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Kanakis M, Petrou P, Lourida G, Georgalas I. Erdheim-Chester disease: a comprehensive review from the ophthalmologic perspective. Surv Ophthalmol 2021; 67:388-410. [PMID: 34081930 DOI: 10.1016/j.survophthal.2021.05.013] [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: 07/26/2020] [Revised: 05/18/2021] [Accepted: 05/24/2021] [Indexed: 01/18/2023]
Abstract
Erdheim-Chester disease (ECD) is a rare clonal histiocytic neoplasm with less than 1200 documented cases to date. The disease is life-threatening and difficult to recognize, although increasing awareness as well as the integration of clinical, imaging, pathology information , and genetic studies have led to a recent exponential increase in new reported cases. ECD affects multiple organs and systems, including skeletal, neurologic, and cardiovascular. Pulmonary, retroperitoneal, and cutaneous lesions have also been reported in various combinations. Until the discovery that more than half of ECD patients harbor the BRAF-V600E mutation or other mutations in the mitogen-activated protein kinase (MAPK) and RAS pathways, Interferon-a was the first-line treatment. Nowadays BRAF and MEK-inhibitors targeted therapies are the mainstay of treatment. Ophthalmologic involvement occurs in 25% -30% of ECD cases, usually in the form of orbital involvement presenting with exophthalmos and ophthalmoplegia. Other ophthalmologic manifestations include palpebral xanthelasmas, anterior uveitis and vitritis, optic disk edema, choroidal infiltration, recurrent serous retinal detachment, retinal drusen-like deposits and retinal pigment epithelial changes. ECD patients can also present with ocular symptoms as a result of adverse effects of the treatment regimens. In some cases with smoldering or protean symptoms, the emergence of eye manifestations triggered the diagnosis. Ophthalmologists have to be aware of the disease, recognize the constellation of ECD symptoms, and contribute to the diagnosis, treatment, and follow-up of ECD patients.
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Affiliation(s)
| | - Petros Petrou
- G. Genimatas General Hospital, National and Kapodistrian University of Athens, 1st University Eye Clinic, Athens, Greece
| | - Giota Lourida
- Department of Internal Medicine and Infectious Disease, Sotiria Hospital, Athens, Greece
| | - Ilias Georgalas
- G. Genimatas General Hospital, National and Kapodistrian University of Athens, 1st University Eye Clinic, Athens, Greece.
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2
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Rodríguez-Carrio J, Nucera V, Masala IF, Atzeni F. Behçet disease: From pathogenesis to novel therapeutic options. Pharmacol Res 2021; 167:105593. [PMID: 33826948 DOI: 10.1016/j.phrs.2021.105593] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/17/2021] [Accepted: 03/31/2021] [Indexed: 10/21/2022]
Abstract
Behçet disease (BD) is a complex, multi-systemic inflammatory condition mainly hallmarked by oral and genital ulcers which can also affect the vessels, gastrointestinal tract, central nervous system and even the axial skeleton. Without a clear classification among autoimmune or autoinflammatory conditions, BD has been recently classified as a MHC-I-opathy. BD aetiology is still obscure, but it is thought that certain microorganisms can elicit an aberrant adaptive immune response in the presence of a permissive genetic background. Altered T-cell homeostasis, mostly Th1/Th17 expansion and Treg impairment, could lead to an overactivation of the innate immunity, which underlies tissue damage and thus, signs and symptoms. Immunosuppression and/or immunomodulation are central to the BD management. A complex armamentarium ranging from classical synthetic disease-modifying antirrheumatic drugs to new-era biologic agents or small molecules is available in BD, with different therapeutic outcomes depending on disease manifestations. However, the precise disease mechanisms that underlie BD symptoms are not fully deciphered, which may limit their therapeutic potential and add a significant layer of complexity to the treatment decision-making process. The aim of the present review is to provide an exhaustive overview of the latest breakthroughs in BD pathogenesis and therapeutic options.
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Affiliation(s)
- Javier Rodríguez-Carrio
- Department of Functional Biology, Immunology Area, Faculty of Medicine, University of Oviedo, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Valeria Nucera
- Rheumatology Unit, Department of Experimental and Internal Medicine, University of Messina, Messina, Italy
| | - Ignazio Francesco Masala
- Rheumatology Unit, Department of Experimental and Internal Medicine, University of Messina, Messina, Italy; Trauma and Orthopedic Unit, Santissima Trinità Hospital, Cagliari, Italy
| | - Fabiola Atzeni
- Rheumatology Unit, Department of Experimental and Internal Medicine, University of Messina, Messina, Italy.
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3
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Bajwa A, Maleki A, Payal AR, Fandiño A, Padrón MIM, Walsh M, Foster CS. Efficacy and Safety of Infliximab in HLA-B27-associated Ocular Inflammation Refractory or Intolerant to Conventional Immunomodulatory Therapy. J Ophthalmic Vis Res 2020; 15:459-469. [PMID: 33133436 PMCID: PMC7591838 DOI: 10.18502/jovr.v15i4.7786] [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: 03/25/2020] [Accepted: 07/10/2020] [Indexed: 12/05/2022] Open
Abstract
Purpose To determine the efficacy and safety of infliximab therapy in patients with HLA B-27-associated ocular inflammation resistant or intolerant to conventional immunomodulatory therapy. Methods This was a retrospective observational case series. All cases were uveitic patients with positive HLA-B27, confirmed through HLA testing, resistant or intolerant to conventional immunomodulatory therapy. The primary outcome of the study was to identify the efficacy of infliximab determined by the control of inflammation, duration of remission, and the ability to reduce conventional immunomodulatory therapy. The secondary outcome was an improvement of two or more lines of best-corrected visual acuity (BCVA) on the Snellen visual acuity chart. Results Twenty-four patients (38 eyes) were included in the study. All patients were followed for 24 months. Twenty-one (87.5%) patients completed 24 months of follow-up. Sixteen (66.7%) patients had active uveitis at the beginning of therapy. One patient out of these active patients had active inflammation at the end of follow-up period. Thirteen (87.5%) out of sixteen active patients were in steroid-free remission. The mean duration of treatment to induce remission was 16.5 months (range 6–24 months). Corticosteroid was stopped in 19 (90.5%) patients by the end of the study. At the end of the study, in patients who achieved remission, 14 (58.3%) patients were in remission on infliximab therapy and 6 (25%) patients were in remission off infliximab therapy. Of the 38 eyes, 8 (21.05%) showed improvement in BCVA (three eyes had successful cataract extraction with intraocular lens implantation during infliximab therapy with no subsequent inflammation), while 26 eyes (68.4%) had stable BCVA over the 24-month study period. The side effects included allergic reaction, fatigue, cellulitis, headache, restlessness, elevation of liver enzymes, and anemia. Two patients (n = 24, 8.3%) experienced severe adverse effects and the treatment was stopped prematurely in these two patients. Conclusion Infliximab might induce and maintain the steroid-free remission in HLA-B27-associated ocular inflammation in patients resistant or intolerant to conventional immunomodulatory therapy.
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Affiliation(s)
- Asima Bajwa
- Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts.,Ocular Immunology and Uveitis Foundation, Waltham, Massachusetts
| | - Arash Maleki
- Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts.,Ocular Immunology and Uveitis Foundation, Waltham, Massachusetts
| | - Abhishek R Payal
- Ocular Immunology and Uveitis Foundation, Waltham, Massachusetts.,University of Pennsylvania, Scheie Eye Institute, Philadelphia, Pennsylvania
| | - Adriana Fandiño
- Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts.,Ocular Immunology and Uveitis Foundation, Waltham, Massachusetts
| | - María Inés Menéndez Padrón
- Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts.,Ocular Immunology and Uveitis Foundation, Waltham, Massachusetts
| | - Marisa Walsh
- Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts.,Ocular Immunology and Uveitis Foundation, Waltham, Massachusetts
| | - C Stephen Foster
- Harvard Medical School, Boston, Massachusetts.,Ocular Immunology and Uveitis Foundation, Waltham, Massachusetts
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4
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De Simone L, Invernizzi A, Aldigeri R, Mastrofilippo V, Marvisi C, Gozzi F, Bolletta E, Adani C, Pipitone N, Muratore F, Fontana L, Salvarani C, Cimino L. Effectiveness of Infliximab and Interferon Alpha-2a for the Treatment of Behçet’s Uveitis: Customizing Therapy according to the Clinical Features. Ocul Immunol Inflamm 2020; 30:506-514. [DOI: 10.1080/09273948.2020.1815797] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Luca De Simone
- Ocular Immunology Unit, Azienda USL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Alessandro Invernizzi
- Eye Clinic, Department of Biomedical and Clinical Science “L. Sacco”, Luigi Sacco Hospital, University of Milan, Milan, Italy
- Save Sight Institute, University of Sydney, Sydney, Australia
| | | | | | - Chiara Marvisi
- Division of Rheumatology, University of Modena and Reggio Emilia, Modena, Italy
| | - Fabrizio Gozzi
- Ocular Immunology Unit, Azienda USL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Elena Bolletta
- Ocular Immunology Unit, Azienda USL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Chantal Adani
- Ocular Immunology Unit, Azienda USL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Nicolò Pipitone
- Department of Rheumatology, Azienda USL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Francesco Muratore
- Department of Rheumatology, Azienda USL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Luigi Fontana
- Ophthalmology Unit, Azienda USL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Carlo Salvarani
- Division of Rheumatology, University of Modena and Reggio Emilia, Modena, Italy
- Department of Rheumatology, Azienda USL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Luca Cimino
- Ocular Immunology Unit, Azienda USL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
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5
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Martín-Varillas JL, Atienza-Mateo B, Calvo-Rio V, Beltrán E, Sánchez-Bursón J, Adán A, Hernández-Garfella M, Valls-Pascual E, Sellas-Fernández A, Ortego N, Maíz O, Torre I, Fernández-Espartero C, Jovani V, Peiteado D, Valle DD, Aurrecoechea E, Caracuel MA, García-González AJ, Álvarez ER, Vegas-Revenga N, Demetrio-Pablo R, Castañeda S, González-Gay MA, Hernández JL, Blanco R. Long-term Follow-up and Optimization of Infliximab in Refractory Uveitis Due to Behçet Disease: National Study of 103 White Patients. J Rheumatol 2020; 48:741-750. [PMID: 33004539 DOI: 10.3899/jrheum.200300] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE In a large series of White patients with refractory uveitis due to Behçet disease (BD) being treated with infliximab (IFX), we assessed (1) long-term efficacy and safety of IFX, and (2) IFX optimization when ocular remission was achieved. METHODS Our multicenter study of IFX-treated patients with BD uveitis refractory to conventional immunosuppressant agents treated 103 patients/185 affected eyes with IFX as first biologic therapy in the following intervals: 3-5 mg/kg intravenous at 0, 2, 6, and then every 4-8 weeks. The main outcome variables were analyzed at baseline, first week, first month, sixth month, first year, and second year of IFX therapy. After remission, based on a shared decision between patient and clinician, IFX optimization was performed. Efficacy, safety, and cost of IFX therapy were evaluated. RESULTS In the whole series (n = 103), main outcome variables showed a rapid and maintained improvement, reaching remission in 78 patients after a mean IFX duration of 31.5 months. Serious adverse events were observed in 9 patients: infusion reactions (n = 4), tuberculosis (n = 1), Mycobacterium avium pneumonia (n = 1), severe oral ulcers (n = 1), palmoplantar psoriasis (n = 1), and colon carcinoma (n = 1). In the optimization subanalysis, the comparative study between optimized and nonoptimized groups showed (1) no differences in clinical characteristics at baseline, (2) similar maintained improvement in most ocular outcomes, (3) lower severe adverse events, and (4) lower mean IFX costs in the optimized group (€4826.52 vs €9854.13 per patient/yr). CONCLUSION IFX seems to be effective and relatively safe in White patients with refractory BD uveitis. IFX optimization is effective, safe, and cost-effective.
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Affiliation(s)
- José Luis Martín-Varillas
- J.L. Martín-Varillas, MD, B. Atienza-Mateo, MD, V. Calvo-Rio, MD, PhD, R. Demetrio-Pablo, MD, PhD, M.A. González-Gay, MD, PhD, J.L. Hernández, MD, PhD, R. Blanco, MD, PhD, Rheumatology, Internal Medicine and Ophthalmology, Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, University of Cantabria
| | - Belén Atienza-Mateo
- J.L. Martín-Varillas, MD, B. Atienza-Mateo, MD, V. Calvo-Rio, MD, PhD, R. Demetrio-Pablo, MD, PhD, M.A. González-Gay, MD, PhD, J.L. Hernández, MD, PhD, R. Blanco, MD, PhD, Rheumatology, Internal Medicine and Ophthalmology, Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, University of Cantabria
| | - Vanesa Calvo-Rio
- J.L. Martín-Varillas, MD, B. Atienza-Mateo, MD, V. Calvo-Rio, MD, PhD, R. Demetrio-Pablo, MD, PhD, M.A. González-Gay, MD, PhD, J.L. Hernández, MD, PhD, R. Blanco, MD, PhD, Rheumatology, Internal Medicine and Ophthalmology, Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, University of Cantabria
| | - Emma Beltrán
- E. Beltrán, MD, Rheumatology, Hospital del Mar, Barcelona
| | - Juan Sánchez-Bursón
- J. Sánchez-Bursón, MD, PhD, Rheumatology, Hospital Universitario Virgen de Valme, Sevilla
| | - Alfredo Adán
- A. Adán, MD, PhD, Rheumatology and Ophthalmology, Hospital Clinic de Barcelona, Barcelona
| | | | - Elia Valls-Pascual
- E. Valls-Pascual, MD, Rheumatology, Hospital Universitario Doctor Peset, Valencia
| | | | - Norberto Ortego
- N. Ortego, MD, PhD, E. Raya Álvarez, MD, PhD, Autoimmune Diseases, Hospital Universitario San Cecilio, Granada
| | - Olga Maíz
- O. Maíz, MD, Rheumatology, Hospital Universitario de Donostia, San Sebastián
| | - Ignacio Torre
- I. Torre, MD, Rheumatology, Hospital Universitario Basurto, Bilbao
| | | | - Vega Jovani
- V. Jovani, MD, PhD, Rheumatology, Hospital General Universitario de Alicante, Alicante
| | - Diana Peiteado
- D. Peiteado, MD, PhD, Rheumatology, Hospital Universitario La Paz
| | - David Díaz Valle
- D. Díaz Valle, MD, PhD, Ophthalmology, Hospital Clínico San Carlos, Madrid
| | - Elena Aurrecoechea
- E. Aurrecoechea, MD, PhD, Rheumatology, Hospital Sierrallana, Torrelavega
| | - Miguel A Caracuel
- M.A. Caracuel, MD, PhD, Rheumatology, Hospital Universitario Reina Sofía, Córdoba
| | | | - Enrique Raya Álvarez
- N. Ortego, MD, PhD, E. Raya Álvarez, MD, PhD, Autoimmune Diseases, Hospital Universitario San Cecilio, Granada
| | | | - Rosalía Demetrio-Pablo
- J.L. Martín-Varillas, MD, B. Atienza-Mateo, MD, V. Calvo-Rio, MD, PhD, R. Demetrio-Pablo, MD, PhD, M.A. González-Gay, MD, PhD, J.L. Hernández, MD, PhD, R. Blanco, MD, PhD, Rheumatology, Internal Medicine and Ophthalmology, Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, University of Cantabria
| | - Santos Castañeda
- S. Castañeda, MD, PhD, Rheumatology, Hospital Universitario de La Princesa, IIS-Princesa, Madrid, Spain
| | - Miguel A González-Gay
- J.L. Martín-Varillas, MD, B. Atienza-Mateo, MD, V. Calvo-Rio, MD, PhD, R. Demetrio-Pablo, MD, PhD, M.A. González-Gay, MD, PhD, J.L. Hernández, MD, PhD, R. Blanco, MD, PhD, Rheumatology, Internal Medicine and Ophthalmology, Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, University of Cantabria
| | - José Luis Hernández
- J.L. Martín-Varillas, MD, B. Atienza-Mateo, MD, V. Calvo-Rio, MD, PhD, R. Demetrio-Pablo, MD, PhD, M.A. González-Gay, MD, PhD, J.L. Hernández, MD, PhD, R. Blanco, MD, PhD, Rheumatology, Internal Medicine and Ophthalmology, Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, University of Cantabria;
| | - Ricardo Blanco
- J.L. Martín-Varillas, MD, B. Atienza-Mateo, MD, V. Calvo-Rio, MD, PhD, R. Demetrio-Pablo, MD, PhD, M.A. González-Gay, MD, PhD, J.L. Hernández, MD, PhD, R. Blanco, MD, PhD, Rheumatology, Internal Medicine and Ophthalmology, Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, University of Cantabria
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Squires H, Poku E, Bermejo I, Cooper K, Stevens J, Hamilton J, Wong R, Denniston A, Pearce I, Quhill F. A systematic review and economic evaluation of adalimumab and dexamethasone for treating non-infectious intermediate uveitis, posterior uveitis or panuveitis in adults. Health Technol Assess 2018; 21:1-170. [PMID: 29183563 DOI: 10.3310/hta21680] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Non-infectious intermediate uveitis, posterior uveitis and panuveitis are a heterogeneous group of inflammatory eye disorders. Management includes local and systemic corticosteroids, immunosuppressants and biological drugs. OBJECTIVES To evaluate the clinical effectiveness and cost-effectiveness of subcutaneous adalimumab (Humira®; AbbVie Ltd, Maidenhead, UK) and a dexamethasone intravitreal implant (Ozurdex®; Allergan Ltd, Marlow, UK) in adults with non-infectious intermediate uveitis, posterior uveitis or panuveitis. DATA SOURCES Electronic databases and clinical trials registries including MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and the World Health Organization's International Clinical Trials Registry Platform were searched to June 2016, with an update search carried out in October 2016. REVIEW METHODS Review methods followed published guidelines. A Markov model was developed to assess the cost-effectiveness of dexamethasone and adalimumab, each compared with current practice, from a NHS and Personal Social Services (PSS) perspective over a lifetime horizon, parameterised with published evidence. Costs and benefits were discounted at 3.5%. Substantial sensitivity analyses were undertaken. RESULTS Of the 134 full-text articles screened, three studies (four articles) were included in the clinical effectiveness review. Two randomised controlled trials (RCTs) [VISUAL I (active uveitis) and VISUAL II (inactive uveitis)] compared adalimumab with placebo, with limited standard care also provided in both arms. Time to treatment failure (reduced visual acuity, intraocular inflammation, new vascular lesions) was longer in the adalimumab group than in the placebo group, with a hazard ratio of 0.50 [95% confidence interval (CI) 0.36 to 0.70; p < 0.001] in the VISUAL I trial and 0.57 (95% CI 0.39 to 0.84; p = 0.004) in the VISUAL II trial. The adalimumab group showed a significantly greater improvement than the placebo group in the 25-item Visual Function Questionnaire (VFQ-25) composite score in the VISUAL I trial (mean difference 4.20; p = 0.010) but not the VISUAL II trial (mean difference 2.12; p = 0.16). Some systemic adverse effects occurred more frequently with adalimumab than with placebo. One RCT [HURON (active uveitis)] compared a single 0.7-mg dexamethasone implant against a sham procedure, with limited standard care also provided in both arms. Dexamethasone provided significant benefits over the sham procedure at 8 and 26 weeks in the percentage of patients with a vitreous haze score of zero (p < 0.014), the mean best corrected visual acuity improvement (p ≤ 0.002) and the percentage of patients with a ≥ 5-point improvement in VFQ-25 score (p < 0.05). Raised intraocular pressure and cataracts occurred more frequently with dexamethasone than with the sham procedure. The incremental cost-effectiveness ratio (ICER) for one dexamethasone implant in one eye for a combination of patients with unilateral and bilateral uveitis compared with limited current practice, as per the HURON trial, was estimated to be £19,509 per quality-adjusted life-year (QALY) gained. The ICER of adalimumab for patients with mainly bilateral uveitis compared with limited current practice, as per the VISUAL trials, was estimated to be £94,523 and £317,547 per QALY gained in active and inactive uveitis respectively. Sensitivity analyses suggested that the rate of blindness has the biggest impact on the model results. The interventions may be more cost-effective in populations in which there is a greater risk of blindness. LIMITATIONS The clinical trials did not fully reflect clinical practice. Thirteen additional studies of clinically relevant comparator treatments were identified; however, network meta-analysis was not feasible. The model results are highly uncertain because of the limited evidence base. CONCLUSIONS Two RCTs of systemic adalimumab and one RCT of a unilateral, single dexamethasone implant showed significant benefits over placebo or a sham procedure. The ICERs for adalimumab were estimated to be above generally accepted thresholds for cost-effectiveness. The cost-effectiveness of dexamethasone was estimated to fall below standard thresholds. However, there is substantial uncertainty around the model assumptions. In future work, primary research should compare dexamethasone and adalimumab with current treatments over the long term and in important subgroups and consider how short-term improvements relate to long-term effects on vision. STUDY REGISTRATION This study is registered as PROSPERO CRD42016041799. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Hazel Squires
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Edith Poku
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Inigo Bermejo
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Katy Cooper
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - John Stevens
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jean Hamilton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Ruth Wong
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Ian Pearce
- St Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Fahd Quhill
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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7
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Abstract
The relationship between the eye and psoriasis has been recognized for decades, but the precise eye manifestations in patients with psoriasis and psoriatic arthritis are only recently coming to light. Psoriatic eye findings may include conjunctivitis, dry eye, episcleritis, and uveitis, all of which may precede articular changes. Uveitis, seen in 7% to 25% of psoriatic arthritis patients, may be recognized by the presence of conjunctival injection, photophobia, pain, lid swelling, or otherwise unexplained visual changes. Early recognition is paramount because its natural course may lead to vision loss. Immunopathogenesis has shown evidence for T-helper cell (Th) type 1 (Th1) and Th17 involvement in the pathogenesis of uveitis according to the murine experimental autoimmune uveitis model. Corticosteroids are the primary treatment modality; however, increasing emphasis has been placed on immunomodulators and biologics for more intractable cases. Referral to an ophthalmologist is essential for definitive diagnosis and treatment.
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Affiliation(s)
- Shiu-chung Au
- Department of Dermatology, Tufts Medical Center, Boston, Massachusetts
| | - Shimrat Yaniv
- Albert Einstein College of Medicine, New York, New York
| | - Alice B. Gottlieb
- Department of Dermatology, Tufts Medical Center, Boston, Massachusetts
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Lin FL, Ho JD, Cheng YW, Chiou GCY, Yen JL, Chang HM, Lee TH, Hsiao G. Theissenolactone C Exhibited Ocular Protection of Endotoxin-Induced Uveitis by Attenuating Ocular Inflammatory Responses and Glial Activation. Front Pharmacol 2018; 9:326. [PMID: 29686615 PMCID: PMC5900795 DOI: 10.3389/fphar.2018.00326] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 03/21/2018] [Indexed: 12/11/2022] Open
Abstract
The aim of this study was to investigate the effects of a natural component, theissenolactone C (LC53), on the ocular inflammation of experimental endotoxin-induced uveitis (EIU) and its related mechanisms in microglia. Evaluation of the severity of anterior uveitis indicated that LC53 treatment significantly decreased iridal hyperemia and restored the clinical scores. Additionally, the deficient retina functions of electroretinography were improved by LC53. LC53 significantly reduced levels of tumor necrosis factor (TNF)-α, monocyte chemoattractant protein-1, protein leakage and activation of matrix metalloproteinases in the anterior section during EIU. Moreover, LC53 treatment decreased the oxidative stress as well as neuroinflammatory reactivities of GFAP and Iba-1 in the posterior section. Furthermore, LC53 decreased the phosphorylation of p65, expression of HSP90, Bax, and cleaved-caspase-3 in EIU. According to the microglia studies, LC53 significantly abrogated the productions of TNF-α, PGE2, NO and ROS, as well as inducible NO synthase and cyclooxygenase-2 expression in LPS-stimulated microglial BV2 cells. The microglial activation of IKKβ, p65 phosphorylation and nuclear phosphorylated p65 translocation were strongly attenuated by LC53. On the other hand, LC53 exhibited the inhibitory effects on JNK and ERK MAPKs activation. Our findings indicated that LC53 exerted the ocular-protective effect through its inhibition on neuroinflammation, glial activation, and apoptosis in EIU, suggesting a therapeutic potential with down-regulation of the NF-κB signaling for uveitis and retinal inflammatory diseases.
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Affiliation(s)
- Fan-Li Lin
- Graduate Institute of Medical Sciences and Department of Pharmacology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Jau-Der Ho
- Department of Ophthalmology, Taipei Medical University Hospital, Taipei, Taiwan
| | - Yu-Wen Cheng
- School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - George C Y Chiou
- Department of Neuroscience and Experimental Therapeutics and Institute of Ocular Pharmacology, College of Medicine, Texas A&M Health Science Center, College Station, TX, United States
| | - Jing-Lun Yen
- Graduate Institute of Medical Sciences and Department of Pharmacology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hung-Ming Chang
- Department of Anatomy, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Tzong-Huei Lee
- Institute of Fisheries Science, National Taiwan University, Taipei, Taiwan
| | - George Hsiao
- Graduate Institute of Medical Sciences and Department of Pharmacology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Ph.D. Program for the Clinical Drug Discovery from Botanical Herbs, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
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9
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Oxidative stress and reactive oxygen species: a review of their role in ocular disease. Clin Sci (Lond) 2017; 131:2865-2883. [DOI: 10.1042/cs20171246] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 10/26/2017] [Accepted: 11/06/2017] [Indexed: 12/13/2022]
Abstract
For many years, oxidative stress arising from the ubiquitous production of reactive oxygen species (ROS) has been implicated in the pathogenesis of various eye diseases. While emerging research has provided some evidence of the important physiological role of ROS in normal cell function, disease may arise where the concentration of ROS exceeds and overwhelms the body’s natural defence against them. Additionally, ROS may induce genomic aberrations which affect cellular homoeostasis and may result in disease. This literature review examines the current evidence for the role of oxidative stress in important ocular diseases with a view to identifying potential therapeutic targets for future study. The need is particularly pressing in developing treatments for conditions which remain notoriously difficult to treat, including glaucoma, diabetic retinopathy and age-related macular degeneration.
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Advancements in the management of uveitis. Best Pract Res Clin Rheumatol 2016; 30:304-315. [PMID: 27886802 DOI: 10.1016/j.berh.2016.07.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 07/28/2016] [Indexed: 02/08/2023]
Abstract
Uveitis may exist as a clinical manifestation of an underlying systemic disease or may represent an idiopathic entity, sometimes with a very characteristic pattern. Different forms of uveitis have been defined on the basis of three important variables: chronicity, anatomic location, and underlying etiology. The evolving understanding of the immune system has resulted in a more targeted approach to manage patients with different forms of uveitis, although clearly this approach is at a very early stage. Altered patterns of cellular processing and different cytokine expression, including TNF, IL-1, IL-2, IL-6, and IL17, have been defined in uveitis, and this has laid the pathway for targeted therapy. Furthermore, approved biologic therapies for some of the more common autoimmune illnesses have now been tested in uveitis. Adalimumab and infliximab have been the best studied anti-TNF agents and indeed have now been recommended by an expert panel as the first line of treatment for ocular manifestations of Behçet's disease and the second line of treatment for other forms of uveitis. Adalimumab has been recently approved for intermediate uveitis, posterior uveitis, and panuveitis. Other biologic agents have been tested, including daclizumab, a monoclonal antibody directed against IL-2, anti-IL1, and anti-IL-6 receptor agents and therapies that block antigen-presenting cell and T-cell interaction, such as abatacept. In small case series, other biologics such as interferon and rituximab have also been evaluated. Although these biologic therapies have provided a larger armamentarium to treat uveitis, challenges remain. Uveitis is not a disease, but a manifestation of many potential systemic diseases that may have specific individual therapeutic targets. Identification and characterization of these underlying diseases are not always possible and, more importantly, the most effective therapies for each entity have not been defined. In this study, an approach to manage patients with uveitis is presented and current therapy is reviewed.
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Paovic J, Paovic P, Sredovic V, Jovanovic S. Clinical Manifestations, Complications and Treatment of Ocular Sarcoidosis: Correlation between Visual Efficiency and Macular Edema as Seen on Optical Coherence Tomography. Semin Ophthalmol 2016:1-8. [PMID: 27628176 DOI: 10.1080/08820538.2016.1206576] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Sarcoidosis is a chronic systemic autoimmune disease which belongs to a group of systemic granulomatous diseases. It can be confirmed through characteristic systemic and ocular manifestations and histological findings. Biopsy is the golden standard for diagnosing sarcoidosis. Ocular sarcoidosis can be confirmed, probable, or possible. Over a two-year period, ocular manifestations were studied on a sample of 52 patients, each followed for four months and diagnosed with some form of systemic sarcoidosis. Most frequent systemic manifestations in patients with ocular sarcoidosis were pulmonary, skin, glandular, and systemic generalized sarcoidosis. The disease was diagnosed four times more frequently in females than males (42:10, respectively; p < 0.05). Most frequent, and statistically significant, manifestation of ocular sarcoidosis is anterior uveitis (64.61%; p < 0.01). Macular edema and periphlebitis associated with periarteritis were frequent, and statistically significant (43.90% and 29.26%, respectively; p < 0.05). Overall, with regards to gender and location (right eye; left eye), visual acuity was >0.5 and of statistical significance (76.92%; p < 0.01). The most common therapy consisted of systemic corticosteroids (26.67%) and/or a combination of corticosteroids and immunosuppressive drugs (23.33%). In 16 eyes treated with repeated doses of sub-Tenon's injections, both initial and control visual acuity correlated with average thickness. There was positive correlation between several optical coherence tomography findings before and after treatment.
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Affiliation(s)
- Jelena Paovic
- a University Eye Clinic , Clinical Center of Serbia , Belgrade , Serbia
| | - Predrag Paovic
- a University Eye Clinic , Clinical Center of Serbia , Belgrade , Serbia
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Abstract
Therapy for autoimmune ophthalmic disease is currently evolving. The improved understanding of the abnormal immune response in the various forms of uveitis has resulted in targeted therapy. The aberrations of the immune system have been characterized by atypical cell populations, cytokine expression, and cell-cell interactions. Different patterns of cytokine expression have now been delineated in the abnormal uveal tract with exaggerated and/or abnormal expression of TNF, IL-1, IL-2, IL-6, and IL-17. The development of therapies for other conditions in which these cytokines play an important role has resulted in the availability of biological agents that have been adopted for use in the therapy for uveitis. Adalimumab and infliximab have been the best studied anti-TNF agents and indeed have now been recommended by an expert panel as first-line treatment of ocular manifestations of Behçet's disease and second-line treatment for other forms of uveitis (Levy-Clarke et al. (Ophthalmology, 2013). Other anti-TNF agents have been studied as well. Daclizumab, a monoclonal antibody directed against the IL-2 receptor, has also demonstrated utility in treating uveitis as have some of the anti-IL1 agents. Gevokizumab has been granted orphan drug designation for the treatment of resistant forms of uveitis. Therapies affecting IL-6, including tocilizumab are being studied, and available medications that block antigen presenting cell and T cell interaction such as abatacept have been reported to be effective in uveitis. Interferons as well as rituximab have also been evaluated in small studies. Although these biologic therapies have provided a larger armamentarium to treat uveitis, challenges remain. Uveitis is not a single illness; rather, it is a manifestation of many potential systemic diseases that may have very specific individual therapeutic targets. Identifying and characterizing these underlying diseases is not always achieved, and more importantly, the most effective therapies for each entity have not been defined.
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Abstract
Sarcoidosis is one of the leading causes of inflammatory eye disease. Ocular sarcoidosis can involve any part of the eye and its adnexal tissues and may cause uveitis, episcleritis/scleritis, eyelid abnormalities, conjunctival granuloma, optic neuropathy, lacrimal gland enlargement, and orbital inflammation. Glaucoma and cataract can be complications from inflammation itself or adverse effects from therapy. Ophthalmic manifestations can be isolated or associated with other organ involvement. Patients with ocular sarcoidosis can present with a wide range of clinical presentations and severity. Multidisciplinary approaches are required to achieve the best treatment outcomes for both ocular and systemic manifestations.
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Affiliation(s)
- Sirichai Pasadhika
- Vitreoretinal and Uveitis Service, Legacy Devers Eye Institute, 1040 Northwest 22nd Avenue Suite 168, Portland, OR 97210, USA.
| | - James T Rosenbaum
- Legacy Devers Eye Institute, 1040 Northwest 22nd Avenue Suite 168, Portland, OR 97210, USA
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Abstract
PURPOSE To evaluate the efficacy of systemic infliximab for the induction of remission in patients with retinal vasculitis, inadequately responsive to other immunomodulatory therapy, based on fluorescein angiography grading for retinal vasculitis evaluation. METHODS We analyzed 60 patients with retinal vasculitis, from the Massachusetts Eye Research and Surgery Institution in Cambridge, MA. Response to therapy was based on analysis of serial fluorescein angiography and fundus photography, including a baseline angiogram before initiation of infliximab. RESULTS Sixty patients received infliximab therapy between July 2007 and July 2012 at Massachusetts Eye Research and Surgery Institution for a diagnosis of retinal vasculitis. All had previously showed a poor clinical response to other immunomodulatory regimens, or ceased therapy due to intolerable side effects. The initial dose of infliximab was 5 mg/kg in all patients and remained at this dose for the extent of treatment in 57 (95%) patients. At 6 months, 45 of 51 (88.23%) patients were maintaining remission with therapy, 5 (9.8%) were in partial remission, and 1 patient had failed. At 12 months, 39 of 39 (100%) patients were maintaining remission with therapy. CONCLUSION Infliximab is effective for the treatment of recalcitrant noninfectious retinal vasculitis, refractory to conventional immunomodulatory therapy.
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Riancho-Zarrabeitia L, Calvo-Río V, Blanco R, Mesquida M, Adan AM, Herreras JM, Aparicio Á, Peiteado-Lopez D, Cordero-Coma M, García Serrano JL, Ortego-Centeno N, Maíz O, Blanco A, Sánchez-Bursón J, González-Suárez S, Fonollosa A, Santos-Gómez M, González-Vela C, Loricera J, Pina T, González-Gay MA. Anti-TNF-α therapy in refractory uveitis associated with sarcoidosis: Multicenter study of 17 patients. Semin Arthritis Rheum 2015; 45:361-8. [DOI: 10.1016/j.semarthrit.2015.05.010] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 04/08/2015] [Accepted: 05/14/2015] [Indexed: 12/11/2022]
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Idiopathic multifocal choroiditis/punctate inner choroidopathy with acute photoreceptor loss or dysfunction out of proportion to clinically visible lesions. Retina 2015; 35:334-43. [PMID: 25322466 DOI: 10.1097/iae.0000000000000370] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To report acute/subacute vision loss and paracentral scotomata in patients with idiopathic multifocal choroiditis/punctate inner choroidopathy due to large zones of acute photoreceptor attenuation surrounding the chorioretinal lesions. METHODS Multimodal imaging case series. RESULTS Six women and 2 men were included (mean age, 31.5 ± 5.8 years). Vision ranged from 20/20-1 to hand motion (mean, 20/364). Spectral domain optical coherence tomography demonstrated extensive attenuation of the external limiting membrane, ellipsoid and interdigitation zones, adjacent to the visible multifocal choroiditis/punctate inner choroidopathy lesions. The corresponding areas were hyperautofluorescent on fundus autofluorescence and were associated with corresponding visual field defects. Full-field electroretinogram (available in three cases) showed markedly decreased cone/rod response, and multifocal electroretinogram revealed reduced amplitudes and increased implicit times in two cases. Three patients received no treatment, the remaining were treated with oral corticosteroids (n = 4), oral acyclovir/valacyclovir (n = 2), intravitreal/posterior subtenon triamcinolone acetate (n = 3), and anti-vascular endothelial growth factor (n = 2). Visual recovery occurred in only three cases of whom two were treated. Varying morphological recovery was found in six cases, associated with decrease in hyperautofluorescence on fundus autofluorescence. CONCLUSION Multifocal choroiditis/punctate inner choroidopathy can present with transient or permanent central photoreceptor attenuation/loss. This presentation is likely a variant of multifocal choroiditis/punctate inner choroidopathy with chorioretinal atrophy. Associated changes are best evaluated using multimodal imaging.
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Abstract
PURPOSE To report thirteen cases of idiopathic multifocal choroiditis with discrete chorioretinal lesions who were found to have zonal, multizonal, or diffuse outer retinal or chorioretinal atrophy. METHODS A retrospective observational case series using multimodal imaging including high-definition optical coherence tomography, fundus autofluorescence imaging, and fluorescein and indocyanine green angiography. RESULTS Twenty-one eyes in 13 patients with idiopathic multifocal choroiditis were found to have zonal, multizonal, or diffuse outer retinal or chorioretinal atrophy visualized using multimodal imaging. Thirteen eyes presented with diffuse disease, six eyes with multizonal, and two with zonal atrophy. Patterns of atrophy included zones surrounding the optic nerve, multiple geographic zones in the mid and far periphery, and a diffuse peripheral pattern with relative sparing of the central macula until later in the course of disease. Eleven of the 13 patients were treated with topical, periocular, or systemic corticosteroids, and 1 patient was also treated with systemic immunomodulatory treatment. The atrophic changes progressed over an average of 8 years of follow-up in 10 eyes despite therapy. CONCLUSION Idiopathic multifocal choroiditis can present with an uncommon pattern of zonal, multizonal, or diffuse outer retinal or chorioretinal atrophy as part of its clinical spectrum. The severity, extent, and progression of these atrophic changes are best appreciated using multimodal diagnostic imaging.
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Abstract
Behçet disease is a chronic inflammatory systemic disorder, characterized by a relapsing and remitting course. It manifests with oral and genital ulcerations, skin lesions, uveitis, and vascular, central nervous system and gastrointestinal involvement. The main histopathological finding is a widespread vasculitis of the arteries and veins of any size. The cause of this disease is presumed to be multifactorial involving infectious triggers, genetic predisposition, and dysregulation of the immune system. As the clinical expression of Behçet disease is heterogeneous, pharmacological therapy is variable and depends largely on the severity of the disease and organ involvement. Treatment of Behçet disease continues to be based largely on anecdotal case reports, case series, and a few randomized clinical trials.
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Affiliation(s)
| | - Thurayya Arayssi
- Weill Cornell Medical College-Qatar, Education City, PO Box 24144, Doha, Qatar
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Levy-Clarke G, Jabs DA, Read RW, Rosenbaum JT, Vitale A, Van Gelder RN. Expert Panel Recommendations for the Use of Anti–Tumor Necrosis Factor Biologic Agents in Patients with Ocular Inflammatory Disorders. Ophthalmology 2014; 121:785-96.e3. [DOI: 10.1016/j.ophtha.2013.09.048] [Citation(s) in RCA: 328] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 09/24/2013] [Accepted: 09/30/2013] [Indexed: 12/14/2022] Open
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Pasadhika S, Rosenbaum JT. Update on the use of systemic biologic agents in the treatment of noninfectious uveitis. Biologics 2014; 8:67-81. [PMID: 24600203 PMCID: PMC3933243 DOI: 10.2147/btt.s41477] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Uveitis is one of the leading causes of blindness worldwide. Noninfectious uveitis may be associated with other systemic conditions, such as human leukocyte antigen B27-related spondyloarthropathies, inflammatory bowel disease, juvenile idiopathic arthritis, Behçet’s disease, and sarcoidosis. Conventional therapy with corticosteroids and immunosuppressive agents (such as methotrexate, azathioprine, mycophenolate mofetil, and cyclosporine) may not be sufficient to control ocular inflammation or prevent non-ophthalmic complications in refractory patients. Off-label use of biologic response modifiers has been studied as primary and secondary therapeutic agents. They are very useful when conventional immunosuppressive therapy has failed or has been poorly tolerated, or to treat concomitant ophthalmic and systemic inflammation that might benefit from these medications. Biologic therapy, primarily infliximab, and adalimumab, have been shown to be rapidly effective for the treatment of various subtypes of refractory uveitis and retinal vasculitis, especially Behçet’s disease-related eye conditions and the uveitis associated with juvenile idiopathic arthritis. Other agents such as golimumab, abatacept, canakinumab, gevokizumab, tocilizumab, and alemtuzumab may have great future promise for the treatment of uveitis. It has been shown that with proper monitoring, biologic therapy can significantly improve quality of life in patients with uveitis, particularly those with concurrent systemic symptoms. However, given high cost as well as the limited long-term safety data, we do not routinely recommend biologics as first-line therapy for noninfectious uveitis in most patients. These agents should be used with caution by experienced clinicians. The present work aims to provide a broad and updated review of the current and in-development systemic biologic agents for the treatment of noninfectious uveitis.
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Affiliation(s)
- Sirichai Pasadhika
- Department of Ophthalmology, Southern Arizona Veterans Administration Health Care System, Tucson, AZ, USA
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Fraser-Bell S, Pavesio C. Advances in the treatment of intermediate and posterior uveitis. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/17469899.3.4.449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Abstract
Birdshot chorioretinopathy is a relatively uncommon subtype of idiopathic posterior uveitis with distinct clinical characteristics and a strong genetic association with the Human Leukocyte Antigen (HLA)-A29 allele. The diagnosis remains clinical and is based on the presence of typical clinical features, including multiple, distinctive, hypopigmented choroidal lesions throughout the fundus. The long-term visual prognosis of this disorder, however, remains guarded – central visual acuity can be preserved until late in the disease and it is not uncommon for patients to receive inadequate immunosuppressive treatment, leading to a poor long-term outcome in which peripheral retinal damage eventually leads to visual deterioration. Birdshot chorioretinopathy has proven a particularly attractive area of study within the field of uveitis, as it is a relatively easily defined disease with an associated human leukocyte antigen haplotype. Despite this, however, the immune mechanisms involved in its pathogenesis remain unclear, and some patients continue to lose retinal function despite therapy with corticosteroids and conventional immunosuppressive agents. Laboratory research continues to investigate the underlying mechanisms of disease, and clinical research is now being driven to improve the phenotyping and monitoring of this condition as, in the era of so-called personalized medicine, it is becoming increasingly important to identify patients at risk of visual loss early so that they can be treated more aggressively with targeted therapies such as the newer biological agents. This approach requires the formation of collaborative groups, as the relative rarity of the condition makes it difficult for one center to accumulate enough patients for worthwhile studies. Nevertheless, results obtained with newer therapies, such as biological agents directed against particular cytokines or cell-surface receptors, demonstrate ever improving control of the inflammation in refractory cases, providing hope that the outlook for visual function in this condition can only improve.
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Affiliation(s)
- Victor Menezo
- Institut Catala de Retina, Barcelona, Spain ; Department of Ophthalmology, Provincial Hospital Consortium Castellon, Castello, Spain
| | - Simon Rj Taylor
- Faculty of Medicine, Imperial College London, Hammersmith Hospital, London, UK ; Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
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Pleyer U, Hazirolan D, Winterhalter S, Stübiger N. [Behcet's disease--ophthalmological and general aspects: Part 2: Therapy]. Ophthalmologe 2013; 110:273-84. [PMID: 23504099 DOI: 10.1007/s00347-012-2780-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Behcet's disease (also called Admantiades-Behcet syndrome) is a chronic vasculitis. The disease is characterized by exacerbations and remissions of symptoms and organ manifestations and may produce only mild mucocutaneous lesions, whereas ocular lesions can cause blindness. In addition, involvement of the gastrointestinal tract, central nervous system (CNS) and large blood vessels is sometimes life-threatening. Cyclosporin A is the only agent for treatment of ocular lesions registered in Germany; however, the neurotoxicity and nephrotoxicity restrict usage of the drug. In patients suffering from severe uveitis, biologics have been a breakthrough. Interferon (IFN) alpha therapy has shown significant efficacy for intraocular inflammation. Monoclonal antibodies to TNF-alpha and interleukin-1 have been successful in clinical trials and are approved in some countries. This article summarizes the current state of knowledge and emphasizes the important role of the ophthalmologist in the therapy of Behcet's disease.
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Affiliation(s)
- U Pleyer
- Universitäts-Augenklinik, Uveitis Zentrum, Charité, Universitätsmedizin Berlin, Humboldt University, Augustenburger Platz 1, 13353, Berlin, Deutschland.
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Artornsombudh P, Gevorgyan O, Payal A, Siddique SS, Foster CS. Infliximab Treatment of Patients with Birdshot Retinochoroidopathy. Ophthalmology 2013. [DOI: 10.1016/j.ophtha.2012.05.048] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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Cordero-Coma M, Yilmaz T, Onal S. Systematic Review of Anti-Tumor Necrosis Factor-alpha Therapy for Treatment of Immune-mediated Uveitis. Ocul Immunol Inflamm 2013; 21:19-27. [DOI: 10.3109/09273948.2012.723107] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Complications infectieuses liées au traitement par anti-TNFα : à propos de deux cas de leishmaniose. J Fr Ophtalmol 2012; 35:695-9. [DOI: 10.1016/j.jfo.2012.06.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Accepted: 06/10/2012] [Indexed: 11/19/2022]
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Servat JJ, Mears KA, Black EH, Huang JJ. Biological agents for the treatment of uveitis. Expert Opin Biol Ther 2012; 12:311-28. [PMID: 22339439 DOI: 10.1517/14712598.2012.658366] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The conventional treatment of uveitis includes corticosteroids and immunosuppressive agents, which are highly efficacious, but can be associated with serious systemic side effects. Over the last two decades, advances in the understanding of the pathogenesis of inflammatory diseases, as well as improved biotechnology, have enabled selective targeting of the chemical mediators of diseases. Recently, a new class of drugs called biologics, that target the various mediators of the inflammation cascade, may potentially provide more effective and less toxic treatment. AREAS COVERED This article is a review and summary of the peer-reviewed evidence for biologic agents in the treatment of various forms of ocular inflammation and it focuses on the potential use of other biologic agents that have been tested in experimental autoimmune uveitis. Pubmed was used as our main tool for our literature search. Some additional references were taken from books written on the subject. EXPERT OPINION There are a wide variety of new and emerging biological agents currently being used in the treatment of uveitis which has expanded the therapeutic horizons far beyond previous limitations.
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Affiliation(s)
- Juan Javier Servat
- Yale University School of Medicine, Department of Ophthalmology and Visual Science, 40 Temple Street, NH 06510, USA
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Martel JN, Esterberg E, Nagpal A, Acharya NR. Infliximab and Adalimumab for Uveitis. Ocul Immunol Inflamm 2012; 20:18-26. [DOI: 10.3109/09273948.2011.633205] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Cantini F, Niccoli L, Nannini C, Kaloudi O, Cassarà E, Susini M, Lenzetti I. Efficacy of infliximab in refractory Behçet's disease-associated and idiopathic posterior segment uveitis: a prospective, follow-up study of 50 patients. Biologics 2011; 6:5-12. [PMID: 22291462 PMCID: PMC3266861 DOI: 10.2147/btt.s27343] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE To evaluate the long-term efficacy of infliximab in patients with refractory Behçet's disease (BD)-associated and idiopathic posterior uveitis (PU). METHODS Single center, prospective, 6-year duration, follow-up study on 50 consecutive patients (20 [40%] males and 30 [60%] females with a mean age of 37.5 ± 12.3 years) with refractory BD-associated PU (36 patients) and idiopathic PU (14 patients) who had failed at least one immunosuppressive drug. At baseline, patients received prednisone 1 mg/kg/day with rapid tapering and infliximab infusions (5 mg/kg) at weeks 0, 2, 6, and every 8 weeks thereafter. Nonresponders after the third infusion withdrew from the study. Primary outcome measures were visual acuity (VA) value improvement compared to baseline. Secondary outcome measures were proportion of patients with VA improvement from baseline; proportion of patients achieving disease remission; number of PU flare-ups; and incidence of adverse events. RESULTS At the final follow-up, mean right and left eye VA respectively increased from 0.57 ± 0.31 at baseline to 0.68 ± 0.33 (P = 0.048) and from 0.67 ± 0.28 to 0.76 ± 0.27 (P = 0.047). None of the patients had VA worsening and new onset ocular complications. A complete response of PU was recorded in 34/50 (68%) patients and partial response in 11/50 (22%). Five patients were nonresponders and withdrew from the study after the third infusion. A significant reduction of ocular attacks and of the proportion of patients with cystoid macular edema was observed. No differences in infliximab efficacy was recorded between patients with BD-associated and idiopathic PU. No serious adverse events occurred. The mean follow-up duration was 36.8 months. CONCLUSION Long-term infliximab therapy was equally effective and safe with a significant VA gain in refractory BD-associated and idiopathic PU.
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Affiliation(s)
- Fabrizio Cantini
- Second Division of Internal Medicine, Rheumatology Unit, Prato, Italy
| | - Laura Niccoli
- Second Division of Internal Medicine, Rheumatology Unit, Prato, Italy
| | - Carlotta Nannini
- Second Division of Internal Medicine, Rheumatology Unit, Prato, Italy
| | - Olga Kaloudi
- Second Division of Internal Medicine, Rheumatology Unit, Prato, Italy
| | - Emanuele Cassarà
- Second Division of Internal Medicine, Rheumatology Unit, Prato, Italy
| | | | - Ivo Lenzetti
- Division of Ophthalmology, Prato Hospital, Prato, Italy
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Callejas-Rubio JL, López-Pérez L, Ortego-Centeno N. Tumor necrosis factor-alpha inhibitor treatment for sarcoidosis. Ther Clin Risk Manag 2011; 4:1305-13. [PMID: 19337437 PMCID: PMC2643111 DOI: 10.2147/tcrm.s967] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Sarcoidosis is a chronic multisystem disease of unknown etiology, characterized by noncaseating granulomatous infiltration of virtually any organ system. Treatment is often undertaken in an attempt to resolve symptoms or prevent progression to organ failure. Previous studies have suggested a prominent role for tumor necrosis factor-alpha (TNF-α) in the inflammatory process seen in sarcoidosis. TNF-α and interleukin-1 are released by alveolar macrophages in patients with active lung disease. Corticosteroids have proved to be efficacious in the treatment of sarcoidosis, possibly by suppressing the production of TNF-α and other cytokines. Three agents are currently available as specific TNF antagonists: etanercept, infliximab, and adalimumab. Although data from noncomparative trials suggest that all three have comparable therapeutic effects in rheumatoid arthritis, their effects in a granulomatous disease such as sarcoidosis are less consistent. In this review, current data on the effectiveness are summarized.
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Anti-TNF Agents for Behçet's Disease: Analysis of Published Data on 369 Patients. Semin Arthritis Rheum 2011; 41:61-70. [PMID: 21168186 DOI: 10.1016/j.semarthrit.2010.09.002] [Citation(s) in RCA: 238] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Revised: 08/30/2010] [Accepted: 09/14/2010] [Indexed: 01/08/2023]
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Management and clinical outcome of penetrating keratoplasty for long-term corneal changes in sympathetic ophthalmia. J Ophthalmol 2011; 2011:439025. [PMID: 21772984 PMCID: PMC3136120 DOI: 10.1155/2011/439025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Accepted: 02/12/2011] [Indexed: 12/25/2022] Open
Abstract
Purpose. To report the visual outcome of penetrating keratoplasty performed on the sympathizing eye in three cases of sympathetic ophthalmitis. Methods. Interventional case series of three patients, diagnosed with sympathetic ophthalmitis, with corneal changes in the form of band keratopathy and decompensation underwent penetrating keratoplasty to the sympathizing eye. They had each sustained penetrating trauma as a child and had undergone previous cataract surgery and superficial keratectomy. Two patients had undergone lamellar keratoplasty prior to this procedure. One patient had undergone trabeculectomy for glaucoma, and she was on antiglaucoma medication. The preoperative visual acuity was 1/60 in the affected eye of each patient. Penetrating keratoplasty was performed in the sympathizing eye and the donor graft size was 7.50 mm, and the host graft size was 7.25 mm. Our patients were immunosuppressed prior to the procedure to help prevent graft rejection. Result. At one year follow-up, a BCVA of 6/36 or better was achieved in all three patients. Postoperative examination of the fundus showed peripheral chorioretinal atrophy with pigmentary changes at the macula, accounting for the limited vision. The grafts remain clear to date, and there has been no recurrence of uveitis or rejection. Conclusion. Penetrating keratoplasty can be considered as a surgical option to restore useful vision in a stable sympathizing eye in sympathetic ophthalmitis, and this depends on the extent of the pathology. However, these cases require treatment with immunosuppressives to prevent graft rejection and to prolong graft survival.
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Siemanowski B, Regueiro M. Efficacy of infliximab for extraintestinal manifestations of inflammatory bowel disease. ACTA ACUST UNITED AC 2011; 10:178-84. [PMID: 17547856 DOI: 10.1007/s11938-007-0011-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Crohn's disease (CD) and ulcerative colitis (UC), collectively referred to as inflammatory bowel disease (IBD), are associated with extraintestinal manifestations (EIMs) in approximately 40% of patients. Infliximab, a chimeric monoclonal antibody to tumor necrosis factor-alpha, is effective for induction and maintenance of remission of CD and UC. The role of infliximab for EIMs related to IBD has been less studied, but it is likely as effective. The EIMs may run a course that parallels IBD activity or may present separately. The EIMs that parallel intestinal inflammation (eg, peripheral arthritis, pyoderma gangrenosum, erythema nodosum, and episcleritis) generally respond to infliximab. Therefore, treating patients with IBD who have one of these EIMs will more often than not improve the EIM. The EIMs that run a separate course from IBD are more difficult to treat. Ankylosing spondylitis (AS), uveitis, and primary sclerosing cholangitis (PSC) have variable responses to IBD medications. Infliximab is efficacious for uveitis and is approved by the US Food and Drug Administration for treatment of AS. The efficacy of infliximab for PSC is unknown. The dosing schedule of infliximab for IBD patients with EIMs should be induction doses with 5 mg/kg at 0, 2, and 6 weeks followed by every 8 weeks. Whether long-term infliximab therapy is necessary to maintain remission of EIMs, as in the case of IBD, has not been established.
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Affiliation(s)
- Benjamin Siemanowski
- Miguel Regueiro, MD Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, 200 Lothrop Street, PUH-C Wing Mezzanine Level, Pittsburgh, PA 15213, USA.
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Uvéites sarcoïdosiques : actualités diagnostiques et thérapeutiques. Rev Med Interne 2011; 32:86-92. [PMID: 20970226 DOI: 10.1016/j.revmed.2010.09.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Revised: 07/26/2010] [Accepted: 09/20/2010] [Indexed: 12/23/2022]
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Pato E, Muñoz-Fernández S, Francisco F, Abad MA, Maese J, Ortiz A, Carmona L. Systematic Review on the Effectiveness of Immunosuppressants and Biological Therapies in the Treatment of Autoimmune Posterior Uveitis. Semin Arthritis Rheum 2011; 40:314-23. [DOI: 10.1016/j.semarthrit.2010.05.008] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2010] [Revised: 05/17/2010] [Accepted: 05/20/2010] [Indexed: 12/14/2022]
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Karampetsou MP, Liossis SNC, Sfikakis PP. TNF-α antagonists beyond approved indications: stories of success and prospects for the future. QJM 2010; 103:917-28. [PMID: 20802008 DOI: 10.1093/qjmed/hcq152] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Tumour necrosis factor alpha (TNF-α) is a key molecule of the inflammatory response and data derived from studies in experimental animal models and humans suggest that TNF-α may be implicated in the pathogenesis of various autoimmune and non-infectious inflammatory conditions. Over the past decade pharmaceutical agents directed against TNF-α (infliximab, adalimumab and etanercept) have been widely and successfully employed for the management of rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriasis, psoriatic arthritis, juvenile idiopathic arthritis and inflammatory bowel disease, whereas two novel anti-TNF-α agents, golimumab and certolimumab pegol, recently entered the market for the treatment of RA, AS, Crohn's disease and psoriasis. Encouraged by the positive results obtained from the use of TNF-α antagonists in terms of efficacy and safety and due to the increasingly accumulating evidence regarding the implication of TNF-α in the pathogenesis of numerous disorders, anti-TNF-α agents have been considered for the management of diseases other than the ones they were initially approved for. Although in the case of multiple sclerosis and chronic heart failure the outcome from the administration of TNF-α blockers had been less than favourable, in other cases of non-infectious inflammatory conditions the response to TNF-α inhibition had been fairly beneficial. More specifically, according to well-documented clinical trials, anti-TNF-α agents exhibited favourable results in Behçet's disease, non-infectious ocular inflammation, pyoderma gangrenosum and hidradenitis suppurativa. In this review we discuss the successful outcomes as well as the prospects for the future from the off-label use of TNF-α antagonists.
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Affiliation(s)
- M P Karampetsou
- Department of Medicine, University of Patras, 26504, Patras, Greece
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Effects of infliximab in the treatment of refractory posterior uveitis of Behçet’s disease after withdrawal of infusions. Int Ophthalmol 2010; 30:577-81. [DOI: 10.1007/s10792-010-9372-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2009] [Accepted: 05/02/2010] [Indexed: 10/19/2022]
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Régent A, Mouthon L. [Anti-TNFalpha therapy in systemic autoimmune and/or inflammatory diseases]. Presse Med 2009; 38:761-73. [PMID: 19349142 DOI: 10.1016/j.lpm.2009.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2009] [Accepted: 02/16/2009] [Indexed: 01/08/2023] Open
Abstract
TNFalpha plays a crucial role in the physiopathology of a large number of auto-immune and/or inflammatory systemic diseases. In addition to authorized indications including rheumatoid arthritis, ankylosing spondylitis, Crohn disease, ulcerative colitis, psoriatic arthritis and plaque psoriasis, TNFalpha blockers have been tested in a wide range of auto-immune and/or inflammatory diseases. TNFalpha blockers might be an option in refractory ANCA-associated vasculitis, sarcoïdosis, adult onset Still disease, Behçet disease, AA amyloïdosis and TRAPS. However, pertaining to the limited number of prospective randomized trails available, the small number of patients included and the poor methodology, it is difficult to define their place in the therapeutic strategy in these conditions. The therapeutic effect of TNFalpha blockers is often suspensive and disease flares are frequently observed during sustained treatment, as in the case of Behçet's disease. Published data do not support the use of TNFalpha blockers in connective tissue diseases.
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Affiliation(s)
- Alexis Régent
- UPRES EA 4058, Université Paris Descartes, Faculté de Médecine, F-75005 Paris, France
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Diaz-Llopis M, García-Delpech S, Salom D, Udaondo P, Hernández-Garfella M, Bosch-Morell F, Quijada A, Romero FJ. Adalimumab therapy for refractory uveitis: a pilot study. J Ocul Pharmacol Ther 2008; 24:351-61. [PMID: 18476805 DOI: 10.1089/jop.2007.0104] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE The aim of this study was to assess the efficacy and safety of adalimumab in treating refractory autoimmune uveitis. METHODS This work was a prospective, noncomparative, nonrandomized, clinical trial. Nineteen (19) patients meeting eligibility criteria received a 40-mg subcutaneous (s.c.) injection of adalimumab every other week during 1 year. RESULTS All patients underwent an outcome assessment at month 12. Visual acuity improved by -0.3 logMar in 12 (31%) eyes of 38, and worsened by +0.3 logMar in 1 (2.6%) eye. All patients had an active intraocular inflammation at baseline, and 12 patients (63%) achieved control of their inflammation with adalimumab at the end of follow-up. After optic coherence tomography, 33 eyes (86%) had cystoid macular edema (CME) at baseline, and at the end of follow-up there was a complete resolution of CME in 18 of these 33 eyes (54.54%). All patients were able to reduce at least 50% of the dose of the concomitant immunosuppressive drugs at the end of follow-up. Adalimumab was well tolerated in all patients, and only local minor side effects at the s.c. injection site were observed. Nevertheless, 8 patients (42.10%) had relapses during the follow-up period that were controlled with 1 periocular steroid injection. CONCLUSIONS Adalimumab seems to be an effective, safe therapy for the management of refractory uveitis and may provide the possibility to reduce the concomitant immunosuppressive drugs in these patients. Further long-term studies are warranted to determine the safety and efficacy of adalimumab in treating intraocular inflammation.
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Affiliation(s)
- Manuel Diaz-Llopis
- Uveitis and Retina Unit, Department of Ophthalmology, University General Hospital of Valencia, Valencia, Spain.
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Drug insight: anti-tumor necrosis factor therapies for the vasculitic diseases. ACTA ACUST UNITED AC 2008; 4:364-70. [PMID: 18506159 DOI: 10.1038/ncprheum0825] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2007] [Accepted: 03/18/2008] [Indexed: 11/08/2022]
Abstract
The introduction of targeted biologic agents directed against tumor necrosis factor (TNF) has represented a novel and exciting avenue for investigation into therapies for the vasculitic diseases. In vasculitic diseases that are associated with granuloma formation, anti-TNF agents are a particularly attractive approach to treatment in that their mechanism of action targets immunologic pathways that are thought to have a role in disease pathogenesis. To date, a number of important trials have investigated the use of anti-TNF agents in patients with a vasculitic disease: most notably, Wegener's granulomatosis, giant-cell arteritis, Takayasu's arteritis, and Behçet's disease. Randomized, placebo-controlled trials of anti-TNF therapies for vasculitic diseases have advanced our knowledge not only in terms of their clinical results but also by demonstrating that networks of researchers can conduct multicenter trials in these uncommon diseases. Experience with the use of anti-TNF agents in patients with Wegener's granulomatosis or giant-cell arteritis has emphasized the crucial role of randomized trials in determining whether a treatment is effective, even in the face of promising preliminary data. Caution is necessary in clinical practice until such data become available.
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Graña Gil J. [New Clinical Aspects of Behçet's Disease]. REUMATOLOGIA CLINICA 2008; 4 Suppl 1:50-55. [PMID: 21794555 DOI: 10.1016/s1699-258x(08)76141-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Behçet's disease/syndrome (BD) continues being aloof in his etiopathogenesis and very complex in its clinical manifestations. BD generates a good amount of scientific articles. For example, a simple search in PubMed sample that in the last 5 years has been published 1394 articles, 159 of them revisions. In addition to the basic studies on etiopahtogenesis and disease mechanisms, the diverse clinical manifestations and their treatments, also the own definition of the disease, its classification and the criteria of classification and diagnosis are debate source. In this article we reviewed some aspects in discussin as well as the last therapeutic alternatives and the situation of the EB in Spain.
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Affiliation(s)
- Jenaro Graña Gil
- Servicio de Reumatología. Complejo Hospitalario Universitario Juan Canalejo. A Coruña. España
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Abstract
PURPOSE OF REVIEW This review summarizes the current evidence for biologic therapies in the treatment of uveitis. The review emphasizes published research in this field since 2005. RECENT FINDINGS The anti-tumour necrosis factor-alpha infliximab and adalimumab have demonstrated significant efficacy in controlling uveitis associated with seronegative spondyloarthropathies and juvenile idiopathic arthritis; however, etanercept has failed to show a similar treatment effect in uveitis associated with these conditions. The majority of reports of biologic therapies in posterior uveitis have been uncontrolled trials, or retrospective studies, of uveitis resistant to immunosuppression. Encouragingly, successful control of such refractory intraocular inflammation has been consistently reported with infliximab and interferon alpha, particularly Behcet's disease-associated uveitis. A limited number of reports of anti-interleukin therapies, daclizumab and anakinra, have supported a role for these therapies in some types of uveitis. SUMMARY Biologic therapies have increased the treatment options for sight-threatening uveitis. Despite experimental rationale, the lack of evidence from randomized controlled studies limits our understanding of when to commence therapy, which agent to choose and how long to continue treatment. Additionally, the high cost and potential side effects of all biologic agents have limited their current use to uveitis refractory to immunosuppression.
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Diaz-Llopis M, García-Delpech S, Salom D, Udaondo P, Bosch-Morell F, Quijada A, Romero FJ, Amselem L. High-dose infliximab prophylaxis in endotoxin-induced uveitis. J Ocul Pharmacol Ther 2007; 23:343-50. [PMID: 17803432 DOI: 10.1089/jop.2006.0148] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE The aim of this study to analyze the preventive effect of high-dose infliximab in endotoxin-induced uveitis (EIU) in rabbits. METHODS An experimental study was conducted on 64 rabbits. Salmonella typhimurium lipopolysaccharide endotoxin was intravitreally injected. Infliximab was intravenously (i.v.) injected 24 h before the intravitreal injection (20 mg/kg). The animals were randomly assigned to five groups: group A, saline intravitreal injection; group B, Infliximab i.v. group C, infliximab + saline; group D, intravitreal endotoxin and group E, infliximab i.v. + intravitreal endotoxin. With two masked observers, a microscopic examination of aqueous humor (cells, tumor necrosis factor [TNF] alpha) and aqueous protein level were performed 24 h after an endotoxin injection and 48 h after an infliximab infusion. RESULTS Infliximab treatment, at a dose of 20 mg/kg, significantly improved all the parameters. Inflammatory cell infiltration was significantly reduced in the iris, ciliary body, and anterior chamber (U Mann-Whitney test, P = 0.01). Associated with a lower level of TNF-alpha and protein exudate in aqueous humor (U Mann-Whitney test, P = 0.01). CONCLUSIONS Infliximab, at a dose of 20 mg/kg, is effective in the prophylaxis of the EIU.
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Affiliation(s)
- Manuel Diaz-Llopis
- Department of Ophthalmology, Uveitis Unit, Hospital General Universitario, Valencia, Spain.
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Imrie FR, Dick AD. Nonsteroidal drugs for the treatment of noninfectious posterior and intermediate uveitis. Curr Opin Ophthalmol 2007; 18:212-9. [PMID: 17435428 DOI: 10.1097/icu.0b013e3281107fef] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW This review summarizes current nonsteroidal drug therapies for noninfectious posterior and intermediate uveitis. RECENT FINDINGS Continuing evidence shows that second-line agents including antimetabolites, T-cell inhibitors and alkylating agents, are effective in many patients, allowing reduction in steroid dose and preservation of visual function. There is an increased use of mycophenolate mofetil. Biologic therapies, including the antitumour necrosis factor-alpha agents and interferons, have demonstrated a high degree of efficacy in controlling uveitis refractory to immunosuppressants. SUMMARY There are an increasing number of treatment options. As the vast majority of published studies in uveitis are case series or nonrandomized trials, there remains a lack of level 1 evidence to guide the choice and duration of therapy. Standard initial treatment for steroid-resistant disease is to add a single immunosuppressant to the regime, with additional agents being substituted or added as required. Combination of two immunosuppressants in addition to steroids may be indicated especially in chronic uveitis. High cost and limited long-term experience with biologic agents have restricted their use to uveitis refractory to immunosuppressants, but evidence suggests a potential therapeutic role earlier in Bechet's disease.
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Affiliation(s)
- Fraser R Imrie
- Academic Unit of Ophthalmology, University of Bristol and Bristol Eye Hospital, Lower Maudlin Street, Bristol, UK
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Accorinti M, Pirraglia MP, Paroli MP, Priori R, Conti F, Pivetti-Pezzi P. Infliximab Treatment for Ocular and Extraocular Manifestations of Behçet's Disease. Jpn J Ophthalmol 2007; 51:191-6. [PMID: 17554481 DOI: 10.1007/s10384-006-0425-y] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2006] [Accepted: 12/20/2006] [Indexed: 10/23/2022]
Abstract
PURPOSE To assess the efficacy and safety of infliximab in the treatment of sight-threatening uveitis and extraocular manifestations in patients with Behçet's disease. METHODS Twelve patients with Behçet's disease and uveitis were treated with infliximab after unsuccessful therapy with other immunosuppressive drugs. The main outcome measures were as follows: the number of uveitis relapses, the number of Behçet's disease-related extraocular lesions, and the amount of corticosteroids administered during the treatment as well as during an equal prior period of time while the patients were on other immunosuppressive agents. Visual acuity was recorded at the beginning of infliximab therapy and at the end of follow-up, and was defined as stable if it did not change from baseline, increased if it showed at least one line of improvement from baseline, and decreased if it showed at least a one line decrease from baseline. RESULTS During an average follow-up of 16.67 +/- 7.63 months (median, 15 months), 11 patients (91.6%) showed a reduction in the number of ocular relapses (relapse/month, from 0.35 +/- 0.17 to 0.12 +/- 0.17, P < 0.001). All of the patients (n = 11) who were taking corticosteroids before infliximab were able to reduce the amount of corticosteroids taken daily during infliximab treatment (from 24.33 +/- 10.84 mg/prednisone per day to 8.97 +/- 6.81 mg/prednisone per day, P < 0.001), and all presented with a reduced onset of extraocular manifestations of Behçet's disease (mean total number, from 2.83 +/- 3.61 to 1.51 +/- 2.35, P = 0.039). One patient, who had to stop treatment 2 months after starting because of the onset of pulmonary tuberculosis, showed the same number of relapses during infliximab treatment but was able to reduce the mean daily corticosteroid dose. Visual acuity increased by one or more lines in three eyes (12.5%) and remained unchanged in 87.5% of the eyes. Infliximab-related side effects appeared in four patients (33.3%). CONCLUSIONS Infliximab was effective in the treatment of uveitis in these Behçet's disease patients, significantly reducing the number of ocular relapses and making possible a significant reduction in the daily dose of corticosteroids administered. Extraocular manifestations of Behçet's disease were also controlled by infliximab. Nevertheless, side effects were not uncommon, and an extensive study of systemic conditions before infliximab administration had to be carried out to exclude systemic infection, particularly prior tuberculosis.
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Affiliation(s)
- Massimo Accorinti
- Servizio di Immunovirologia Oculare, Dipartimento di Scienze Oftalmologiche, Università degli Studi di Roma La Sapienza, Rome, Italy
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Theodossiadis PG, Markomichelakis NN, Sfikakis PP. Tumor necrosis factor antagonists: preliminary evidence for an emerging approach in the treatment of ocular inflammation. Retina 2007; 27:399-413. [PMID: 17420690 DOI: 10.1097/maj.0b013e3180318fbc] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The anti-tumor necrosis factor (TNF) monoclonal antibody infliximab and the soluble TNF receptor etanercept inhibit the pleiotropic actions of TNF and are widely used for the treatment of rheumatoid arthritis (RA), juvenile idiopathic arthritis (JIA), spondyloarthropathies (SpA), Crohn's disease, and psoriasis with an acceptable safety profile. A pathogenetic role of TNF in ocular inflammatory conditions has recently emerged from small trials reporting preliminary results on the efficacy of these agents in patients with noninfectious uveitis, regardless of the origin of the disease. The authors review the published experience, derived mostly from investigator-sponsored trials and uncontrolled case series, on the use of TNF antagonists in approximately 280 patients with various ocular conditions who were inadequately controlled on currently available therapy. These reports suggest that TNF antagonists, mainly infliximab, which may have better efficacy than etanercept, are useful in the treatment of ocular inflammation associated with Adamantiades-Behçet's disease, RA, JIA, SpA, Crohn's, sarcoidosis, and Graves' disease ophthalmopathy. Infliximab was also beneficial in small numbers of patients with idiopathic uveitis or scleritis, birdshot retinochoroiditis, uveitic and diabetic cystoid macular edema, and age-related macular degeneration. The currently available data are nonrandomized and thus preliminary, providing the foundation and justification for randomized trials to assess efficacy and safety. Until such results are available, knowledge regarding the use of anti-TNF regimens in ophthalmology is incomplete. However, the preliminary evidence points to a growing optimism for targeting TNF in patients with ocular inflammation.
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Salama B, Gicquel JJ, Lenoble P, Dighiero PL. Optic neuropathy in refractory neurosarcoidosis treated with TNF-α antagonist. Can J Ophthalmol 2006. [DOI: 10.3129/i06-074] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Bibliography. Current world literature. Neuro-ophthalmology. Curr Opin Ophthalmol 2006; 17:574-5. [PMID: 17065928 DOI: 10.1097/icu.0b013e32801121a1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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