Clinical outcome of chronic immunosuppression in patients with non-infectious uveitis

Efficacy, safety and cost-effectiveness of methotrexate, adalimumab or their combination in non-infectious non-anterior uveitis: a protocol for a multicentre, randomised, parallel three arms, active-controlled, phase III open label with blinded outcome assessment study

INTRODUCTION

Non-infectious uveitis include a heterogeneous group of sight-threatening and incapacitating conditions. Their correct management sometimes requires the use of immunosuppressive drugs (ISDs), prescribed in monotherapy or in combination. Several observational studies showed that the use of ISDs in combination could be more effective than and as safe as their use in monotherapy. However, a direct comparison between these two treatment strategies has not been carried out yet.

METHODS AND ANALYSIS

The Combination THerapy with mEthotrexate and adalImumAb for uveitis (CoTHEIA) study is a phase III, multicentre, prospective, randomised, single-blinded with masked outcome assessment, parallel three arms with 1:1:1 allocation, active-controlled, superiority study design, comparing the efficacy, safety and cost-effectiveness of methotrexate, adalimumab or their combination in non-infectious non-anterior uveitis. We aim to recruit 192 subjects. The duration of the treatment and follow-up will last up to 52 weeks, plus 70 days follow-up with no treatment. The complete and maintained resolution of the ocular inflammation will be assessed by masked evaluators (primary outcome). In addition to other secondary measurements of efficacy (quality of life, visual acuity and costs) and safety, we will identify subjects' subgroups with different treatment responses by developing prediction models based on machine learning techniques using genetic and proteomic biomarkers.

ETHICS AND DISSEMINATION

The protocol, annexes and informed consent forms were approved by the Reference Clinical Research Ethic Committee at the Hospital Clínico San Carlos (Madrid, Spain) and the Spanish Agency for Medicines and Health Products. We will elaborate a dissemination plan including production of materials adapted to several formats to communicate the clinical trial progress and findings to a broad group of stakeholders. The promoter will be the only access to the participant-level data, although it can be shared within the legal situation.

TRIAL REGISTRATION NUMBER

2020-000130-18; NCT04798755.

Intraocular Inflammation Control and Changes in Retinal and Choroidal Architecture in Refractory Non-Infectious Uveitis Patients after Adalimumab Therapy

Background: Non-infectious uveitis represents a leading cause of visual impairment, and inflammation control represents a major priority in tackling visual acuity loss due to complications such as macular edema; different immunomodulatory drugs are currently being used, including anti-TNF-alpha Adalimumab. Methods: This was a monocentric observational study of 18 eyes of 18 patients with non-infectious uveitis treated with Adalimumab. The primary endpoint was the control of ocular inflammation. The secondary endpoints included the study of macular and choroidal thickness and architecture, visual acuity, changes in other treatments, and adverse effects. Results: Ocular inflammation was controlled at 12 months for 83.3% of patients. Central macular thickness improved from a median of 229.75 µm at baseline to 213 µm at 12 months, while choroidal thickness decreased by 11.54% at the end of the follow-up. A reduction of vasculitis on fluorescein angiography and of hyperreflective spots on optical coherence tomography was noted. Visual acuity also improved from 0.51 (logMAR) before treatment to 0.24 at more than 12 months (p = 0.01). A total of 11.1% of patients experienced side effects. Conclusion: Our study confirms the efficacy of adalimumab for the control of ocular inflammation, visual acuity preservation, and for corticosteroid sparing.

Inhibition of Noncanonical Murine Double Minute 2 Homolog Abrogates Ocular Inflammation through NF-κB Suppression

Uveitis is estimated to account for 10% of all cases of blindness in the United States, including 30,000 new cases of legal blindness each year. Intraocular and oral corticosteroids are the effective mainstay treatment, but they carry the risk of serious long-term ocular and systemic morbidity. New noncorticosteroid therapies with a favorable side effect profile are necessary for the treatment of chronic uveitis, given the paucity of existing treatment choices. We have previously demonstrated that Nutlin-3, a small-molecule inhibitor of murine double minute 2 (MDM2) homolog, suppresses pathologic retinal angiogenesis through a p53-dependent mechanism, but the noncanonical p53-independent functions have not been adequately elucidated. Herein, we demonstrate an unanticipated function of MDM2 inhibition, where Nutlin-3 potently abrogates lipopolysaccharide-induced ocular inflammation. Furthermore, we identified a mechanism by which transcription and translation of NF-κB is mediated by MDM2, independent of p53, in ocular inflammation. Small-molecule MDM2 inhibition is a novel noncorticosteroid strategy for inhibiting ocular inflammation, which may potentially benefit patients with chronic uveitis.

Use of Immunosuppressive Medications for Treatment of Pediatric Intermediate Uveitis

PURPOSE

To describe the treatment and outcomes of a cohort of pediatric intermediate uveitis (IU) patients, with a particular focus on the use of immunomodulatory therapy (IMT).

METHODS

The disease course, treatment, and outcomes of 39 pediatric IU patients treated in the Uveitis Clinic at the University of Utah from 1999 to 2012 were reviewed, retrospectively.

RESULTS

Mean age at presentation was 7.7 years (SD 3.1). In total, 95% had bilateral involvement. Out of 77 total eyes involved, the most frequent disease complications were ocular hypertension (0.71 events per person year, PPY), cataracts (events PPY = 0.39), and cystoid macular edema (events PPY = 0.33). A total of 20 patients received IMT; 19/20 were tapered off systemic corticosteroids without a uveitis recurrence; 75% of eyes had inactive disease at final follow-up (mean 37 months).

CONCLUSIONS

The use of IMT, including biologic therapies, may effectively manage disease inflammation and reduce steroid dosages in pediatric IU patients.

Adalimumab in Patients with Active Noninfectious Uveitis

BACKGROUND

Patients with noninfectious uveitis are at risk for long-term complications of uncontrolled inflammation, as well as for the adverse effects of long-term glucocorticoid therapy. We conducted a trial to assess the efficacy and safety of adalimumab as a glucocorticoid-sparing agent for the treatment of noninfectious uveitis.

METHODS

This multinational phase 3 trial involved adults who had active noninfectious intermediate uveitis, posterior uveitis, or panuveitis despite having received prednisone treatment for 2 or more weeks. Investigators and patients were unaware of the study-group assignments. Patients were randomly assigned in a 1:1 ratio to receive adalimumab (a loading dose of 80 mg followed by a dose of 40 mg every 2 weeks) or matched placebo. All patients received a mandatory prednisone burst followed by tapering of prednisone over the course of 15 weeks. The primary efficacy end point was the time to treatment failure occurring at or after week 6. Treatment failure was a multicomponent outcome that was based on assessment of new inflammatory lesions, best corrected visual acuity, anterior chamber cell grade, and vitreous haze grade. Nine ranked secondary efficacy end points were assessed, and adverse events were reported.

RESULTS

The median time to treatment failure was 24 weeks in the adalimumab group and 13 weeks in the placebo group. Among the 217 patients in the intention-to-treat population, those receiving adalimumab were less likely than those in the placebo group to have treatment failure (hazard ratio, 0.50; 95% confidence interval, 0.36 to 0.70; P<0.001). Outcomes with regard to three secondary end points (change in anterior chamber cell grade, change in vitreous haze grade, and change in best corrected visual acuity) were significantly better in the adalimumab group than in the placebo group. Adverse events and serious adverse events were reported more frequently among patients who received adalimumab (1052.4 vs. 971.7 adverse events and 28.8 vs. 13.6 serious adverse events per 100 person-years).

CONCLUSIONS

In our trial, adalimumab was found to be associated with a lower risk of uveitic flare or visual impairment and with more adverse events and serious adverse events than was placebo. (Funded by AbbVie; VISUAL I ClinicalTrials.gov number, NCT01138657 .).

Sepsis During Immunosuppression for Sight-threatening Uveitis: The Flip side

PURPOSE

To highlight the rare but life-threatening infective consequences of immunosuppression or biologic treatment for sight-threatening uveitis.

PATIENTS AND METHODS

Retrospective case series of four immunosuppressed patients with uveitis complicated by sepsis.

RESULTS

The affected patients were all treated using prednisolone 10 mg/day or greater, together with oral immunosuppression (2 mycophenolate mofetil, 1 azathioprine + ciclosporin, 1 methotrexate) and, in one case, infliximab. All patients survived following intensive treatment.

CONCLUSION

Life-threatening infection is a rare but important risk in immunosuppressed patients with uveitis. Complete protection is not possible and prophylaxis regimens are of unproven efficacy. Patients should understand the risks before agreeing to a course of treatment.

The effectiveness of pharmacological agents for the treatment of uveitic macular oedema (UMO): a systematic review protocol

BACKGROUND

Macular oedema (MO) describes the accumulation of fluid in the central part of the retina, known as the 'macula' which provides central vision. MO is the leading cause of sight loss in patients with intraocular inflammation (uveitis). There is a lack of consensus over the treatment of uveitic macular oedema (UMO). The proposed systematic review will evaluate the evidence on the effectiveness of pharmacological agents used to treat UMO. All systemic, local, or topical pharmacological agents will be included.

METHOD/DESIGN

Standard systematic review methodology will be employed to identify, select and extract data from comparative studies (randomised/non-randomised trials and observational studies) of the pharmacological interventions in patients with UMO. Searches will be conducted through bibliographic databases (Cochrane Library, MEDLINE, EMBASE and CINAHL) and clinical trials registers. No restriction will be placed on either language or year of publication. Translation of non-English language articles will be undertaken to minimise selection bias. The primary outcome of interest will be best corrected visual acuity and secondary outcomes will be adverse events, health-related quality of life, assessment of UMO using central macular thickness (e.g. by optical coherence topography (OCT)), clinical and angiographic assessment of UMO, clinical estimation of vitreous haze. Risk of bias assessment appropriate to each study design will be undertaken. Data will be grouped by comparison, tabulated and narratively synthesised. Meta-analysis will be undertaken where clinical and methodological homogeneity exists. Subgroup and sensitivity analyses, also network analyses and intra/inter-pharmacological class analyses will be undertaken where deemed appropriate.

DISCUSSION

A number of published studies have investigated the effectiveness of the pharmacological agents used to treat UMO. However, there is no recent systematic review that synthesises this evidence. This systematic review will analyse the effectiveness of systemic, local and topical therapies to treat UMO. The findings will provide important evidence to inform clinical and health policy decision-making for the treatment of UMO.

SYSTEMATIC REVIEW REGISTRATION

Prospero CRD42015019170.

Fast and Successful Management of Intraocular Inflammation with a Single Intravitreal Dexamethasone Implant

Purpose: To investigate the efficacy and safety of a single dexamethasone intravitreal implant (Ozurdex®, 700 µg). Methods: In this prospective noncomparative case series, 84 patients (54 females) received a dexamethasone intravitreal implant. At weeks 4, 12 and 24 after the injection, vitreous haze, macular thickness and best corrected visual acuity (BCVA) were assessed and adverse events reported. Results: Clearance of vitreous haze could be achieved after 4 weeks in 61% of all eyes (p < 0.001) and remained significant until week 24 (p < 0.001). This was paralleled by a reduction of central retinal thickness after 4 (p < 0.001), 12 (p < 0.001) and 24 weeks (p < 0.006). Significant and fast improvement of BCVA was already achieved after 4 weeks (p < 0.001) but vanished by week 24. Intraocular pressure reached ≥35 mm Hg in 3 eyes and was significantly more frequent in intermediate uveitis compared to posterior uveitis (p < 0.016). Conclusions: The dexamethasone implant is effective in controlling intraocular posterior segment inflammation and reduces central retinal thickness fast and effectively. © 2014 S. Karger AG, Basel.

Think global--act local: intravitreal drug delivery systems in chronic noninfectious uveitis

The eye is probably the most attractive site of the body for treatment using locally delivered therapeutic agents. An ideal indication for such an approach is noninfectious posterior uveitis. Since intraocular structures of the posterior segment are difficult to reach and are otherwise accessible only by systemic treatment, current interest is focused on the pros and cons of intravitreal drug delivery. Because of its chronic and recurrent nature, the long-term release of anti-inflammatory agents is a major treatment goal. Intravitreal injections, intravitreal implants and biodegradable devices are the most commonly used and approved approaches to deliver various agents to the vitreous. Because of their broad and potent effects, corticosteroids (CS) have been the first-line candidates for intraocular delivery. An increasing spectrum of CS preparations including nondegradable and biodegradable devices is currently available. Since repeated and long-term applications bear the risk of steroid-related complications such as increased intraocular pressure and cataract, alternative agents are currently being tested. Intravitreal injection of methotrexate, anti-VEGF (vascular endothelial growth factor), anti-TNFα (tumor necrosis factor α) and sirolimus have also been applied in patients with conflicting results. Intravitreal treatment has significantly reduced the incidence of adverse effects compared to systemic application, but due to greater ocular side effects there are still some limitations.

Review and update of intraocular therapy in noninfectious uveitis

PURPOSE OF REVIEW

To review new clinically relevant data regarding the intraocular treatment of noninfectious uveitis.

RECENT FINDINGS

Triamcinolone acetonide, the most commonly used intravitreal corticosteroid for treatment of uveitis and uveitic macular oedema has a limited duration of action and is associated with a high risk of corticosteroid-induced intraocular pressure (IOP) rise and cataract. Recent advances have led to the development of sustained-release corticosteroid devices using different corticosteroids such as dexamethasone and fluocinolone acetonide. Treatment options for patients who have previously exhibited corticosteroid hypertensive response have also expanded through the use of new noncorticosteroid intravitreal therapeutics such as methotrexate and antivascular endothelial growth factor (anti-VEGF) agents.

SUMMARY

Ozurdex dexamethasone implant appears to have a better safety profile, and a slightly long-lasting effect than triamcinolone acetonide. The Retisert implant allows the release of corticosteroids at a constant rate for 2.5 years, but it requires surgical placement and its use is associated with a very high risk of cataract and requirement for IOP-lowering surgery. For patients who are steroid responders, methotrexate may offer a better alternative to corticosteroid treatment than anti-VEGF agents, but controlled trials are required to confirm this.

Recent developments in the treatment of uveitis: an update

The management of complex uveitis is often based around the use of oral corticosteroids. To spare the side effects of corticosteroids, second-line oral immunosuppressant drugs are used. Newer systemic immunosuppressive drugs, including biologics, and locally delivered treatments are being evaluated. This article reviews current conventional treatments, discusses their limitations and evaluates newer treatment strategies. Current theories about the pathogenesis of uveitis and potential targets for treatment are discussed in this context. We are still in search of a low-risk, where possible, locally delivered and targeted treatment for uveitis.

Non-infectious pediatric uveitis: an update on immunomodulatory management

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.

Discontinuous drug combination therapy in autoimmune ocular disorders

PURPOSE

This study aimed to assess the effectiveness of a steroid-sparing immunosuppressive treatment (IST) protocol in the control of severe or steroid-resistant autoimmune ocular inflammatory diseases.

METHODS

We carried out a prospective, non-randomized clinical study. Patients presenting with ocular inflammations that failed to respond adequately to steroids alone after monotherapy for a mean period of 9 +/- 2 months (internal control) were offered the option to switch to a combined IST. The protocol consisted of different immunosuppressive drugs added in a stepladder sequence, where each drug (including the steroids) was administered discontinuously. Main outcome measures were control of inflammation, visual acuity and safety of treatment.

RESULTS

A total of 76 subjects (121 affected eyes) enrolled in the IST protocol. Mean length of follow-up was 43 +/- 15 months. Complete control of inflammation was achieved in 86% of patients. During the first year of IST, the rate of inflammatory recurrences/patient was 0.78 +/- 1.13. This ratio diminished further during succeeding follow-up. Mean best corrected visual acuity improved from 0.31 logMAR to 0.24 logMAR (p < 0.001). Blood pressure and uric acid blood levels significantly altered for the worse in the study group.

CONCLUSIONS

Immunosuppressive treatment was effective in achieving inflammatory quiescence in a large majority of patients. The study also demonstrated the longterm safety of the protocol and its steroid-sparing effect.

Efficacy and complications of intravitreal injection of triamcinolone acetonide for refractory cystoid macular edema associated with intraocular inflammation

PURPOSE

To assess the effects and complications of intravitreal injection of triamcinolone acetonide (IVTA) for posterior sub-Tenon injection of triamcinolone acetonide (PSTA)-resistant cystoid macular edema (CME) with intraocular inflammation.

METHODS

Medical records of eight eyes of six patients with PSTA-resistant CME were retrospectively examined. Each eye received a 4-mg IVTA, and an additional injection was performed when CME recurred. Visual acuity as logarithm of the minimum angle of resolution (logMAR), intraocular pressure (IOP), and central macular thickness (CMT) were assessed before and after each treatment.

RESULTS

CME improved in six eyes (75%) with mean visual acuity recovering from 0.56+/-0.29 to 0.41+/-0.195 (logMAR, P=0.13) and mean CMT decreasing from 470 microm (range, 275-660 microm) to 297 microm (range, 150-697 microm) (P=0.04) 2 months after the initial IVTA. CME recurred an average of 9 months (range, 5-11 months) after IVTA. A higher dose (16-mg) IVTA was effective for two eyes refractory to repeated 4-mg IVTA. IOP was elevated in two eyes (25%), of which one required filtration surgery (12.5%). In phakic eyes, cataracts progressed and necessitated surgery.

CONCLUSIONS

IVTA is effective for PSTA-resistant CME with intraocular inflammation, and its efficacy might be dose dependent.

Nonsteroidal drugs for the treatment of noninfectious posterior and intermediate uveitis

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.

The prevalence of sight-threatening uveitis in Scotland

AIM

To identify and quantify the prevalence of patients with uveitis receiving systemic immunosuppression in Scotland.

METHODS

Anonymised data were prospectively collected on all patients with uveitis requiring systemic immunosuppression. Seven health boards participated over a 4-month period between 1 August 2005 and 30 November 2005.

RESULTS

373 patients were identified, of whom 205 (55%) were female. The mean age was 46.4 (range 7-97 years). Using the data from the seven participating health boards, an estimated Scottish prevalence of 9 per 100 000 was calculated. Prevalence varied between 2 and 59 per 100 000. In National Health Service Grampian, all patients with uveitis, whether sight-threatening or not, are followed up at a specialist clinic. Extrapolating this figure to Scotland gives a prevalence of 25 per 100 000.

DISCUSSION

The data from National Health Service Grampian suggest that there is a significant shortfall in the number of patients identified by survey. If the "missing population" exists, then where are they? Some might be receiving appropriate treatment at non-specialist clinics, although simple under-reporting may play a part. Greater concern is for those patients receiving inappropriate treatment for their uveitis, or for those within the community who are either oblivious to or in self denial of their condition.

Outcome of intravitreal triamcinolone in uveitis

PURPOSE

To report the short-term outcome of intravitreal triamcinolone acetate (TA) in the treatment of uveitic cystoid macular edema (CME).

DESIGN

Retrospective noncomparative (nonrandomized, uncontrolled) interventional case series.

PARTICIPANTS

Sixty-five eyes of 54 patients with uveitis-related CME inadequately responsive to treatment combinations of oral corticosteroid, periocular orbital floor corticosteroid injections, and second-line immunosuppressive agents.

INTERVENTION

Intravitreal injection of 4 mg/0.1 ml of TA.

MAIN OUTCOME MEASURES

Visual acuity (VA), intraocular pressure (IOP), levels of inflammation, and immunosuppressive therapy were assessed. Other potential complications, including cataract progression, vitreous hemorrhage, endophthalmitis, and retinal detachment (RD), were looked for.

RESULTS

The mean follow-up was 8.0 months (range, 3-51), and the mean improvement of VA after intravitreal TA was 0.26 (from 0.65 to 0.39 logarithm of the minimum angle of resolution; Snellen, 6/24-6/12, approximately). This occurred at a mean of 4 weeks (range, 1-30). The improvement in VA was more significant if the duration of CME before intravitreal TA was < or =12 months (P = 0.006) and if patients were < or =60 years old (P = 0.005). Patients with the worst vision before treatment also improved the least. The most important side effect was raised IOP (mean rise, 10.3 mmHg), with 28 eyes (43.1%) experiencing an IOP rise of >10 mmHg. Patients younger than 40 years were more likely to experience this IOP rise than those older than 40. Thirty-three eyes (51%) were treated with antiglaucoma medications, with a mean duration of treatment of 17.4+/-13.3 weeks, and no patient required trabeculectomy or lost vision. The dosage of oral corticosteroids and/or second-line immunosuppressive medication was reduced or stopped altogether in 18 of 33 eyes (54.5%) during the study period. There were no cases of injection-related vitreous hemorrhage, endophthalmitis, or RD.

CONCLUSIONS

In patients with uveitic CME, intravitreal TA can effectively reduce CME and improve VA and, in some eyes, allows the cessation and/or reduction of immunosuppressive therapy. The period of effectivity varies in different patients and, in some eyes, is limited. Treatment was associated in 43.1% with a rise in IOP, which was transient and treatable medically.