Clinical Follow-up of Patients with Behçet Uveitis after Discontinuation of Infliximab Therapy

Shaping the Future of Behçet's Uveitis Management: A Comprehensive Review of Efficacy, Challenges, and Prospects of Biologic Therapies

Behçet's uveitis (BU), a vision-threatening manifestation of Behçet's disease, poses substantial management challenges due to its chronic, relapsing nature and potential for vision loss. This review explores the role of biologic therapies in the treatment of BU, providing a comprehensive overview of their effectiveness, drawbacks, and future possibilities. Traditionally, management has relied heavily on corticosteroids and conventional immunosuppressants. However, their long-term use is frequently associated with systemic side effects and insufficient control of ocular inflammation. Biologic therapies, particularly TNF-alpha inhibitors like infliximab and adalimumab, have emerged as effective alternatives, offering better disease control and a more favorable safety profile. We critically evaluated these agents, noting their clinical efficacy in reducing inflammatory flares and preserving visual acuity. Despite their benefits, several issues remain. Accessibility, cost, and lack of long-term safety data limit their widespread use. Additionally, individual variability in treatment response necessitates personalized therapeutic strategies. Recent research has shown promise in addressing these challenges, with the emergence of novel biologic agents and personalized medicine approaches. In summary, biologic therapies represent a paradigm shift in BU management, contributing to better patient outcomes. Yet, there are significant challenges to be overcome. As we move forward, continued research, development of novel biologic agents, and a precision medicine approach will shape the future landscape of BU treatment.

Uveitis in Behçet disease - an update

PURPOSE OF REVIEW

Uveitis is a major manifestation of Behçet disease (BD) and potentially has a high morbidity. This article reviews recently published data on BD uveitis.

RECENT FINDINGS

A set of classification criteria and a diagnostic algorithm have been developed for BD uveitis. Recent reports have confirmed male predominance and posterior segment inflammation in the majority of BD uveitis patients. A high uveitis attack severity score, fluorescein angiographic leakage at the posterior pole, and disruption of outer retinal layers on optical coherence tomography (OCT) predict poor visual outcome. OCT-angiography studies have suggested subclinical changes of retinal capillaries in patients with or without ocular involvement. In a randomized controlled trial, interferon-α was superior to cyclosporine. Favorable outcomes were reported with earlier initiation, optimization, and withdrawal of infliximab after remission. Adalimumab as first-line was superior to conventional therapy.

SUMMARY

Classification criteria will be used to select a homogeneous group of patients for research and the diagnostic algorithm may help ophthalmologists predict the probability of BD uveitis based on ocular findings. Fluorescein angiography and OCT are the routine imaging modalities. Clinical relevance of OCT-angiography is unclear. Interferon-α, infliximab, and adalimumab have proven superior efficacy compared to conventional therapy.

Efficacy and safety of the optimisation of biological therapy in non-infectious uveitis: Systematic review

OBJECTIVE

To conduct a systematic critical review of the literature on the efficacy and safety of biological therapy (BT) optimisation in non-infectious uveitis (NIU).

METHODS

Searches were conducted (PubMed, Embase, Cochrane and conference abstracts) up to March 2021. The study population comprised patients with NIU in remission after BT. We analysed BT optimisation strategies. The main outcome measures were efficacy and safety. To assess the risk of bias, the ROBINS-1 tool was used. A qualitative review of the data was performed to assess heterogeneity and bias. Evidence tables (study characteristics and outcomes) were generated, and quantitative synthesis was performed if data were homogeneous.

RESULTS

We selected 11 studies (prospective and retrospective) including 513 patients. The studies were at moderate/high risk of bias and there was considerable variability between studies in sample size, underlying diseases, definitions and outcome variables. Criteria for starting optimisation were not uniform. All BTs optimised were TNF inhibitors. Optimisation could be attempted after 3-6 months in remission. Relapse occurred in 25-50% of patients but was controlled after dose re-escalation or BT switching. No safety issues were identified.

CONCLUSIONS

The optimization of BT (with TNF inhibitors) has been applied in patients with NIU in remission. There is no consensus on criteria for attempting BT optimisation and protocols are heterogeneous. There is a least moderate risk of bias, so no robust conclusions on efficacy and safety of optimization can be reached. Preliminary evidence suggests that relapses might be controlled using standard doses. Larger studies using uniform criteria are needed.

Advances in the Treatment of Behcet's Disease

Purpose of Review

To assess current management of Behcet’s disease (BD). Controversies on therapeutic approaches to different manifestations, whether conventional immunosuppressives (IS) or biologic agents, should be chosen, and options for refractory disease are discussed.

Recent Findings

Glucocorticoids are still the main agents for remission-induction and azathioprine the first-line conventional IS in maintenance phase to prevent relapses of major organ involvement. Apremilast is shown to be a safe and effective option approved by the FDA for oral ulcers. Large case series confirmed the efficacy and safety of TNFα inhibitors and Interferon-α. Promising results are observed with IL-1 inhibitors, ustekinumab, secukinumab, and tocilizumab for refractory BD.

Summary

Although both conventional IS and biologic agents are effectively used to suppress inflammation in BD, there is still an unmet need for clear therapeutic strategies in the management for different manifestations. Further controlled studies with new biologic agents, anticoagulants and the benefit of concomitant IS usage with biologics are needed to optimize the management of BD.