Interferon alfa-2b, colchicine, and benzathine penicillin versus colchicine and benzathine penicillin in Behçet's disease: a randomised trial

Integrated Analysis of Key Pathways and Drug Targets Associated With Vogt-Koyanagi-Harada Disease

Background

Vogt-Koyanagi-Harada (VKH) disease is a complex disease associated with multiple molecular immunological mechanisms. As the underlying mechanism for VKH disease is unclear, we hope to utilize an integrated analysis of key pathways and drug targets to develop novel therapeutic strategies.

Methods

Candidate genes and proteins involved in VKH disease were identified through text-mining in the PubMed database. The GO and KEGG pathway analyses were used to examine the biological functions of the involved pathways associated with this disease. Molecule-related drugs were predicted through Drug-Gene Interaction Database (DGIdb) analysis.

Results

A total of 48 genes and 54 proteins were associated with VKH disease. Forty-two significantly altered pathways were identified through pathway analysis and were mainly related to immune and inflammatory responses. The top five of significantly altered pathways were termed as “inflammatory bowel disease,” “cytokine-cytokine receptor interaction,” “allograft rejection,” “antigen processing,” and “presentation and Herpes simplex infection” in the KEGG database. IFN-γ and IL-6 were identified as the key genes through network analysis. The DGIdb analysis predicted 48 medicines as possible drugs for VKH disease, among which Interferon Alfa-2B was co-associated both with IFN-γ and IL-6.

Conclusions

In this study, systematic analyses were utilized to detect key pathways and drug targets in VKH disease via bioinformatics analysis. IFN-γ and IL-6 were identified as the key mediators and possible drug targets in VKH disease. Interferon Alfa-2B was predicted to be a potentially effective drug for VKH disease treatment by targeting IFN-γ and IL-6, which warrants further experimental and clinical investigations.

Efficacy and safety of immunomodulatory drugs in patients with anterior uveitis: A systematic literature review

BACKGROUND

To assess the efficacy and safety of immunomodulatory drugs in patients with noninfectious anterior uveitis (AU).

METHODS

Systematic review of studies were retrieved from Medline (1961 to March 2016), Embase (1961 to March 2016), and Cochrane Library (up to March 2016), and a complementary hand search was also performed. The selection criteria were as follows: (population) noninfectious AU patients, adults; (intervention) immunomodulatory drugs (any dose, regimen, route of administration, duration of treatment); (outcome) control of inflammation, steroid-sparing effect, AU flares, adverse events, and so on; (study design) systematic literature reviews, randomized controlled trials, and observational studies. The study quality was assessed using the Jadad scale and according to The Oxford Centre for Evidence-based Medicine (update 2009).

RESULTS

We included 13 studies of moderate-poor quality, with a mean duration from 5 months to 20 years, and number of AU patients ranging from 9 to 274. Patient's demographic and clinical characteristics were very heterogeneous. In most cases, uveitis anatomic classification criteria and outcomes definitions were unclear. Some of the studies only included AU patients with a systemic disease associated, mostly spondyloarthritis, others, mixed populations (idiopathic and systemic disease associated patients), and in some articles this data is not described. We found that methotrexate, cyclosporine A, azathioprine, adalimumab, and golimumab might prevent AU flares, improve ocular inflammation and visual acuity, and decrease systemic steroids doses.

CONCLUSIONS

Although there is a lack of robust evidence, methotrexate, cyclosporine A, azathioprine, adalimumab, and golimumab might be effective in AU patients.

Noncompliance with Human Subjects' Protection Requirements as a Reason for Retracting Papers: Survey of Retraction Notices on Medical Papers Published from 1981 to 2011

Though protection of human research subjects is universally recognized as a critical requirement for the ethical conduct of research, few studies have examined retractions of medical articles through apparent noncompliance with that requirement. From our survey of 99 retracted papers published from 1981 to 2011, we found that the basis for those decisions was poorly explained in retraction notices and that most of the articles continued to be cited. In retraction notices, the current manner of explaining failure to protect human subjects is misleading and confusing.

Behçet’s Disease: A Review

Behçet’s disease (BD) is a multi-system inflammatory disorder dominated clinically by recurrent oral and genital ulceration, uveitis, and erythema nodosum. Behçet’s disease runs a chronic course, with unpredictable exacerbations and remissions whose frequency and severity may diminish with time. Behçet’s disease typically arises in young adults, although childhood-onset BD has also been reported. The disease can affect both genders and has a worldwide distribution, although it is more prevalent in countries of the ancient Silk Route. The cause of BD remains unknown, although an autoimmune reaction triggered by an infectious agent in a genetically predisposed individual has been suggested. The treatment of BD is symptomatic and empirical, but generally specific to the clinical features of each patient. The majority of affected individuals do not have life-threatening disease, although mortality can be associated with vascular-thrombotic and neurological disease.

The efficacy of intravitreal interferon alpha-2b for the treatment of experimental endotoxin-induced uveitis

PURPOSE

To study the efficacy of intravitreal interferon alpha-2b for endotoxin-induced uveitis.

MATERIALS AND METHODS

A total of 36 rabbits were randomly allocated to one of the three groups: (1) received interferon plus balanced-salt solution; (2) received lipopolysaccharide (LPS) plus interferon; and (3) received LPS plus balanced-salt solution. Intraocular inflammation was evaluated by slit-lamp biomicroscopy (standardization of uveitis nomenclature grading), binocular indirect ophthalmoscopy (BIO) score, and histopathology.

RESULTS

Group 2 showed significantly lower mean (±standard deviation) anterior chamber reaction than Group 3 (3.1 ± 0.9 vs. 3.8 ± 0.4) on day 1 postinjection, lower vitreous cells on days 1 through 7 (day 1: 3.1 ± 0.9 vs. 3.8 ± 0.4; day 3: 2.1 ± 1.6 vs. 3.8 ± 0.4; day 7: 1.9 ± 1.3 vs. 3.6 ± 0.7), and lower BIO score on days 1-7 (day 1: 3.3 ± 1.2 vs. 4.4 ± 0.7; day 3: 3.0 ± 1.4 vs. 4.3 ± 0.9; day 7: 2.4 ± 1.4 vs. 3.7 ± 1.2). The protein content of anterior and vitreous aspirates was lower in Group 2 than 3 (1618.5 ± 411.4 vs. 2567.3 ± 330.8 and 2157.0 ± 283.3 vs. 3204.6 ± 259.5, respectively).

CONCLUSION

Intravitreal interferon alpha-2b was effective in controlling endotoxin-induced uveitis.

The treatment of chronic recurrent oral aphthous ulcers

BACKGROUND

Chronic recurrent oral aphthous ulcers are the most common type of inflammatory efflorescence of the oral mucosa, with a prevalence of 2% to 10% in Caucasian populations. To treat them properly, physicians should know their clinical appearance and course, conditioning factors, underlying causes, and differential diagnosis.

METHOD

This review is based on pertinent articles that were retrieved by a selective search in PubMed and in the Cochrane Central Register of Controlled Trials.

RESULTS

Hard, acidic, and salty foods and toothpastes containing sodium lauryl sulfate should be avoided, along with alcohol and carbonated drinks. In Germany, the only drugs that have been approved to treat oral aphthous ulcers are corticosteroids, topical antiseptic/anti-inflammatory agents such as triclosan and diclofenac, and local anesthetics such as lidocaine. Antiseptic agents and local anesthetics should be tried first; if these are ineffective, topical cortico steroids should be used. In severe cases, local measures can be combined with systemic drugs, e.g., colchicine, pentoxifylline, or prednisolone. The efficacy of systemic treatment is debated. Other immunosuppressive agents should be given systemically only for refractory or particularly severe oral aphthous ulcers due to Adamantiades-Behçet disease.

CONCLUSION

The treatment of chronic recurrent oral aphthous ulcers is symptomatic, mainly with topically applied agents. It is tailored to the severity of the problem in the individual case, i.e., the frequency of ulcers, the intensity of pain, and the responsiveness of the lesions to treatment. Effective treatment relieves pain, lessens functional impairment, and lowers the frequency and severity of recurrences.

[Clinical aspects and treatment of recurrent aphthous ulcers]

Recurrent aphthous ulcers are the most common inflammatory lesions of the oral mucosa, occurring in up to 10% of the population and even more common in children. The history, morphological characteristics, predilection sides and typical stages of aphthae help to distinguish them from other diseases that may exhibit aphthous-like lesions. Underlying diseases should be excluded. The main goals of therapy are to minimize pain and functional disabilities as well as decrease frequency and severity of recurrences. Topical symptomatic relief is the standard of care for simple cases of recurrent aphthosis. In cases of major aphthosis or systemic involvement, topical therapies are still useful but should be combined with systemic therapy, such as colchicine, pentoxifylline or prednisolone. In case of Adamantiades-Behçet disease, systemic immunomodulatory drugs can inhibit the development of new lesions. This overview summarizes morphological and presentation forms of aphthae, differential diagnoses and evidence-based therapeutic possibilities.

Retracted publications in the drug literature

Recent studies have suggested an increase in the number of retracted scientific publications. It is unclear how broadly the issue of misleading and fraudulent publications pertains to retractions of drug therapy studies. Therefore, we sought to determine the trends and factors associated with retracted publications in drug therapy literature. A PubMed search was conducted to identify retracted drug therapy articles published from 2000-2011. Articles were grouped according to reason for retraction, which was classified as scientific misconduct or error. Scientific misconduct was further divided into data fabrication, data falsification, questions of data veracity, unethical author conduct, and plagiarism. Error was defined as duplicate publication, scientific mistake, journal error, or unstated reasons. Additional data were extracted from the retracted articles, including type of article, funding source, author information, therapeutic area, and retraction issue. A total of 742 retractions were identified from 2000-2011 in the general biomedical literature, and 102 drug studies met our inclusion criteria. Of these, 73 articles (72%) were retracted for a reason classified as scientific misconduct, whereas 29 articles (28%) were retracted for error. Among the 73 articles classified as scientific misconduct, those classified as unethical author conduct (32 articles [44%]) and data fabrication (24 articles [33%]) constituted the majority. The median time from publication of the original article to retraction was 31 months (range 1-130). Fifty percent of retracted articles did not state a funding source, whereas pharmaceutical manufacturer funding accounted for only 13 articles (13%) analyzed. Many retractions were due to repeat offenses by a small number of authors, with nearly 40% of the retracted studies associated with two individuals. We found that a greater proportion of drug therapy articles were retracted for reasons of misconduct and fraud compared with other biomedical studies. It is important for health care practitioners to monitor the literature for retractions so that recommendations for drug therapy and patient management may be modified accordingly.

Behcet's Disease: New Concepts in Cardiovascular Involvements and Future Direction for Treatment

Behcet's disease (BD) is the only systemic vasculitis involving both arteries and vein in any sizes. It frequently encounters in rheumatology clinics. It has some major morbidities and even fatal outcomes in some cases. The aim of this paper is to analyze the main concepts on pathophysiology and treatment options in BD, focusing on cardiovascular aspects, thrombosis, and potential future treatment.

Uveitis

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

New approaches in the treatment of Adamantiades-Behçet's disease

PURPOSE OF REVIEW

To update clinicians on the recent advances in the treatment of Adamantiades-Behçet's disease.

RECENT FINDINGS

Interferon-alpha-2a and infliximab have proved able to induce prompt remission in the vast majority of Adamantiades-Behçet's patients with DMARD-resistant uveoretinitis. Efficacy of interferon-alpha-2a has also been reported for mucocutaneous lesions, arthritis, and (more anecdotally) for neuro-Behçet, while results from small case series suggest that infliximab is beneficial for mucocutaneous lesions and (more anecdotally) for arthritis and gastro-intestinal manifestations. Two cases of neuro-Behçet treated with infliximab showed a complete resolution. Finally, in a randomized controlled trial of patients with mucocutaneous, arthritic manifestations, or both, etanercept effectively suppressed mucocutaneous lesions.A different approach is tolerization by oral administration of the 336-351 peptide of the human heat shock protein 60 (thought to have a pathogenic role in Adamantiades-Behçet's disease-associated uveitis), linked to recombinant cholera B-toxin B-subunit. Preliminary results have shown that tolerization is safe and effective in preventing relapses of uveitis.

SUMMARY

Biologic agents have proved effective in patients resistant to conventional treatment. However, disease subsets characterized by severe morbidity and mortality such as vasculo-Behçet and neuro-Behçet still pose major therapeutic challenges. Further studies are needed to devise better treatment strategies for severe Adamantiades-Behçet's disease.

The use of interferon alpha in Behçet disease: review of the literature

OBJECTIVES

To evaluate the efficacy and safety of interferon (IFN) alpha for the treatment of Behçet's disease (BD) and discuss its possible mechanisms of action.

METHODS

Reports published until July 2002 in all languages were identified by the PubMed Database and the BD conference proceedings and abstract booklets. The indexing terms used were "Behçet" and "interferon."

RESULTS

Thirty-two original reports and 4 selected abstracts were included in the analysis. Systemic IFN-alpha was administered to 338 patients. One hundred eighty-two patients with acute ocular disease were treated with IFN-alpha. Two hundred sixty-four patients received IFN-alpha2a, and 74 received IFN-alpha2b. Eighty-six percent of the patients with mucocutaneous symptoms, 96% with arthritis, and 94% with uveitis exhibited a partial or complete response. Higher IFN doses were more effective than low-dose regimens and led to up to 56% long-term remissions after discontinuation of IFN-alpha were reported. IFN-alpha2a apparently was superior to IFN-alpha2b, with more complete remissions, but this probably was the result of a bias caused by the larger number of patients treated with IFN-alpha2a. Side effects were dose-dependent and similar to those noted in patients with hepatitis C.

CONCLUSIONS

Although the comparability of the studies is hampered because of different study designs, IFN-alpha is effective for the treatment of BD. It was beneficial even in resistant posterior uveitis, in which long-term remissions with preservation of visual acuity was achieved. In contrast, mostly partial remissions were reported for mucocutaneous symptoms.

Uveitis: A Potentially Blinding Disease

Uveitis (intraocular inflammation) is a potentially blinding group of, probably autoimmune, conditions predominantly occurring in the working age group. Although the aetiology is unknown in most cases, many patients have an associated underlying systemic disease. Central vision loss, in the form of cystoid macular oedema, is the commonest type of visual impairment. Although historical incidence and prevalence data exists, little is known about the degree of vision loss experienced, and the social and financial consequences of having temporary or permanent visual impairment in this age group. The literature is also full of uncontrolled studies and case reports of different modalities of drug therapy for uveitis. This article attempts to raise the awareness of uveitis as an important sight-threatening group of conditions by highlighting the paucity of evidence-based data on epidemiological, quality of life, socioeconomic, and therapeutic aspects.

Differential efficacy of human recombinant interferon-α2a on ocular and extraocular manifestations of behçet disease: results of an open 4-center trial

OBJECTIVE

Behçet disease (BD) is a multisystem vasculitis of unknown origin. Standard treatment mainly comprises systemic immunosuppressive agents. In a study primarily designed for refractory ocular disease, we additionally evaluated the efficacy of recombinant human interferon-alpha2a (rhIFN-alpha2a) on the extraocular manifestations of BD.

METHODS

Fifty patients were included in the study. RhIFN-alpha2a was applied at a dose of 6 x 10(6) units subcutaneously daily. Dose reduction was performed according to a decision tree until discontinuation. Disease activity was evaluated by the Behçet's Disease Activity Scoring System and the Uveitis Scoring System.

RESULTS

Response rate of the ocular manifestations was 92%. Visual acuity rose significantly from 0.56 to 0.84 at week 24 (P <.0001). Mean Behçet's Disease Activity Score fell in a dose-dependent fashion by 1.2 points in the first week (P <.0001) and from 5.8 to 3.3 at week 24 and further to 2.8 at week 52. After a mean observation period of 36.4 months, 17 patients have been off treatment and disease-free for 29.5 months (mean). In the other patients, maintenance IFN dosage is 3 million units 3 times weekly. Whereas extraocular manifestations such as genital ulcerations, arthritis, and skin lesions remitted with IFN, only 36% of oral aphthous ulcers responded.

CONCLUSIONS

RhIFN-alpha2a is effective in ocular BD, resulting in significant improvement of vision and complete remission of ocular vasculitis in the majority of patients. It is also beneficial for the extraocular manifestations of the disease, although less so for oral aphthous ulcers.

[Colchicine in dermatology]

<zakljucak> Kolhicin je stari lek cija je primena, kao monoterapija ili u kombinaciji sa drugim lekovima, aktuelna i u savremenoj medicini. Najznacajnija mu je primena za lecenje i profilaksu perzistentne palmoplantarne pustuloze i oralnih aftoznih ulceracija, lecenje Svitovog sindroma, Beh?etove bolesti, sklerodermije i fibromatoze penisa.

Exocytotic "constipation" is a mechanism of tubulin/lysosomal interaction in colchicine myopathy

Colchicine, a known microtubule disrupting agent, produces a human myopathy, characterized by accumulation of lysosomes. We have created a reliable animal model of colchicine myopathy that replicates the subacute myopathy seen in humans, reproducing the chronic proximal weakness and vacuolar changes in nonnecrotic myofibers. If a microtubule network plays a role in lysosomal function in muscle, disturbance of it could alter degradation of intrinsic membrane receptors, presumably at some intracellular processing site or at exocytosis. Thus, we examined, as a possible cellular pathogenesis of colchicine myopathy, how the muscle cytoskeleton affects the degradation of membrane proteins, which are processed through the endosomal/lysosomal pathway. We used the acetylcholine receptor as a model membrane component in cultured myotubes allowed to preincubate with colchicine. We tested at which step colchicine interferes with receptor trafficking by accounting for internalization, delivery to lysosomes, hydrolysis, or exocytotic release of debris. We report that colchicine significantly decreases the exocytosis of AChRs but does not affect receptor internalization, lysosomal hydrolysis, or the number of surface membrane receptors. Further, our immunofluorescence observations revealed a morphologic tubulin network in rat skeletal muscle that is more densely distributed in white (mitochondria-poor) muscle fibers than in red (mitochondria-rich) fibers but is present in both. Ultrastructurally, immunogold labeling localized tubulin in the intermyofibrillar region in a long and linear fashion, unassociated with myofibers or mitochondria. Taken together, our findings suggest the following: (1) Microtubules likely play a functional role in the pathway of lysosomal degradation in normal adult skeletal muscle; (2) The observed decrease in overall apparent degradation of membrane receptors by colchicine must be due primarily to inhibition of exocytosis. These data indicate that lysosomal "constipation" underlies colchicine myopathy. (3) An animal model faithful to the human disorder will allow further pathogenetic studies.

Human recombinant interferon alfa-2a for the treatment of Behçet's disease with sight threatening posterior or panuveitis

BACKGROUND

Behçet's disease is a multisystem vasculitis of unknown origin. Standard treatment mainly comprises systemic immunosuppressive agents. Ocular involvement, mostly posterior uveitis with retinal vasculitis, leads to blindness in 20-50% of the involved eyes within 5 years. The efficacy of interferon alfa-2a was studied in patients with sight threatening posterior uveitis or retinal vasculitis.

METHODS

50 patients were included in this open, non-randomised, uncontrolled prospective study. Recombinant human interferon alfa-2a (rhIFNalpha-2a) was applied at a dose of 6 million units subcutaneously daily. Dose reduction was performed according to a decision tree until discontinuation. Disease activity was evaluated every 2 weeks by the Behçet's disease activity scoring system and the uveitis scoring system.

RESULTS

Response rate of the ocular manifestations was 92% (three non-responder, one incomplete response). Mean visual acuity rose significantly from 0.56 to 0.84 at week 24 (p<0.0001). Posterior uveitis score of the affected eyes fell by 46% every week (p<0.001). Remission of retinal inflammation was achieved by week 24. Mean Behçet's disease activity score fell from 5.8 to 3.3 at week 24 and further to 2.8 at week 52. After a mean observation period of 36.4 months (range 12-72), 20 patients (40%) are off treatment and disease free for 7-58 months (mean 29.5). In the other patients maintenance IFN dosage is three million units three times weekly.

CONCLUSIONS

rhIFNalpha-2a is effective in ocular Behçet's disease, leading to significant improvement of vision and complete remission of ocular vasculitis in the majority of the patients.

Lethal fulminate S. aureus sepsis in M. Behçet overnight cold exposure

Whether patients with Behçet's disease (BD) and immunosuppressive therapy are generally prone to acquire severe infectious diseases is unknown. A 48-year-old man under corticosteroids and azathioprine for BD since 1995 was admitted because of a transitory ischemic attack. Between the third and fourth hospital day he was accidentally locked up, insufficiently dressed, in the hospital's chapel over night. On the following day, he developed fever and deteriorating consciousness until he became comatose. CT scans of the brain were normal and there was only a slight pleocytosis. Despite adequate therapy, the patient's condition further deteriorated such that he died. Responsible for his decline was a fulminate sepsis, diagnosed upon fever, increased C-reactive protein, thrombocyte decline, multi-organ failure, rhabdomyolysis, growth of S. aureus on blood culture, and autopsy. Patients with BD and immunosuppressive therapy, may be more vulnerable to infections and may develop lethal overwhelming sepsis already after overnight cold exposure.

Behçet's disease: immunopathologic and therapeutic aspects

Behçet's disease (BD) is a systemic inflammatory disease of unknown etiology. The disease is strongly associated with the human leukocyte antigen (HLA) B51. BD has a chronic course with periodic exacerbations and progressive deterioration. There are no specific diagnostic laboratory tests, although recurrent oral ulceration is an obligatory manifestation for diagnosis. The treatment, which includes local, systemic, or surgical therapies, is based on the severity of the illness; the most appropriate management requires a multidisciplinary approach. This paper summarizes all aspects of BD with particular emphasis on the latest immunologic and treatment aspects.

Atopic phenotype in children is associated with decreased virus-induced interferon-alpha release

BACKGROUND

Interferon-alpha (IFN-alpha) production in humans is an early event in the nonspecific cellular response to viruses and mediates a wide range of antiviral and immunoregulatory activities. Little is known about the role of IFN-alpha in allergic disease.

METHODS

In the present study, we performed a retrospective comparative analysis of 88 children with and without an atopic phenotype for virus-induced IFN-alpha production in blood cultures.

RESULTS

We were able to demonstrate that patients with allergic asthma (aA) produced significantly lower amounts of virus-induced IFN-alpha than healthy children and patients with nonallergic asthma (naA). Furthermore, the number of eosinophils in atopic children as a marker for allergic inflammation correlated negatively with the IFN-alpha level in blood cultures. Additionally, we found differences between aA and naA patients with respect to the capacity to produce IFN-gamma. Although atopy is thought to be associated with a Th2 cytokine response, in our study, IFN-gamma release was not reduced in the allergic children. In contrast, patients with allergic rhinitis showed a significant increase in IFN-gamma release compared to naA patients.

CONCLUSIONS

In our study, an early atopic phenotype was related to a reduction in virus induced IFN-alpha release from blood cultures. Thus, after further prospective evaluation, the IFN-alpha level may serve as an additional in vitro marker for the definition of atopy in children.

New approaches to treatment in systemic vasculitis: biological therapies

Although the effectiveness of biological agents in systemic vasculitis is unproven, their introduction heralds a new era of vasculitis treatment. These agents offer the promise of targeted immunotherapies; the possibility of greater efficacy (and fewer side-effects) than conventional vasculitis treatments; and the potential to provide novel insights into the pathophysiology of these diseases-insights that may be gained only by using these agents in humans. Challenges to the investigation of these therapies in the systemic vasculitides exist, but important basic and clinical investigations are already in progress. We review the major issues facing the investigation of biological agents in vasculitis; examine the rationale for believing that biological strategies in vasculitis will be efficacious; identify several candidate targets for biological approaches; and discuss the results to date of early studies. The potential biological targets discussed include cytokines such as tumour necrosis factor; interleukins-1, -6, and -12; interferon-gamma; the co-stimulatory molecules B7-1 and B7-2; and others.

Interferon-alpha 2a treatment of neuro-Behcet disease

Behcet disease is a multisystemic, chronic, recurrent inflammatory disorder characterized as a triad of hypopyon uveitis, oral aphthae, and genital ulcers. Neurologic involvement in Behcet disease (neuro-Behcet) is common. Neuro-Behcet disease typically manifests late after disease onset, rarely coincides with ocular involvement, and often heralds a poor prognosis for final vision and survival. We present a case of neuro-Behcet disease with neurologic onset concomitant with systemic and ocular involvement that was responsive to treatment with interferon-alpha 2a.

Current and future trends in the use of immunosuppressive agents in patients with uveitis

Therapeutic trials for uveitis are seldom performed because of the relative rarity of the disease and its heterogeneity. Promising new approaches to therapy include cytokine or cytokine receptor inhibition; cytokine addition (alpha-interferon or interleukin-10); novel anti-metabolites; combination therapies; intravenous immunoglobulin; intravitreally inserted corticosteroid implants; and oral tolerance. Additional modalities or targets that deserve further testing include T-cell subsets, adhesion molecules, accessory molecules in antigen presentation, novel inflammatory mediators, inducers of apoptosis, photodynamic therapy, and neuroprotective agents.

Guidelines for the use of immunosuppressive drugs in patients with ocular inflammatory disorders: recommendations of an expert panel

PURPOSE

To provide recommendations for the use of immunosuppressive drugs in the treatment of patients with ocular inflammatory disorders.

PARTICIPANTS

A 12-person panel of physicians with expertise in ophthalmologic, pediatric, and rheumatologic disease, in research, and in the use of immunosuppressive drugs in patient care.

EVIDENCE

Published clinical study results. Recommendations were rated according to the quality and strength of available evidence.

PROCESS

The panel was convened in September of 1999 and met regularly through May 2000. Subgroups of the panel summarized and presented available information on specific topics to the full panel; recommendations and ratings were determined by group consensus.

CONCLUSIONS

Although corticosteroids represent one of the mainstays in the management of patients with ocular inflammation, in many patients, the severity of the disease, the presence of corticosteroid side effects, or the requirement for doses of systemic corticosteroids highly likely to result in corticosteroid complications supports the rationale for immunosuppressive drugs (for example, antimetabolites, T-cell inhibitors, and alkylating agents) being used in the management of these patients. Because of the potential for side effects, treatment must be individualized and regular monitoring performed. With careful use of immunosuppressive drugs for treatment of ocular inflammatory disorders, many patients will benefit from them either with better control of the ocular inflammation or with a decrease in corticosteroid side effects.

Perspective on future therapy of vasculitis

This article summarizes recent advances in the management of various vasculitic syndromes and discusses potential new therapies based on a better understanding of their pathogenesis and natural history. Current efforts for optimization of testing for antineutrophil cytoplasmic antibodies and improvement of diagnostic criteria will certainly have a significant impact on future therapy. Biologic agents such as interferon-alpha are already in use in various vasculitides, whereas others, such as inhibitors of tumor necrosis factor-alpha, are in phase I clinical trials. Agents that selectively inhibit distinct steps in the pathogenesis of vasculitis are in preclinical or early clinical stages of development. Newer (mycophenolate mofetil, leflunamide) or older (methotrexate, azathioprine) immunosuppresive agents are finding new roles in the management of vasculitides. For patients with severe vasculitis, short-term use of cytotoxic agents, such as cyclophosphamide, alone or in combination with biologic agents, may expedite remission, which could then be better maintained with other, less toxic (and less expensive) immunosuppressive agents, such as methotrexate, azathioprine, mycophenolate mofetil, and leflunamide. For patients with mild or moderately severe vasculitis, these latter agents alone may be adequate. New therapeutic studies in vasculitis should better address the impact of therapy on health-related quality of life and its long-term toxicity.

Novel approaches to Behçet's disease

Behçet's disease is a systemic inflammatory disorder. The patients have repeated exacerbations and remissions of the symptoms. This disease may produce a wide variety of symptoms. In mild cases, mucocutaneous lesions are only the symptoms during the whole clinical course, whereas ocular lesions, which occur in about 70% of the patients, can cause blindness. Involvement of the gastrointestinal tract, CNS and large vessels is less frequent, but sometimes life-threatening. Colchicine, NSAIDs, corticosteroids and immunosuppressants are employed for the treatment of Behçet's disease with therapies tailored to individual patients depending on clinical manifestations. Cyclosporin A is the most effective drug for ocular lesions at the present, but its neurotoxicity, which occurs in 20-30% of patients receiving cyclosporin A, restricts usage of the agent. Many patients are still suffering from a severe form of uveitis and serious neurological symptoms, which are resistant to any conventional therapies. New drugs have been investigated for Behçet's disease. IFN-alpha therapy has shown significant efficacy for common symptoms including ocular lesions without any serious adverse effects. Thalidomide and its analogues also appear to be applicable to this disease. Monoclonal antibody to TNF-alpha is now in clinical trials. These novel therapeutic approaches may provide much needed treatment options for patients with Behçet's disease.