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Qin M, Luo J, Patel B, Thong KX, Latefa S, Shao D, Tanner A, Yu-Wai-Man C. Developing a synergistic rate-retarding polymeric implant for controlling monoclonal antibody delivery in minimally invasive glaucoma surgery. Int J Biol Macromol 2024; 272:132655. [PMID: 38797299 DOI: 10.1016/j.ijbiomac.2024.132655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 05/18/2024] [Accepted: 05/23/2024] [Indexed: 05/29/2024]
Abstract
Monoclonal antibodies (mAbs) have garnered substantial attention within the field of ophthalmology and can be used to suppress scar formation after minimally invasive glaucoma surgeries. Here, by controlling mAb passive diffusion, we developed a polymeric, rate-controlling membrane reservoir loaded with poly(lactic-co-glycolic acid) microspheres to deliver mAb for several weeks. Different parameters were tested to ensure that the microspheres achieved a good quality characteristic, and our results showed that 1 %W/V emulsifier with 5 %W/V NaCl achieved mAb-loaded microspheres with the highest stability, encapsulation efficiency and minimal burst release. Then, we fabricated and compared 10 types of microporous films based on polylactic acid (PLA), polycaprolactone (PCL), and polyethylene glycol (PEG). Our results revealed distinct pore characteristics and degradation patterns in different films due to varying polymer properties, and all the polymeric film formulations showed good biocompatibility in both human trabecular meshwork cells and human conjunctival fibroblasts. Finally, the optimized microspheres were loaded into the reservoir-type polymeric implant assembled by microporous membranes with different surface coating modifications. The implant formulation, which was fabricated by 60 PCL: 40 PEG (3 %W/V) polymer with 0.1 %W/V poly(lactic-co-glycolic acid) barrier, exerted the best drug release profile that can sustained release mAb (83.6 %) for 4 weeks.
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Affiliation(s)
- Mengqi Qin
- Faculty of Life Sciences & Medicine, King's College London, London SE1 1UL, UK
| | - Jinyuan Luo
- Faculty of Life Sciences & Medicine, King's College London, London SE1 1UL, UK
| | - Brihitejas Patel
- Faculty of Life Sciences & Medicine, King's College London, London SE1 1UL, UK
| | - Kai Xin Thong
- Faculty of Life Sciences & Medicine, King's College London, London SE1 1UL, UK
| | - Samar Latefa
- Faculty of Life Sciences & Medicine, King's College London, London SE1 1UL, UK
| | - Daniel Shao
- Faculty of Life Sciences & Medicine, King's College London, London SE1 1UL, UK
| | - Alexander Tanner
- Faculty of Life Sciences & Medicine, King's College London, London SE1 1UL, UK
| | - Cynthia Yu-Wai-Man
- Faculty of Life Sciences & Medicine, King's College London, London SE1 1UL, UK.
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Cassinotti A, Batticciotto A, Parravicini M, Lombardo M, Radice P, Cortelezzi CC, Segato S, Zanzi F, Cappelli A, Segato S. Evidence-based efficacy of methotrexate in adult Crohn's disease in different intestinal and extraintestinal indications. Therap Adv Gastroenterol 2022; 15:17562848221085889. [PMID: 35340755 PMCID: PMC8949794 DOI: 10.1177/17562848221085889] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 02/18/2022] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Methotrexate (MTX) is included in the therapeutic armamentarium of Crohn's disease (CD), although its positioning is currently uncertain in an era in which many effective biological drugs are available. No systematic reviews or meta-analysis have stratified the clinical outcomes of MTX according to the specific clinical scenarios of its use. METHODS Medline, PubMed and Scopus were used to extract eligible studies, from database inception to May 2021. A total of 163 studies were included. A systematic review was performed by stratifying the outcomes of MTX according to formulation, clinical indication and criteria of efficacy. RESULTS The use of MTX is supported by randomized clinical trials only in steroid-dependent CD, with similar outcomes to thiopurines. The use of MTX in patients with steroid-refractoriness, failure of thiopurines or in combination with biologics is not supported by high levels of evidence. Combination therapy with biologics can optimize the immunogenic profile of the biological drug, but the impact on long-term clinical outcomes is described only in small series with anti-TNFα. Other off-label uses, such as fistulizing disease, mucosal healing, postoperative prevention and extraintestinal manifestations, are described in small uncontrolled series. The best performance in most indications was shown by parenteral MTX, favouring higher doses (25 mg/week) in the induction phase. DISCUSSION Evidence from high-quality studies in favour of MTX is scarce and limited to the steroid-dependent disease, in which other drugs are the leading players today. Many limitations on study design have been found, such as the prevalence of retrospective underpowered studies and the lack of stratification of outcomes according to specific types of patients and formulations of MTX. CONCLUSION MTX is a valid option as steroid-sparing agent in steroid-dependent CD. Numerous other clinical scenarios require well-designed clinical studies in terms of patient profile, drug formulation and dosage, and criteria of efficacy.
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Affiliation(s)
| | | | | | | | - Paolo Radice
- Ophtalmology Unit, ASST Sette Laghi, Varese, Italy
| | | | - Simone Segato
- Gastroenterology Unit, ASST Sette Laghi, Varese, Italy
| | | | | | - Sergio Segato
- Gastroenterology Unit, ASST Sette Laghi, Varese, Italy
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Karam M, Alsaif A, Al-Naseem A, Hayre A, Al Jabbouri A, Aldubaikhi A, Kahlar N, Al-Mutairi S. Mycophenolate versus Methotrexate in Non-infectious Ocular Inflammatory Disease: A Systematic Review and Meta-Analysis. Ocul Immunol Inflamm 2022; 31:613-620. [PMID: 35201968 DOI: 10.1080/09273948.2022.2034166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE To compare the outcomes of mycophenolate mofetil (MMF) versus methotrexate (MTX) in non-infectious ocular inflammatory disease (NIOID). METHODS The study was performed as per the PRISMA Guidelines. A search identified all studies comparing MMF versus MTX in NIOID. Treatment result and side effects were primary outcomes. RESULTS Four studies enrolling 905 patients were identified. There was no significant difference between MMF and MTX groups in overall treatment success (OR = 0.97, P = .96), treatment failure (OR = 0.86, P = .85). MTX showed a significantly improved effect in cases involving posterior uveitis and panuveitis (OR = 0.41, P = .003). In addition, MTX was associated with a faster median time to treatment success and had less side effects when compared to MTX, however this was not significant. For secondary outcomes, no significant difference was found in visual acuity and resolution of macular oedema. CONCLUSION MMF is comparable to MTX in the treatment of NIOID.
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Affiliation(s)
- Mohammad Karam
- Bachelor of Medicine and Bachelor of Surgery (MBChB), School of Medicine, University of Leeds, Leeds, UK.,Farwaniya Hospital, Ministry of Health, State of Kuwait
| | - Abdulmalik Alsaif
- Bachelor of Medicine and Bachelor of Surgery (MBChB), School of Medicine, University of Leeds, Leeds, UK.,West Midlands, West Midlands, UK
| | | | - Amrit Hayre
- Bachelor of Medicine and Bachelor of Surgery (MBChB), School of Medicine, University of Leeds, Leeds, UK.,Whittington Health NHS Trust, London, UK
| | | | - Ahmed Aldubaikhi
- Bachelor of Medicine and Surgery (MBBS), College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Narvair Kahlar
- Bachelor of Medicine and Bachelor of Surgery (MBChB), School of Medicine, University of Leeds, Leeds, UK.,Sandwell and West Birmingham Hospitals NHS Trust, West Midlands, UK
| | - Salem Al-Mutairi
- Senior Consultant Ophthalmic Surgeon (M.D, FRCSC, External Eye Diseases, Cornea, Refractive Surgery and Uveitis), Head of Uveitis Unit, Al-Bahar Eye Center, Ministry of Health of Kuwait, State of Kuwait.,Program Director of Kuwait Board of Ophthalmology, Kuwait Institute of Medical Specialities (KIMS), State of Kuwait
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WANG QM, GAO J, ZHANG YL, WANG X, PANG YJ. Effects of Qingli Gandan decoction on IL-23/IL-17 in rats with experimental autoimmune uveitis. FOOD SCIENCE AND TECHNOLOGY 2022. [DOI: 10.1590/fst.69122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
| | - Juan GAO
- Tianjin Key Laboratory of Ophthalmology and Visual Science, China
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Zhang J, Liu Z, Tao C, Lin X, Zhang M, Zeng L, Chen X, Song H. Cationic nanoemulsions with prolonged retention time as promising carriers for ophthalmic delivery of tacrolimus. Eur J Pharm Sci 2020; 144:105229. [PMID: 31958581 DOI: 10.1016/j.ejps.2020.105229] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 01/07/2020] [Accepted: 01/16/2020] [Indexed: 12/11/2022]
Abstract
Tacrolimus, also known as FK506, is a first-line drug for the topical treatment of immune-mediated inflammatory anterior ocular diseases (IIAODs). However, due to its limited water solubility, hydrophobic nature and relatively high molecular weight, topical application of FK506 features poor bioavailability. Numbers of formulations have been attempted to enhance the erratic bioavailability of FK506 through various techniques. But until now, none of them could satisfy the clinical needs completely. Here, a novel formulation of FK506, FK506-loaded cationic nanoemulsions (FK506 CNE), was developed to prolong the precorneal residence time of FK506, thereby enhancing the bioavailability of FK506 for IIAODs therapy. FK506 CNE was prepared by high-pressure homogenization, and its composition was screened and optimized by single-factor experiments. The FK506 CNE showed spherical morphology with a mean diameter of 178.8 ± 2.7 nm and a zeta potential of +25.6 ± 0.6 mV. Results from in vivo gamma scintigraphy studies proved that the precorneal residence time of FK506 CNE was significantly increased, compared with FK506-loaded neutral nanoemulsions (FK506 NE) and saline. The data of aqueous humor pharmacokinetic study in rabbits showed that the relative bioavailability of FK506 CNE was 1.68-fold and 1.77-fold of FK506 NE and the marketed FK506 eye drops (Talymus®), respectively. Finally, hematoxylin and eosin staining images and in vitro cytotoxicity data confirmed the safety of the FK506 CNE. Taking all these into consideration, we propose that FK506 CNE is a promising topical ophthalmic nanoformulation for the management of IIAODs.
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Affiliation(s)
- Jialiang Zhang
- Department of Pharmacy, Dong Fang Hospital (900 Hospital of the Joint Logistics Team), School of Medicine, Xiamen University, Fuzhou 350025, PR China
| | - Zhihong Liu
- Department of Pharmacy, Dong Fang Hospital (900 Hospital of the Joint Logistics Team), School of Medicine, Xiamen University, Fuzhou 350025, PR China
| | - Chun Tao
- Department of Pharmacy, Dong Fang Hospital (900 Hospital of the Joint Logistics Team), School of Medicine, Xiamen University, Fuzhou 350025, PR China
| | - Xin Lin
- Department of Pharmacy, Dong Fang Hospital (900 Hospital of the Joint Logistics Team), School of Medicine, Xiamen University, Fuzhou 350025, PR China
| | - Minxin Zhang
- Department of Pharmacy, Dong Fang Hospital (900 Hospital of the Joint Logistics Team), School of Medicine, Xiamen University, Fuzhou 350025, PR China
| | - Lingjun Zeng
- Department of Pharmacy, Dong Fang Hospital (900 Hospital of the Joint Logistics Team), School of Medicine, Xiamen University, Fuzhou 350025, PR China
| | - Xu Chen
- Department of Pharmacy, Dong Fang Hospital (900 Hospital of the Joint Logistics Team), School of Medicine, Xiamen University, Fuzhou 350025, PR China
| | - Hongtao Song
- Department of Pharmacy, Dong Fang Hospital (900 Hospital of the Joint Logistics Team), School of Medicine, Xiamen University, Fuzhou 350025, PR China.
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Yang H, Qi B, Ding N, Jiang F, Jia F, Luo Y, Xu X, Wang L, Zhu Z, Liu X, Tu P, Shi S. Polyketides from Alternaria alternata MT-47, an endophytic fungus isolated from Huperzia serrata. Fitoterapia 2019; 137:104282. [PMID: 31381956 DOI: 10.1016/j.fitote.2019.104282] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 07/28/2019] [Accepted: 07/28/2019] [Indexed: 12/29/2022]
Abstract
Four new polyketides, alternatains A-D (1-4), along with 17 known compounds (5-21) were obtained from the solid substrate fermentation cultures of Alternaria alternata MT-47, an endophytic fungus isolated from the medicinal plant of Huperzia serrata. Their structures were elucidated by extensive spectroscopic and spectrometric techniques (1D and 2D NMR, IR, and HRESIMS) and calculated electronic circular dichroism (ECD) method. Compounds 4, 6, 15, and 21 exhibited inhibitory activities on ATP release of thrombin-activated platelets with IC50 values in the range of 18.2-68.8 μM.
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Affiliation(s)
- Hongyun Yang
- Modern Research Center for Traditional Chinese Medicine, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing 100029, People's Republic of China
| | - Bowen Qi
- Modern Research Center for Traditional Chinese Medicine, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing 100029, People's Republic of China
| | - Ning Ding
- Modern Research Center for Traditional Chinese Medicine, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing 100029, People's Republic of China
| | - Fangfang Jiang
- Modern Research Center for Traditional Chinese Medicine, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing 100029, People's Republic of China
| | - Fangfang Jia
- Modern Research Center for Traditional Chinese Medicine, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing 100029, People's Republic of China
| | - Yuan Luo
- Modern Research Center for Traditional Chinese Medicine, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing 100029, People's Republic of China
| | - Xiping Xu
- Modern Research Center for Traditional Chinese Medicine, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing 100029, People's Republic of China
| | - Lili Wang
- Modern Research Center for Traditional Chinese Medicine, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing 100029, People's Republic of China
| | - Zhixiang Zhu
- Modern Research Center for Traditional Chinese Medicine, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing 100029, People's Republic of China
| | - Xiao Liu
- Modern Research Center for Traditional Chinese Medicine, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing 100029, People's Republic of China
| | - Pengfei Tu
- Modern Research Center for Traditional Chinese Medicine, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing 100029, People's Republic of China
| | - Shepo Shi
- Modern Research Center for Traditional Chinese Medicine, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing 100029, People's Republic of China; Beijing Key Lab for Quality Evaluation of Chinese Meteria Medica, Beijing University of Chinese Medicine, Beijing 100029, People's Republic of China.
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LaMattina KC, Escott SM, Malalis JF, Mai D, Harada Y, Goldstein DA. The Influence of Race and Sex on the Side Effect Profile of Methotrexate in the Treatment of Uveitis. Ocul Immunol Inflamm 2018; 27:1160-1164. [DOI: 10.1080/09273948.2018.1498905] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Kara C. LaMattina
- Ophthalmology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Sarah M. Escott
- Ophthalmology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Julia F. Malalis
- Ophthalmology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - David Mai
- Ophthalmology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Debra A. Goldstein
- Ophthalmology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
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Garg V, Suri R, Jain GK, Kohli K. Proglycosomes: A novel nano-vesicle for ocular delivery of tacrolimus. Colloids Surf B Biointerfaces 2017; 157:40-47. [DOI: 10.1016/j.colsurfb.2017.05.049] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 05/12/2017] [Accepted: 05/17/2017] [Indexed: 10/19/2022]
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Lodhi SA, Reddy JL, Peram V. Clinical spectrum and management options in Vogt-Koyanagi-Harada disease. Clin Ophthalmol 2017; 11:1399-1406. [PMID: 28848322 PMCID: PMC5557111 DOI: 10.2147/opth.s134977] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose The aim of this study was to describe the clinical features, treatment options, and visual outcome of Vogt–Koyanagi–Harada (VKH) disease patients over a 9-year period. Method A retrospective chart analysis of 32 patients with VKH, from January 2007 to December 2015, at a tertiary care government medical college eye hospital in South India. Results A total of 32 patients were diagnosed with VKH. The mean age at diagnosis was 32.03±8.8 years. There were 24 patients (42 eyes) with acute VKH and eight patients (16 eyes) with recurrent/chronic VKH. The mean baseline best-corrected visual acuity on presentation in the acute VKH group was 5/60 (1.114±0.565) and at last follow-up it was 6/9 (0.225±0.157). Intravenous methyl prednisolone (IVMP) was administered for 3 days to all patients with acute and recurrent VKH, followed by posterior subtenon triamcinolone (40 mg/mL) and oral azathioprine. Conclusion VKH-related uveitis is more common in the female gender in this South Indian population. Posterior uveitis is the most common initial manifestation. Initial aggressive treatment with IVMP, peribulbar long-acting corticosteroids, and immunosuppressives, avoiding side effects of systemic steroids, gives a good visual outcome without recurrences. Cases of unilateral VKH, seen in six patients, are the initial manifestations in the natural course of the disease, which if managed aggressively at the acute stage prevents recurrence in the other eye.
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Affiliation(s)
- Sikander Ak Lodhi
- Department of Ophthalmology, Osmania Medical College/Sarojini Devi Eye Hospital, Hyderabad, Telangana, India
| | - Jm Lokabhi Reddy
- Department of Ophthalmology, Osmania Medical College/Sarojini Devi Eye Hospital, Hyderabad, Telangana, India
| | - Venkataratnam Peram
- Department of Ophthalmology, Osmania Medical College/Sarojini Devi Eye Hospital, Hyderabad, Telangana, India
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The Effectiveness of Pre- and Postoperative Infliximab in Controlling Behçet's Disease Posterior Uveitis in Patients Undergoing Vitrectomy: A Preliminary Study. J Ophthalmol 2017; 2017:8168369. [PMID: 28484648 PMCID: PMC5397727 DOI: 10.1155/2017/8168369] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 02/04/2017] [Accepted: 02/08/2017] [Indexed: 11/18/2022] Open
Abstract
Purpose. To evaluate the short-term effectiveness of infliximab in controlling ocular manifestations in Behçet's Disease (BD) patients candidate for pars plana vitrectomy, if given in a regimen before and after the planned procedure. Patients and Methods. 30 eyes of 27 adult male BD patients with a mean age of 35.56 yrs presented with refractory posterior uveitis not responding to immunosuppressive drugs and candidate for vitrectomy were included. Infliximab was given in a dose of 5 mg/kg intravenous infusion once every two weeks for 3 treatment sessions before the intended vitrectomy followed by 3 treatment sessions at two-week intervals, after vitrectomy. Results. Improvement of ocular manifestations was noted in all eyes, with complete resolution in 26 eyes (87%). Visual acuity improved from 0.23 ± 0.11 to 0.38 ± 0.17 (p ≤ 0.2), ESR decreased from 65.92 mm/hr ± 17.32 SD to 24.93 mm/hr ± 5.28 SD at the last treatment cycle (p ≤ 0.1). The mean daily dose of systemic corticosteroids was tapered from 44.54 mg/d ± 2.89 to 8.48 mg/d ± 6.38 (p ≤ 0.2), and no relapses were noted during the follow-up period. Conclusion. Infliximab may be safe and effective in controlling posterior uveitis and inducing remissions if given in a regimen before and after vitrecomy in BD patients.
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The Effectiveness of Intraocular Methotrexate in the Treatment of Posterior Uveitis in Behçet's Disease Patients Compared to Retrobulbar Steroids Injection. J Ophthalmol 2016; 2016:1678495. [PMID: 28070412 PMCID: PMC5187492 DOI: 10.1155/2016/1678495] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 10/24/2016] [Accepted: 11/14/2016] [Indexed: 11/18/2022] Open
Abstract
Aim of Work. To evaluate the efficacy of intravitreal methotrexate (MTX) compared to retrobulbar triamcinolone acetonide (TAA), in controlling posterior segment involvement and inducing remissions among Behçet's disease (BD) patients. Study Design. This is a cross-sectional nonrandomized comparative study. Patients and Methods. 31 adult BD male patients with a mean disease duration of 5.45 years who presented with bilateral posterior segment involvement were included. Each patient received intravitreal injection of 400 μg/0.1 mL (MTX) for the right eye (Group A) and 1 mL of retrobulbar 40 mg/mL TAA for the left eye (Group B). Results. 90% of eyes showed complete improvement of anterior chamber reaction, whereas an improvement in vitreous activity in 77% with no significant differences between both groups (p ≤ 0.1). BCVA improved in 77.4% eyes (Group A) compared to 87.1% (Group B) (p ≤ 0.4). Relapses were noted in 11 eyes (35.5%), in group A, with the mean duration of remission being 19.1 weeks ± 2.13 compared to 7.35 ± 2.8 in 20 eyes (64.5%) in group B (p ≤ 0.1). Conclusion. No statistical differences were found between both treatment modalities; however, based on clinical observations, intravitreal MTX may ensure better control of inflammatory reaction and may encourage longer remission as compared to retrobulbar TAA in BD patients.
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Sng CCA, Ang M, Barton K. Uveitis and glaucoma: new insights in the pathogenesis and treatment. PROGRESS IN BRAIN RESEARCH 2015; 221:243-69. [PMID: 26518082 DOI: 10.1016/bs.pbr.2015.06.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Glaucoma is a potentially blinding complication of uveitis, where intraocular inflammation, secondary corticosteroid response, and varying types and degrees of angle abnormalities contribute to its pathogenesis. Management of uveitic glaucoma remains challenging. Treatment is targeted at reducing the inflammation and lowering the intraocular pressure. Recent studies have highlighted the role of viruses, such as cytomegalovirus, herpes simplex virus, and more recently Ebola virus, in the pathogenesis of uveitic glaucoma. Antiviral therapy may be beneficial in eyes with detectable viral DNA. The success of glaucoma surgery is decreased in eyes with uveitic glaucoma, and surgical interventions are associated with a higher incidence of postoperative complications. Novel glaucoma surgical and laser treatments may improve the predictability of surgery for uveitic glaucoma, but these require further evaluation.
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Affiliation(s)
- Chelvin C A Sng
- Glaucoma Service, Moorfields Eye Hospital, London, UK; Department of Ophthalmology, National University Health System, Singapore, Singapore; Singapore Eye Research Institute, Singapore, Singapore
| | - Marcus Ang
- Singapore Eye Research Institute, Singapore, Singapore; Singapore National Eye Centre, Singapore, Singapore
| | - Keith Barton
- Glaucoma Service, Moorfields Eye Hospital, London, UK; Department of Ophthalmology, National University Health System, Singapore, Singapore; National Institute for Health Research, Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital, London, UK; Department of Epidemiology and Genetics, Institute of Ophthalmology, University College, London, UK.
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Urzua CA, Velasquez V, Sabat P, Berger O, Ramirez S, Goecke A, Vásquez DH, Gatica H, Guerrero J. Earlier immunomodulatory treatment is associated with better visual outcomes in a subset of patients with Vogt-Koyanagi-Harada disease. Acta Ophthalmol 2015; 93:e475-80. [PMID: 25565265 DOI: 10.1111/aos.12648] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 11/24/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate clinical outcomes of first-line immunomodulatory therapy (IMT) and prednisone alone or late IMT in Vogt-Koyanagi-Harada disease. METHODS Retrospective cohort study of 152 patients with Vogt-Koyanagi-Harada disease evaluated in a referral uveitis clinic in Chile from 1985 to 2011. Medical records of these patients were reviewed. Demographic data, clinical evaluation, type of treatment, functional outcomes, glucocorticoid (GC) dose and complications were recorded. Multivariate logistic regression was used to identify prognostic factors of poor response to GC. RESULTS There were no significant differences between first-line IMT group and prednisone alone/late IMT group in terms of visual acuity (VA) improvement, complications and GC sparing effect. There was a trend for a higher frequency of systemic adverse effects leading to discontinuation of treatment in patients receiving IMT than in those receiving prednisone (14.6% and 6.5%, respectively). The subgroup of patients with poor response to GC who showed functional improvement had a significantly earlier time to IMT initiation than the patients who had no improvement. We identified following prognostic factors of poor response to GC: VA ≤ 20/200, fundus depigmentation, chronic disease and tinnitus at diagnosis. Patients with a prognostic factor (excluding tinnitus) and VA improvement had an earlier IMT initiation than those who had worse functional outcome. CONCLUSION There were no differences in outcomes between first-line IMT and prednisone alone/late IMT in the entire VKH group. However, in a subset of patients, there was a significant better functional outcome with earlier IMT initiation.
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Affiliation(s)
- Cristhian A. Urzua
- Uveitis Department; Salvador's Hospital; Santiago Chile
- Ophthalmology Department; University of Chile; Santiago Chile
- Physiology Program; Faculty of Medicine; University of Chile; Santiago Chile
| | - Victor Velasquez
- Uveitis Department; Salvador's Hospital; Santiago Chile
- Ophthalmology Department; University of Chile; Santiago Chile
| | - Pablo Sabat
- Uveitis Department; Salvador's Hospital; Santiago Chile
- Ophthalmology Department; University of Chile; Santiago Chile
| | - Osvaldo Berger
- Ophthalmology Department; Catholic University; Santiago Chile
| | | | - Annelise Goecke
- Physiology Program; Faculty of Medicine; University of Chile; Santiago Chile
- Rheumatology Department; University of Chile Clinical Hospital; Santiago Chile
| | | | - Hector Gatica
- Physiology Program; Faculty of Medicine; University of Chile; Santiago Chile
- Rheumatology Department; University of Chile Clinical Hospital; Santiago Chile
| | - Julia Guerrero
- Physiology Program; Faculty of Medicine; University of Chile; Santiago Chile
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Biologic therapy for refractory scleritis: a new treatment perspective. Int Ophthalmol 2015; 35:903-12. [DOI: 10.1007/s10792-015-0124-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 08/23/2015] [Indexed: 12/12/2022]
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Knickelbein JE, Jaworski L, Hasan J, Kaushal P, Sen HN, Nussenblatt RB. Therapeutic options for the treatment of non-infectious uveitis. EXPERT REVIEW OF OPHTHALMOLOGY 2015. [DOI: 10.1586/17469899.2015.1047826] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Abstract
Uveitis is a group of inflammatory ocular conditions that cause significant visual morbidity around the world. Many of the cases of blindness secondary to uveitis can be avoided with adequate and aggressive management of the intraocular inflammation. Steroids have been utilized in the treatment of noninfectious uveitis for more than 60 years, but their chronic use is associated with severe ocular and systemic side-effects. Ophthalmologists are often not familiar with the systemic steroid-sparing agents available for the management of ocular inflammation and depend primarily on the use of corticosteroids. In this article, we review the most common agents utilized in the treatment of uveitis and their side-effect profiles.
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Affiliation(s)
- Eduardo Uchiyama
- Department of Ophthalmology , Massachusetts Eye and Ear Infirmary, Boston, Massachusetts , USA and
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Lee K, Bajwa A, Freitas-Neto CA, Metzinger JL, Wentworth BA, Foster CS. A comprehensive review and update on the non-biologic treatment of adult noninfectious uveitis: part I. Expert Opin Pharmacother 2014; 15:2141-54. [PMID: 25226529 DOI: 10.1517/14656566.2014.948417] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Treatment of adult, noninfectious uveitis remains a challenge for ophthalmologists around the world. The disease accounts for almost 10% of preventable blindness in the US and can be idiopathic or associated with infectious and systemic disorders. Strong evidence is still emerging to indicate that pharmacologic strategies presently used in rheumatologic or autoimmune disease may be translated to the treatment of intraocular inflammation. Corticosteroid monotherapy is widely regarded as wholly inappropriate, due to the unfavorable risk/benefit profile and poor long-term outcomes. Treatment plans have shifted away from low-dose, chronic corticosteroid therapy for maintenance, towards medium- to high-dose therapy for acute inflammation, followed immediately by initiation of immunomodulatory therapy. These therapies follow the 'stepladder approach', whereby least to more aggressive therapies are trialed to induce remission of inflammation, eventually without corticosteroids of any form (topical, local and systemic). AREAS COVERED This two-part review gives a comprehensive overview of the existing medical treatment options for patients with adult, noninfectious uveitis, as well as important advances for the treatment of ocular inflammation. Part I covers classic immunomodulation and latest information on corticosteroid therapy. EXPERT OPINION The hazard of chronic corticosteroid use for the treatment of adult, noninfectious uveitis is well-documented. Corticosteroid-sparing therapies, which offer a very favorable risk-benefit profile when administered properly, should be substituted.
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Affiliation(s)
- Kyungmin Lee
- Massachusetts Eye Research and Surgery Institution , 5 Cambridge Center, 8th Floor, Cambridge, MA 02142 , USA +1 617 621 6377 ; +1 617 494 1430 ;
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Barry RJ, Nguyen QD, Lee RW, Murray PI, Denniston AK. Pharmacotherapy for uveitis: current management and emerging therapy. Clin Ophthalmol 2014; 8:1891-911. [PMID: 25284976 PMCID: PMC4181632 DOI: 10.2147/opth.s47778] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Uveitis, a group of conditions characterized by intraocular inflammation, is a major cause of sight loss in the working population. Most uveitis seen in Western countries is noninfectious and appears to be autoimmune or autoinflammatory in nature, requiring treatment with immunosuppressive and/or anti-inflammatory drugs. In this educational review, we outline the ideal characteristics of drugs for uveitis and review the data to support the use of current and emerging therapies in this context. It is crucial that we continue to develop new therapies for use in uveitis that aim to suppress disease activity, prevent accumulation of damage, and preserve visual function for patients with the minimum possible side effects.
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Affiliation(s)
- Robert J Barry
- Academic Unit of Ophthalmology, Centre for Translational Inflammation, Research, University of Birmingham, UK
| | - Quan Dong Nguyen
- Stanley M Truhlsen Eye Institute, University of Nebraska Medical Center, Omaha, NE, USA
| | - Richard W Lee
- Inflammation and Immunotherapy Theme, National Institute for Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Philip I Murray
- Academic Unit of Ophthalmology, Centre for Translational Inflammation, Research, University of Birmingham, UK
| | - Alastair K Denniston
- Academic Unit of Ophthalmology, Centre for Translational Inflammation, Research, University of Birmingham, UK ; Department of Ophthalmology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Abstract
The purpose of this review is to comprehensively examine the various therapeutic agents available to treat autoimmune eye disease, their indications, clinical safety and recent developments. The stepladder approach is reviewed, including corticosteroid administration of various forms, classic immunomodulators, and newer biologic response modifiers. The authors present that corticosteroid monotherapy is almost never curative and carries significant side effects, while immunomodulatory therapy, when used appropriately as way to induce steroid-free remission, carries far less risk of causing long-term complications and provides greater potential of altering the immune system to induce a durable remission.
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Callanan DG. Novel intravitreal fluocinolone acetonide implant in the treatment of chronic noninfectious posterior uveitis. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/17469899.2.1.33] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Zierhut M, Abu El-Asrar AM, Bodaghi B, Tugal-Tutkun I. Therapy of Ocular Behçet Disease. Ocul Immunol Inflamm 2013; 22:64-76. [DOI: 10.3109/09273948.2013.866257] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Peroxisome proliferator-activated receptor-γ agonist pioglitazone suppresses experimental autoimmune uveitis. Exp Eye Res 2013; 116:291-7. [DOI: 10.1016/j.exer.2013.09.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 09/11/2013] [Accepted: 09/27/2013] [Indexed: 12/31/2022]
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Abstract
PURPOSE Rheumatoid arthritis (RA) often presents with ocular complications: typically dry eye, peripheral corneal ulcer, and scleritis. We report for the first time a case of severe scleritis with RA, accompanying atypical continuous keratitis, which apparently differs from typical peripheral ulcerative keratitis (PUK). METHODS Observational case report. RESULTS A 68-year-old woman with RA presented at our hospital complaining of worsening arthritis accompanying ocular injection and discharge. On examination, nodular scleritis and peripheral corneal infiltration were noted. In addition to administering topical steroid and antibiotics, cyclosporine and an oral steroid were added because of the patient's worsening scleritis. Despite gradual improvement of the scleritis, the efficacy of the additional treatments was limited. Four months after initial treatment, the patient presented with uveitis, thought to be caused by a herpetic virus. Antivirus treatment was effective for the uveitis, but atypical continuous keratitis suddenly appeared. The keratitis was located from 4-o'clock to 10-o'clock positions continuously in the midperipheral cornea and apparently differed from herpetic keratitis or PUK as typically seen in RA cases. Immune reaction was suspected, and the keratitis improved within 2 weeks. After that, the introduction of an anti-tumor necrosis factor α drug (infliximab) completely resolved the severe scleritis and there was no recurrence of ocular inflammation. CONCLUSION As is shown in this case, RA can present with atypical continuous keratitis, thought to be a manifestation of an immunologic reaction other than PUK. In addition, although immunosuppressants are often used for the treatment of RA with scleritis, the efficacy is limited. Infliximab may be a useful treatment for treatment-resistant scleritis.
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Heo J, Sepah YJ, Yohannan J, Renner M, Akhtar A, Gregory A, Shulman M, Do DV, Nguyen QD. The role of biologic agents in the management of non-infectious uveitis. Expert Opin Biol Ther 2012; 12:995-1008. [PMID: 22780091 DOI: 10.1517/14712598.2012.688021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Uveitis is an intriguing group of disorders characterized by inflammation of the uveal tract. Due to the potential grave consequences of the disease process, it is important to assess the various therapeutic options available for treating uveitis, and their outcomes. AREAS COVERED This review discusses the use of conventional agents in the management of uveitis, including discussion of the molecular and clinical properties of corticosteroids, antimetabolites, calcineurin inhibitors and alkylating agents and their side effects. In addition, it also discusses the molecular and clinical properties of novel biologic agents and their side effects. Moreover, recommendations as to when biologic agents should be employed are also discussed. EXPERT OPINION We recommend that in general (except in selected cases of Adamantiades-Behçet's disease) biologics should not be used as a first-line therapy for uveitis due to inconvenience, high cost, and potential immunosuppressive effects. However, many biologics are potent in inducing drug-free remission of uveitis and may be employed to manage recurrent diseases or diseases not responsive to conventional agents.
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Affiliation(s)
- Jangwon Heo
- Johns Hopkins University School of Medicine, Wilmer Eye Institute, Johns Hopkins Hospital, Retinal Imaging Research and Reading Center, 600 North Wolfe Street, Maumenee 745, Baltimore, MD 21287, USA
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Systemic treatment of vitreous inflammation. Mediators Inflamm 2012; 2012:936721. [PMID: 23028205 PMCID: PMC3457724 DOI: 10.1155/2012/936721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 08/21/2012] [Indexed: 02/07/2023] Open
Abstract
Non infectious vitreous inflammation is often vision threatening and can be associated with potentially life-threatening systemic conditions. Treatment is often challenging as it involves systemic medications that can be associated with adverse effects. The classes of drugs are ever expanding and include corticosteroids, antimetabolites, alkylating agents, T-cell and calcineurin agents, biologic agents, and interferons. Each class of systemic therapy for non-infectious vitreous inflammation is reviewed. We discuss the mechanisms of action, usual clinical dosages, the specific conditions that are treated, the adverse effects, and usual course of treatment for each class of therapy.
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Cunningham ET, Pasadhika S, Suhler EB, Zierhut M. Drug-induced inflammation in patients on TNFα inhibitors. Ocul Immunol Inflamm 2012; 20:2-5. [PMID: 22324894 DOI: 10.3109/09273948.2011.644383] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Vadlapudi AD, Patel A, Cholkar K, Mitra AK. Recent Patents on Emerging Therapeutics for the Treatment of Glaucoma, Age Related Macular Degeneration and Uveitis. RECENT PATENTS ON BIOMEDICAL ENGINEERING 2012; 5:83-101. [PMID: 25414810 PMCID: PMC4235159 DOI: 10.2174/1874764711205010083] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Advancements in the field and rising interest among pharmaceutical researchers have led to the development of new molecules with enhanced therapeutic activity. Design of new drugs which can target a particular pathway and/or explore novel targets is of immense interest to ocular pharmacologists worldwide. Delivery of suitable pharmacologically active agents at proper dose (within the therapeutic window) to the target tissues without any toxicity to the healthy ocular tissues still remain an elusive task. Moreover, the presence of static and dynamic barriers to drug absorption including the corneal epithelium (lipophilic), corneal and scleral stroma (hydrophilic), conjunctival lymphatics, choroidal vasculature and the blood-ocular barriers also pose a significant challenge for achieving therapeutic drug concentrations at the target site. Although many agents are currently available, new compounds are being introduced for treating various ocular diseases. Deeper understanding of the etiology and complex mechanisms associated with the disease condition would aid in the development of potential therapeutic candidates. Novel small molecules as well as complex biotechnology derived macromolecules with superior efficacy, safety and tolerability are being developed. Therefore, this review article provides an overview of existing drugs, treatment options, advances in emerging therapeutics and related recent patents for the treatment of ocular disorders such as glaucoma, age related macular degeneration (AMD) and uveitis.
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Affiliation(s)
- Aswani Dutt Vadlapudi
- Division of Pharmaceutical Sciences, School of Pharmacy, University of Missouri-Kansas City, 2464 Charlotte Street, Kansas City, MO 64108-2718, USA
| | - Ashaben Patel
- Division of Pharmaceutical Sciences, School of Pharmacy, University of Missouri-Kansas City, 2464 Charlotte Street, Kansas City, MO 64108-2718, USA
| | - Kishore Cholkar
- Division of Pharmaceutical Sciences, School of Pharmacy, University of Missouri-Kansas City, 2464 Charlotte Street, Kansas City, MO 64108-2718, USA
| | - Ashim K. Mitra
- Division of Pharmaceutical Sciences, School of Pharmacy, University of Missouri-Kansas City, 2464 Charlotte Street, Kansas City, MO 64108-2718, USA
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A randomized trial of tacrolimus versus tacrolimus and prednisone for the maintenance of disease remission in noninfectious uveitis. Ophthalmology 2012; 119:1223-30. [PMID: 22381809 DOI: 10.1016/j.ophtha.2011.12.030] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2011] [Revised: 12/17/2011] [Accepted: 12/19/2011] [Indexed: 11/24/2022] Open
Abstract
PURPOSE To compare tacrolimus monotherapy with tacrolimus and prednisone therapy for the maintenance of disease remission in subjects with noninfectious posterior segment intraocular inflammation (PSII). DESIGN Randomized, controlled, phase 2b, open-label, dual-center noninferiority trial. PARTICIPANTS Fifty-eight patients with sight-threatening PSII. METHODS Patients requiring a second-line systemic immunosuppressive agent to control their PSII were treated with therapeutic doses of oral tacrolimus. Those subjects who subsequently were able to taper their prednisone dose to 10 mg daily without disease reactivation were assigned randomly either to stop prednisone or to continue 7.5 to 10 mg prednisone daily for 9 months. MAIN OUTCOME MEASURES Change in logarithm of the minimum angle of resolution (logMAR) visual acuity (VA) and rate of patient withdrawal resulting from treatment inefficacy or intolerance. RESULTS Thirty-five patients successfully tapered their prednisone to 10 mg daily. Of these, 16 were allocated randomly to receive tacrolimus monotherapy and 19 to continue taking prednisone and tacrolimus dual therapy. The difference in the mean change in VA for monotherapy compared with the dual therapy group was less than 1 logMAR letter (logMAR, -0.008; 95% confidence interval, -0.108 to 0.092; P = 0.870). The proportion of patients who tolerated treatment and maintained disease remission for 9 months after randomization also was similar in both groups (monotherapy, 62.5%; dual therapy, 68.4%; P = 0.694). All monotherapy treatment failures were the result of disease reactivation, whereas 50% of dual-therapy failures were the result of drug intolerance. CONCLUSIONS This study provides preliminary evidence that corticosteroids can be withdrawn in tacrolimus-treated patients who are able to achieve control of PSII with 10 mg prednisone daily, and any advantage of dual therapy in the prevention of disease reactivation was offset by its greater treatment intolerance. These findings support the further evaluation of corticosteroid-free treatment in future phase 3 trials (International Standard Randomised Controlled Trial Number Register identification, ISRCTN46576063). FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.
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Durrani K, Zakka FR, Ahmed M, Memon M, Siddique SS, Foster CS. Systemic Therapy With Conventional and Novel Immunomodulatory Agents for Ocular Inflammatory Disease. Surv Ophthalmol 2011; 56:474-510. [DOI: 10.1016/j.survophthal.2011.05.003] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Revised: 05/18/2011] [Accepted: 05/24/2011] [Indexed: 12/19/2022]
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Siddique SS, Shah R, Suelves AM, Foster CS. Road to remission: a comprehensive review of therapy in uveitis. Expert Opin Investig Drugs 2011; 20:1497-515. [PMID: 21936708 DOI: 10.1517/13543784.2011.617741] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Although uveitis remains the third leading cause of preventable blindness in the US, the care and management of patients with uveitis and ocular inflammatory disease sit poised to make evolutionary if not revolutionary changes in the years ahead. This review serves to highlight important advances in the pharmacologic options available for the treatment of uveitis and ocular inflammation. AREAS COVERED Advances in steroid therapy (both topical and extended delivery), updates in the clinical safety of systemic immune modulation, and the emerging therapies for uveitis and ocular inflammatory disease are some of the areas covered in this review. EXPERT OPINION Corticosteroids have been the mainstay in the care of patients with ocular inflammatory disorders for many years. Indeed, some physicians still use only steroids for treating inflamed eyes. However, the mission is remission of all corticosteroids in order to prevent the complications associated with long-term corticosteroid use. The goal is to achieve quiescence through aggressive use of corticosteroids to extinguish the fire and then move along to achieve steroid-free remission through immunosuppressant agents.
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Affiliation(s)
- Sana S Siddique
- Massachusetts Eye Research and Surgery Institution, 5 Cambridge Center, 8th floor, Cambridge, MA 02412 , USA.
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Chang PY, Giuliari GP, Shaikh M, Thakuria P, Makhoul D, Foster CS. Mycophenolate mofetil monotherapy in the management of paediatric uveitis. Eye (Lond) 2011; 25:427-35. [PMID: 21423146 DOI: 10.1038/eye.2011.23] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To evaluate effectiveness and safety of mycophenolate mofetil (MMF) monotherapy in paediatric autoimmune uveitis. METHODS We reviewed medical records of patients, 18 years of age or younger, with autoimmune uveitis treated with MMF at our practice from 2005 to 2009. The dose and duration of MMF therapy, inflammation status, visual acuity, previous immunomodulatory therapies, and adverse effects were recorded. In addition, the following subgroups were defined: (1) Durable Disease Control: patients whose uveitis remained quiescent for at least 2 years on MMF monotherapy, with no more than two flare-ups successfully treated with an increase in MMF dosage and/or a short course (<1 month) of corticosteroids; (2) Short-term Inflammation Control: patients whose uveitis remained quiescent for less than 2 years, with no more than one flare-up successfully treated with an increase in MMF dosage and/or a short course of corticosteroids, or who initially achieved inflammation control but discontinued MMF because of significant adverse effects. RESULTS A total of 38 out of 52 patients (73.1%) obtained inflammation control following 2 months of MMF monotherapy, achieving ≤ 0.5+ grading in anterior chamber cell/flare and vitreous haze. In the cross-sectional analysis, 25 patients (48.1%) met the criteria for Durable Disease Control, and 13 others (25.0%) qualified for Short-term Inflammation Control. Visual acuity remained stable or improved in 94.2% of the study population. Six patients (11.5%) discontinued MMF because of significant adverse effects, the most common of which was gastrointestinal disturbances. CONCLUSION MMF monotherapy appears to be an effective and safe treatment in paediatric autoimmune uveitis.
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Affiliation(s)
- P Y Chang
- Massachusetts Eye Research and Surgery Institution, Cambridge, MA, USA
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Stübiger N, Winterhalter S, Pleyer U, Doycheva D, Zierhut M, Deuter C. [Janus-faced?: Effects and side-effects of interferon therapy in ophthalmology]. Ophthalmologe 2011; 108:204-12. [PMID: 21350868 DOI: 10.1007/s00347-010-2261-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Interferon alpha (IFN-α) and interferon beta (IFN-β) are naturally occurring cytokines, which belong to the type I interferons and share the same receptor leading to very similar therapeutic effects. The immunomodulatory effect of type I interferons includes modulation of antibody production, inhibition of lymphocyte proliferation, inhibition of delayed-type hypersensitivity and enhancement of T-cell and NK-cell cytotoxicity. An increasing number of open clinical studies and case reports have demonstrated the efficacy of IFN-α for severe ocular inflammation in patients with Behçet's disease and of interferon-β, which has been used mainly for the treatment of multiple sclerosis.
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Affiliation(s)
- N Stübiger
- Augenklinik, Charite Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin, Deutschland.
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Abstract
INTRODUCTION Uveitis is a challenging disease covering both infectious and noninfectious conditions. The current treatment strategies are hampered by the paucity of randomized controlled trials and trials comparing the efficacy of different agents. AREAS COVERED This review describes the current and future treatments of uveitis. A literature search was performed in PUBMED from 1965 to 2010 on drugs treating ocular inflammation with emphasis placed on more recent, larger studies. Readers should gain a basic understanding of current treatment strategies beginning with corticosteroids and transitioning to steroid sparing agents. Steroid sparing agents include antimetabolites such as methotrexate, azathioprine and mycophenolate mofetil; calcineurin inhibitors which include cyclosporine, tacrolimus; alkylating agents which include cyclophosphamide and chlorambucil; and biologics which include the TNF-α inhibitors infliximab, adalimumab and etanercept and daclizumab, IFN-α(2a) and rituximab. EXPERT OPINION Newer agents are typically formulated from existing drugs or developed based on new advances in immunology. Future treatment will require a better understanding of the mechanisms involved in autoimmune diseases and better delivery systems in order to provide targeted treatment with minimal side effects.
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Affiliation(s)
- Theresa Larson
- National Eye Institute, National Institutes of Health, Bethesda, MD, USA.
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Abstract
IMPORTANCE OF THE FIELD The term 'uveitis' covers a broad spectrum of ocular inflammation affecting the iris, ciliary body, and/or the choroid, all of which comprise the uveal tract. Severe cases of uveitis need be treated aggressively to prevent damage caused by chronic inflammation. Untreated or poorly managed cases can lead to ciliary body dysfunction, inadequate aqueous production, chorioretinal damage, and possibly blindness. AREAS COVERED IN THIS REVIEW There are many medications that can be used to treat uveitis. Corticosteroids are available in several formulations: topical drops, regional injections, oral and intravenous. Immunomodulatory agents that can be used for uveitis are antimetabolites, T-cell inhibitors, alkylating agents, and biologic response modifiers. These medications, their appropriate uses, and side effect monitoring will be detailed. WHAT THE READER WILL GAIN There is a stepladder approach to treatment of ocular inflammation. Corticosteroids are the treatment of choice for treating acute flares. Steroid free remission is the goal of therapy and can be achieved with the use of chemotherapeutic agents. Which medications are appropriate and how to escalate therapy will be reviewed. TAKE HOME MESSAGE Chronic systemic corticosteroid therapy is not an acceptable long treatment plan for uveitis, unless all other medications have failed. Steroid sparing immunosuppressive therapy should be pursued as soon as acute flares of uveitis have been controlled.
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Affiliation(s)
- Frank F Lee
- Massachusetts Eye Research and Surgery Institution, 5 Cambridge Center, 8th Floor, Cambridge, MA 02142, USA
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Kaçmaz RO, Kempen JH, Newcomb C, Daniel E, Gangaputra S, Nussenblatt RB, Rosenbaum JT, Suhler EB, Thorne JE, Jabs DA, Levy-Clarke GA, Foster CS. Cyclosporine for ocular inflammatory diseases. Ophthalmology 2010; 117:576-84. [PMID: 20031223 DOI: 10.1016/j.ophtha.2009.08.010] [Citation(s) in RCA: 178] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2009] [Revised: 07/02/2009] [Accepted: 08/04/2009] [Indexed: 11/28/2022] Open
Abstract
PURPOSE To evaluate the clinical outcomes of cyclosporine treatment for noninfectious ocular inflammation. DESIGN Retrospective cohort study. PARTICIPANTS A total of 373 patients with noninfectious ocular inflammation managed at 4 tertiary ocular inflammation clinics in the United States observed to use cyclosporine as a single noncorticosteroid immunosuppressive agent to their treatment regimen, between 1979 and 2007 inclusive. METHODS Participants were identified from the Systemic Immunosuppressive Therapy for Eye Diseases Cohort Study. Demographic and clinical characteristics, including dosage of cyclosporine and main outcome measures, were obtained for every eye of every patient at every visit via medical record review by trained expert reviewers. MAIN OUTCOME MEASURES Control of inflammation, sustained control after reducing corticosteroid dosages, and discontinuation of therapy because of toxicity. RESULTS Of the 373 patients (681 eyes) initiating cyclosporine monotherapy, 33.4% by 6 months and 51.9% by 1 year gained sustained, complete control of inflammation over at least 2 visits spanning at least 28 days. Approximately 25% more improved to a level of slight inflammatory activity by each of these time points. Corticosteroid-sparing success (completely controlled inflammation for at least 28 days with prednisone < or = 10 mg/day) was achieved by 22.1% by 6 months and 36.1% within 1 year. Toxicity led to discontinuation of therapy within 1 year by 10.7% of the population. Patients aged more than 55 years were more than 3-fold more likely to discontinue therapy because of toxicity than patients aged 18 to 39 years. Doses of 151 to 250 mg/day tended to be more successful than lower doses and were not associated with a higher discontinuation for toxicity rate; higher doses did not seem to offer a therapeutic advantage. CONCLUSIONS Cyclosporine, with corticosteroid therapy as indicated, was modestly effective for controlling ocular inflammation. Our data support a preference for cyclosporine adult dosing between 151 and 250 mg/day. Although cyclosporine was tolerated by the majority of patients, toxicity was more frequent with increasing age; alternative agents may be preferred for patients aged more than 55 years.
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Affiliation(s)
- R Oktay Kaçmaz
- Department of Ophthalmology, The Mount Sinai School of Medicine, New York, New York, USA
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Topical cyclosporine A as a steroid-sparing agent in steroid-dependent idiopathic ocular myositis with scleritis: a case report and review of the literature. Eye Contact Lens 2009; 35:275-8. [PMID: 19687744 DOI: 10.1097/icl.0b013e3181b4d135] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To report on a case of idiopathic orbital myositis with scleritis that was effectively controlled with topical 0.05% cyclosporine A and to provide a review of the literature on the treatment of ocular myositis with scleritis. METHODS A case report. RESULTS A 35-year-old woman presented with a longstanding history of intractable periorbital pain, redness on her left eye, and diplopia during ocular movement. Her medical history revealed that she had the same symptoms for 5 years and had used numerous prescribed medications for migraine and ocular myositis. During this period, her symptoms and signs had been lessened on systemic steroid treatment, which recurred or worsened after discontinuing or tapering the therapy. Magnetic resonance imaging scans demonstrated an isolated enlargement of the left medial rectus muscle. Laboratory examination results showed no evidence of dysthyroid ophthalmopathy or another systemic disease. Because of adverse affects of systemic corticosteroid and cyclosporine treatments, topical cyclosporine A (0.05%) and dexamethasone were administered four times daily. The patient continued to use topical 0.05% cyclosporine A for 6 months. Using only topical cyclosporine A, she currently has no recurrences of disease on the last examination after 6 months of treatment. Moreover, magnetic resonance imaging revealed a completely normal extraocular muscle configuration. CONCLUSIONS Topical 0.05% cyclosporine A may be a safe and effective long-term treatment of ocular myositis and scleritis. It should be considered as a steroid-sparing agent, particularly in recurrent disease and in those patients who experience adverse effects of systemic medications.
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Zakka FR, Chang PY, Giuliari GP, Foster CS. Current trends in the management of ocular symptoms in Adamantiades-Behçet's disease. Clin Ophthalmol 2009; 3:567-79. [PMID: 19898629 PMCID: PMC2770868 DOI: 10.2147/opth.s4445] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2009] [Indexed: 12/14/2022] Open
Abstract
Adamantiades-Behçet’s disease (ABD) is a multisystemic vasculitic disease. It is most prevalent in the Eastern Mediterranean countries and the Eastern region of Asia. Its effect on the eye can range from mild to debilitating, resulting in total blindness. A necrotizing and obliterative vasculitis affects both arteries and veins of organs. Recurrent attacks of uveitis, oral aphthous ulcers, skin lesions, and genital ulcers are common. Topical and systemic corticosteroids have been the mainstay in the treatment of ocular inflammation for many years; however, due to the several known side effects of corticosteroids and thanks to scientific advances, more novel approaches to ABD treatment have been emerging. Antimetabolites such as methotrexate and azathioprine have been utilized with the latter showing positive results. Chlorambucil has been utilized effectively for ocular manifestations of ABD. Interferon alpha has shown encouraging results in the management of refractory ocular inflammation associated with ABD, either alone or in combination with other immunosuppressive agents. Surgical interventions to deal with complications from ABD can be safely done if adequate control of inflammation is achieved peri-operatively. Early detection and aggressive treatment, when needed, have proven to be essential in the management of this relentlessly explosive disease.
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Affiliation(s)
- Fouad R Zakka
- Massachusetts Eye Research and Surgery Institution (MERSI), Cambridge, Massachusetts, USA
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Gangaputra S, Newcomb CW, Liesegang TL, Kaçmaz RO, Jabs DA, Levy-Clarke GA, Nussenblatt RB, Rosenbaum JT, Suhler EB, Thorne JE, Foster CS, Kempen JH. Methotrexate for ocular inflammatory diseases. Ophthalmology 2009; 116:2188-98.e1. [PMID: 19748676 DOI: 10.1016/j.ophtha.2009.04.020] [Citation(s) in RCA: 209] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2008] [Revised: 04/04/2009] [Accepted: 04/07/2009] [Indexed: 11/30/2022] Open
Abstract
PURPOSE To evaluate the outcome of treatment with methotrexate for noninfectious ocular inflammation. DESIGN Retrospective cohort study. PARTICIPANTS Patients with noninfectious ocular inflammation managed at 4 tertiary ocular inflammation clinics in the United States observed to add methotrexate as a single, noncorticosteroid immunosuppressive agent to their treatment regimen, between 1979 and 2007, inclusive. METHODS Participants were identified from the Systemic Immunosuppressive Therapy for Eye Diseases Cohort Study. Demographic and clinical characteristics, including dosage, route of administration of methotrexate, and main outcome measures, were obtained for every eye of every patient at every visit via medical record review by trained expert reviewers. MAIN OUTCOME MEASURES Control of inflammation, corticosteroid-sparing effects, and incidence of and reason for discontinuation of therapy. RESULTS Among 384 patients (639 eyes) observed from the point of addition of methotrexate to an anti-inflammatory regimen, 32.8%, 9.9%, 21.4%, 14.6%, 15.1%, and 6.3%, respectively, had anterior uveitis, intermediate uveitis, posterior or panuveitis, scleritis, ocular mucous membrane pemphigoid, and other forms of ocular inflammation. In these groups, complete suppression of inflammation sustained for >or=28 days was achieved within 6 months in 55.6%, 47.4%, 38.6%, 56.4%, 39.5%, and 76.7%, respectively. Corticosteroid-sparing success (sustained suppression of inflammation with prednisone <or=10 mg/d) was achieved within 6 months among 46.1%, 41.3%, 20.7%, 37.3%, 36.5%, and 50.9%, respectively. Overall, success within 12 months was 66% and 58.4% for sustained control and corticosteroid sparing (<or=10 mg), respectively. Methotrexate was discontinued within 1 year by 42% of patients. It was discontinued owing to ineffectiveness in 50 patients (13%); 60 patients (16%) discontinued because of side effects, which typically were reversible with dose reduction or discontinuation. Remission was seen in 43 patients, with 7.7% remitting within 1 year of treatment. CONCLUSIONS Our data suggest that adding methotrexate to an anti-inflammatory regimen not involving other noncorticosteroid immunosuppressive drugs is moderately effective for management of inflammatory activity and for achieving corticosteroid-sparing objectives, although many months may be required for therapeutic success. Methotrexate was well tolerated by most patients, and seems to convey little risk of serious side effects during treatment.
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Affiliation(s)
- Sapna Gangaputra
- Department of Ophthalmology, The Fundus Photograph Reading Center, University of Wisconsin, Madison, Wisconsin, USA
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Abstract
Pediatric non-infectious uveitis remains a rare but potentially sight-threatening group of diseases. However, early screening and treatment can improve outcomes. No single agent has proven to be efficacious in all cases. A wide variety of long-term immunomodulatory treatments are available; these agents differ in both their potency and side effect profiles. Corticosteroids remain an extremely valuable form of treatment in the short-term management of uveitis. Other major groups of immunomodulatory treatments include the calcineurin inhibitors and antimetabolites such as methotrexate, which is frequently used as the first-line agent. The biologics, including anti-tumor necrosis factor agents and interferons, are newer and potentially very useful therapies although side effects limit their use. Successful outcomes may be achieved with appropriate immunosuppressant therapy given early in the disease, although clinical trials are required to define the true efficacy of this strategy.
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Hwang J, Rodgers K, Oliver JC, Schluep T. Alpha-methylprednisolone conjugated cyclodextrin polymer-based nanoparticles for rheumatoid arthritis therapy. Int J Nanomedicine 2008; 3:359-71. [PMID: 18990945 PMCID: PMC2626937 DOI: 10.2147/ijn.s3217] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
A glycinate derivative of α-methylprednisolone (MP) was prepared and conjugated to a linear cyclodextrin polymer (CDP) with a loading of 12.4% w/w. The polymer conjugate (CDP-MP) self-assembled into nanoparticles with a size of 27 nm. Release kinetics of MP from the polymer conjugate showed a half-life (t1/2) of 50 h in phosphate buffer solution (PBS) and 19 h in human plasma. In vitro, the proliferation of human lymphocytes was suppressed to a similar extent but with a delayed effect when CDP-MP was compared with free MP. In vivo, CDP-MP was administered intravenously to mice with collagen-induced arthritis and compared with free MP. CDP-MP was administered weekly for six weeks (0.07, 0.7, and 7 mg/kg/week) and MP was administered daily for six weeks (0.01, 0.1, and 1 mg/kg/day). Body weight changes were minimal in all animals. After 28 days, a significant decrease in arthritis score was observed in animals treated weekly with an intermediate or high dose of CDP-MP. Additionally, dorsoplantar swelling was reduced to baseline in animals treated with CDP-MP at the intermediate and high dose level. Histological evaluation showed a reduction in synovitis, pannus formation and disruption of architecture at the highest dose level of CDP-MP. MP administered daily at equivalent cumulative doses showed minimal efficacy in this model. This study demonstrates that conjugation of MP to a cyclodextrin-polymer may improve its efficacy, leading to lower doses and less frequent administration for a safer and more convenient management of rheumatoid arthritis.
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Kim SJ, Yu HG. The use of low-dose azathioprine in patients with Vogt-Koyanagi-Harada disease. Ocul Immunol Inflamm 2007; 15:381-7. [PMID: 17972222 DOI: 10.1080/09273940701624312] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE To evaluate treatment outcomes with low-dose azathioprine in Vogt-Koyanagi-Harada (VKH) disease patients. DESIGN Retrospective case series. METHODS Medical records of consecutive patients with VKH disease were reviewed. Azathioprine was administered in cases with corticosteroid intolerance or uncontrolled inflammation. Corticosteroid sparing effect, visual acuity, corticosteroid dose, and complication rates were evaluated. RESULTS Sixteen of 34 VKH patients included in this study underwent azathioprine therapy with systemic corticosteroid. Six patients received azathioprine in the acute uveitic phase and 10 patients in the chronic recurrent phase. A corticosteroid sparing effect was achieved in 86.5% of patients given azathioprine in the acute uveitic phase and 90.0% of patients given in the chronic recurrent phase. Median time to corticosteroid sparing effect was 3.5 months. Twelve of 16 patients showed improved activity in 1 month after initiation of azathioprine therapy. CONCLUSION Low-dose azathioprine therapy may be effective as corticosteroid sparing agent in VKH disease.
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Affiliation(s)
- Sang Jin Kim
- Department of Ophthalmology, College of Medicine, Seoul National University, Seoul, Korea
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Abstract
PURPOSE OF REVIEW To summarize general concepts of Behçet's disease, as well as present recent scientific developments in delineating the pathogenesis and treatment of this disorder. RECENT FINDINGS Large, long-term follow-up studies on patients with Behçet's disease have shown improved visual outcomes in recent years when compared with decades ago, presumably due to the more aggressive use of immunosuppressive agents. Increased T-helper cell type 1 activity and increased hypercoagulability continue to be a focus of research into the pathogenesis of the disease. Advanced oxidation protein products and a Behçet's disease activity index may be useful tools for following disease activity. Finally, studies of new treatment modalities, particularly infliximab, interferon-alpha and granulocytapheresis, have reported encouraging results. SUMMARY Historically a scourge among uveitic disorders, there is new hope for improved long-term visual outcomes in patients with Behçet's disease based on recent scientific advances.
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Affiliation(s)
- Annabelle A Okada
- Department of Ophthalmology, Kyorin University School of Medicine, Tokyo, Japan.
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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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Abstract
Uveitis is a leading cause of blindness affecting individuals of all ages, genders, and races. Uveitis may be due to autoimmune, infectious, toxic, malignant, or traumatic processes. Some evidence supports an association between conditions previously presumed to be autoimmune and viral infectious agents. For autoimmune uveitis, therapy is nonspecific, typically beginning with corticosteroids. For nonresponsive disease or for corticosteroid sparing, recent reports on mycophenolate mofetil, infliximab, and interferon therapy show success for various forms of uveitis. Treatment of the complications of uveitis, especially cystoid macular edema, is difficult. Vitamin E appears to offer little benefit, whereas octreotide may be effective. Recent collaborative efforts at standardization in the field should enhance studies on these conditions.
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Affiliation(s)
- Russell W Read
- Department of Ophthalmology, University of Alabama at Birmingham, Birmingham, AL 35233, USA.
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