases. It is reported to comprise approximately 10% of preventable blindness in the USA. The cause of uveitis can be idiopathic or associated with infectious and systemic disorders. The era of biologic medical therapies provides new options for patients with otherwise treatment-resistant inflammatory eye disease. AREAS COVERED This two-part review gives a comprehensive overview of the existing medical treatment options for patients with adult, noninfectious uveitis, as well as important advances for the treatment ocular inflammation. Part I covers classic immunomodulation and latest information on corticosteroid therapy. In part II, emerging therapies are discussed, including biologic response modifiers, experimental treatments and ongoing clinical studies for uveitis. EXPERT OPINION The hazard of chronic corticosteroid use in the treatment of adult, noninfectious uveitis is well documented. Corticosteroid-sparing therapies, which offer a very favorable risk-benefit profile when administered properly, should be substituted. Although nothing is currently approved for on-label use in this indication, many therapies, through either translation or novel basic science research, have the potential to fill the currently exposed gaps.
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Affiliation(s)
- Kyungmin Lee
- Massachusetts Eye Research and Surgery Institution (MERSI) , 5 Cambridge Center, 8th Floor, Cambridge, MA 02142 , USA +1 617 621 6377 ; +1 617 494 1430 ;
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Kalinina Ayuso V, Makhotkina N, van Tent-Hoeve M, de Groot-Mijnes JD, Wulffraat NM, Rothova A, de Boer JH. Pathogenesis of juvenile idiopathic arthritis associated uveitis: the known and unknown. Surv Ophthalmol 2014; 59:517-31. [DOI: 10.1016/j.survophthal.2014.03.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Revised: 03/24/2014] [Accepted: 03/25/2014] [Indexed: 12/17/2022]
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Stoll ML, Cron RQ. Treatment of juvenile idiopathic arthritis: a revolution in care. Pediatr Rheumatol Online J 2014; 12:13. [PMID: 24782683 PMCID: PMC4003520 DOI: 10.1186/1546-0096-12-13] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 04/10/2014] [Indexed: 01/19/2023] Open
Abstract
A generation ago, children with arthritis faced a lifetime of pain and disability. Today, there are a multitude of treatment options, including a variety of biologics targeting key cytokines and other inflammatory mediators. While non-steroidal anti-inflammatory drugs and corticosteroids were once the mainstay of therapy, they are now largely used as bridge or adjunctive therapies. Among the conventional disease-modifying anti-rheumatic drugs, methotrexate remains first-line therapy for most children with juvenile idiopathic arthritis (JIA) due to its long track record of safety and effectiveness in the management of peripheral arthritis. Sulfasalazine and leflunomide may also have a secondary role. The tumor necrosis factor inhibitors (TNFi) have shown tremendous benefit in children with polyarticular JIA and likely in enthesitis-related arthritis and psoriatic JIA as well. There may be additional benefit in combining TNFi with methotrexate. Abatacept and tocilizumab also appear to benefit polyarticular JIA; the role of rituximab remains unclear. For the treatment of systemic JIA, while the TNFi are of less benefit, blockade of interleukin-1 or interleukin-6 is highly effective. Additionally, interleukin-1 blockade appears to be effective treatment of macrophage activation syndrome, one of the most dangerous complications of JIA; specifically, anakinra in combination with cyclosporine and corticosteroids may obviate the need for cytotoxic approaches. In contrast, methotrexate along with the TNFi and abatacept are effective agents for the management of uveitis, another complication of JIA. Overall, the biologics have demonstrated an impressive safety record in children with JIA, although children do need to be monitored for rare but potentially dangerous adverse events, such as tuberculosis and other infections; paradoxical development of additional autoimmune diseases; and possibly an increased risk of malignancy. Finally, there may be a window of opportunity during which children with JIA will demonstrate most optimal responses to aggressive therapy, underscoring the need for rapid diagnosis and initiation of treatment.
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Affiliation(s)
- Matthew L Stoll
- University of Alabama at Birmingham, CPP N 210 M, 1600 7th Avenue South, Birmingham, AL 35233-1711, USA
| | - Randy Q Cron
- University of Alabama at Birmingham, CPP N 210 M, 1600 7th Avenue South, Birmingham, AL 35233-1711, USA
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Pan J, Kapur M, McCallum R. Noninfectious immune-mediated uveitis and ocular inflammation. Curr Allergy Asthma Rep 2014; 14:409. [PMID: 24338488 DOI: 10.1007/s11882-013-0409-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Noninfectious uveitis encompasses a diverse group of ocular inflammatory disorders that share an underlying immune etiology and may be associated with systemic disease or confined primarily to the eye. Uveitis is commonly classified by anatomical location of inflammation into anterior, intermediate, posterior, and panuveitis. The treatment of noninfectious uveitis consists of corticosteroids, immunosuppressive agents, and surgically placed steroid implants. We review the epidemiology, immunopathology, and clinical features of several noninfectious immune-mediated uveitides, including HLA-B27 acute anterior uveitis, juvenile idiopathic arthritis, intermediate uveitis, sarcoidosis, Behcet's disease, Vogt-Koyanagi-Harada syndrome, sympathetic ophthalmia, and white dot syndromes. We also discuss the stepwise approach to medical treatment of immune-mediated uveitis as well as the characteristics, safety, and efficacy of immunosuppressive agents used to treat ocular inflammatory disease.
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Affiliation(s)
- Jennifer Pan
- Texas Tech University Health Sciences Center - Paul L. Foster School of Medicine, El Paso, TX, 79905, USA,
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Zhao BH, Oswald AE. Improved clinical control of a challenging case of Behçet's disease with rituximab therapy. Clin Rheumatol 2013; 33:149-50. [PMID: 24305944 DOI: 10.1007/s10067-013-2433-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 11/01/2013] [Indexed: 01/25/2023]
Abstract
Behçet's disease (BD) is a rare form of vasculitis in North America. Like other rare diseases, there is no high-quality evidence for biologic use beyond case reports/series, and thus, therapy remains controversial. We report on the case of a patient who failed to respond to conventional therapy with colchicine and NSAIDs. She responded to steroids but failed to tolerate steroid tapers despite azathioprine, methotrexate, infliximab, and etanercept and required chronic prednisone up to 20 mg daily due to recurrent severe mucosal ulcers with fever, erythema nodosum (EN), and arthritis. She received cyclophosphamide for another indication but even then failed steroid taper. After three courses of rituximab, she showed marked clinical improvement and was able to reduce prednisone to 8 mg and to return to school and work. A review of disease mechanisms and clinical literature is presented for those facing challenging cases where evidence is limited.
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Affiliation(s)
- Barbara Hong Zhao
- 562 Heritage Medical Research Center, University of Alberta, Edmonton, Alberta, T6G 2S2, Canada,
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Reiff A, Kadayifcilar S, Özen S. Rheumatic Inflammatory Eye Diseases of Childhood. Rheum Dis Clin North Am 2013; 39:801-32. [DOI: 10.1016/j.rdc.2013.05.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Miserocchi E, Modorati G, Pontikaki I, Meroni PL, Gerloni V. Long-term Treatment with Golimumab for Severe Uveitis. Ocul Immunol Inflamm 2013; 22:90-5. [DOI: 10.3109/09273948.2013.844265] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Emerging therapies for the treatment of uveitis: clinical trial observations. ACTA ACUST UNITED AC 2013. [DOI: 10.4155/cli.13.87] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Tomkins-Netzer O, Taylor SRJ, Lightman S. Can rituximab induce long-term disease remission in patients with intra-ocular non-infectious inflammation? ACTA ACUST UNITED AC 2013; 230:109-15. [PMID: 23948944 DOI: 10.1159/000351426] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Treatment of non-infectious uveitis is based primarily on the use of systemic corticosteroids and second-line immunosuppressive drugs. However, their extensive side effect profile, particularly for steroids, has led to the increased use of other immunosuppressive drugs, as sparing capacity agents. Rituximab is an anti-CD20 chimeric antibody, often given as a single course of 2 infusions, resulting in complete depletion of peripheral mature B cells. While it is licensed to treat refractory systemic lymphoma patients, it has also shown promising results in systemic auto-immune diseases, where a single course of treatment is able to achieve long-term clinical remission. Treatment with rituximab has been reported for various ocular conditions, suggesting it may be effective in inducing long-term disease control and other systemic immunosuppressive agents can be reduced or discontinued. When disease relapse occurs, a further course or courses can be given with good results. This review summarizes the current evidence regarding the role of rituximab in treating non-infectious uveitis.
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Selmi C, Gershwin ME. The long-term marriage between autoimmunity and internal medicine: a homage to Manuel Carlos Dias. Clin Rev Allergy Immunol 2013; 43:207-10. [PMID: 22826113 DOI: 10.1007/s12016-012-8333-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Our understanding of autoimmune diseases results from the perfect combination of basic and clinical scientific research, and the figure that is closest to the proposed autoimmunology specialist is certainly the internist. The role of B cells in rheumatoid arthritis, the immunological mechanisms to fibrosis or to tissue specific damage, the classification of Bechet's syndrome, the clinical outcomes of antiphospholid syndrome, and new biomarkers for vascular complications in systemic sclerosis constitute, among others, are ideal examples of this combination. For these reason, this issue includes comprehensive reviews in all these areas and is dedicated to Dr. Manuel Carlos Dias and his career in the perfectioning and teaching of the clinical skills necessary to manage autoimmune disease. We are convinced that these discussions are likely of interest to basic scientists and clinicians alike for the proposed translational applications.
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Affiliation(s)
- Carlo Selmi
- Division of Rheumatology, Allergy, and Clinical Immunology, University of California Davis, Davis, CA 95616, USA.
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Mesquida M, Molins B, Llorenç V, Hernández MV, Espinosa G, Dick AD, Adán A. Current and future treatments for Behçet's uveitis: road to remission. Int Ophthalmol 2013; 34:365-81. [PMID: 23729309 DOI: 10.1007/s10792-013-9788-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 05/02/2013] [Indexed: 12/14/2022]
Abstract
Behçet's disease (BD) is a multisystem inflammatory disorder of uncertain origin, although it remains defined within the spectrum of systemic immune-mediated vasculitic disorders and also represents a spectrum of putative autoimmune disease. Major symptoms include oral aphthous ulcers, genital ulcerations, skin lesions, and ocular lesions. Despite afflicting many systems, ocular complications of BD are some of the more devastating for the patient and their quality of life. Eye involvement, which affects 60-80 % of BD patients, is characterized in its more severe form by posterior or panuveitis including occlusive retinal vasculitis. While pathogenesis of BD remains complex, association with Class I MHC (HLA-B*51) predisposing to inflammation with engagement of the innate-immune system (neutrophils, NK cells), and perpetuated by the adaptive T cell responses against infectious- and/or auto-antigens. Despite the choice of conventional immunosuppressive therapies available, only recently with the advent of biologic therapy has visual prognosis and outcomes been substantially and favorably altered. For example, both interferon-α (IFN-α) and tumour necrosis factor (TNF)-α antagonists deliver promising results and for the first time improve prognosis. With IFN-α therapy, durable remissions of uveitis can be achieved and lead to drug-free remission. Similarly, anti-TNF therapy with infliximab is reported to be rapidly effective in inducing and maintaining remission. Most recently, rising evidence reports on the use of adalimumab, etanercept, and golimumab, while use of anti-interleukin (IL)-1 agents (anakinra, canakinumab, gevokizumab), IL-6 blockers (tocilizumab), and rituximab (depleting anti-CD20 antibody) is also increasing. The aim of this review is to provide evidence for the role of conventional therapies combined with evidence for advantages and disadvantages of biologic therapies in the treatment of ocular BD. Although randomized controlled trials remain sparse, evidence remains strong and enticing that biologic agents are invaluable for the treatment of sight-threatening Behçet's uveitis and makes it an exciting time for Behçet's specialists worldwide.
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Affiliation(s)
- Marina Mesquida
- Ophthalmology Department, Hospital Clinic of Barcelona, University of Barcelona, Sabino de Arana, 1, 08028, Barcelona, Spain,
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Bogdanic-Werner K, Fernandez-Sanz G, Alejandre Alba N, Ferrer Soldevila P, Romero-Bueno FI, Sanchez-Pernaute O. Rituximab Therapy for Refractory Idiopathic Scleritis. Ocul Immunol Inflamm 2013; 21:329-32. [DOI: 10.3109/09273948.2013.788724] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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49
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Biotherapies in inflammatory ocular disorders: Interferons, immunoglobulins, monoclonal antibodies. Autoimmun Rev 2013; 12:774-83. [DOI: 10.1016/j.autrev.2013.02.002] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2013] [Accepted: 02/18/2013] [Indexed: 12/12/2022]
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50
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Beardsley RM, Suhler EB, Rosenbaum JT, Lin P. Pharmacotherapy of scleritis: current paradigms and future directions. Expert Opin Pharmacother 2013; 14:411-24. [PMID: 23425055 DOI: 10.1517/14656566.2013.772982] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Scleritis is an inflammatory condition affecting the eye wall that may be associated with a number of systemic inflammatory diseases. Because scleritis can be refractory to standard treatment, knowledge of the body of available and emerging therapies is paramount and is reviewed here. AREAS COVERED This review focuses on both traditional and emerging therapies for noninfectious scleritis. The authors cover the mechanisms of action and potential adverse effects of each of the treatment modalities. In addition, a summary of the significant MEDLINE indexed literature under the subject heading 'scleritis', 'treatment', 'immunomodulator' will be provided on each therapy, including commentary on appropriate use and relative contraindications. Novel treatments and potential drug candidates that are currently being evaluated in clinical trials with therapeutic potential will also be reviewed. EXPERT OPINION While oral nonsteroidal anti-inflammatory drugs and oral corticosteroids are widely used, effective, first-line agents for inflammatory scleritis, refractory cases require antimetabolites, T-cell inhibitors, or biologic response modifiers. In particular, there is emerging evidence for the use of targeted biologic response modifiers, and potentially, for local drug delivery.
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Affiliation(s)
- Robert M Beardsley
- Oregon Health & Science University, Casey Eye Institute, 3375 SW Terwilliger Blvd, Portland, OR 97239, USA
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