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Kalogeropoulos D, Asproudis I, Stefaniotou M, Moschos MM, Kozobolis VP, Voulgari PV, Katsanos A, Gartzonika C, Kalogeropoulos C. The Large Hellenic Study of Uveitis: Diagnostic and Therapeutic Algorithms, Complications, and Final Outcome. Asia Pac J Ophthalmol (Phila) 2023; 12:44-57. [PMID: 36588192 DOI: 10.1097/apo.0000000000000594] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 11/20/2022] [Indexed: 01/03/2023] Open
Abstract
PURPOSE The purpose of this study is to present the diagnostic and therapeutic algorithms, complications, and final outcome in the management of uveitic patients at a tertiary academic referral center. DESIGN Observational study. METHODS Analysis of the archives of 6191 uveitic patients at the Ocular Inflammation Service of the Department of Ophthalmology of the University Hospital of Ioannina in Greece from 1991 to 2020. RESULTS During the 30 years of the study, the diagnostic ability climbed from 45.43% (1991-1995) to 73.4% (2016-2020). This improvement was linked to several factors including the increase in the number of diagnostic paracenteses for the analysis of intraocular fluids, the range and quality of laboratory blood tests, the multimodal ophthalmic imaging, the proper use of nonophthalmic imaging, and the multidisciplinary approach. The degree of uveitis-related complications was related to the severity and cause of inflammation, the recurrence rate, inappropriate treatment, and the prolonged or initially inactive inflammation. The 3 most common complications included cataract, macular edema, and glaucoma. Apart from the modern treatments and surgical techniques, the 3-month preoperative control of inflammation played a critical role in the surgical outcomes. The percentage of patients with a successful outcome increased from 72% (2001-2005) to 90.50% (2016-2020). The center's experience, prompt referral, patient's compliance, and regular follow-ups are associated with a better outcome. The analysis of the results allowed the development of diagnostic and therapeutic algorithms. CONCLUSIONS Developing diagnostic and therapeutic algorithms allows for the efficient management of uveitis, leading to better visual outcome and therefore a better quality of life.
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Affiliation(s)
- Dimitrios Kalogeropoulos
- Department of Ophthalmology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Greece
| | - Ioannis Asproudis
- Department of Ophthalmology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Greece
| | - Maria Stefaniotou
- Department of Ophthalmology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Greece
| | - Marilita M Moschos
- First Department of Ophthalmology, General Hospital of Athens G. Gennimatas, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Vassilios P Kozobolis
- Department of Ophthalmology, Faculty of Medicine, School of Health Sciences, University of Patras, Greece
| | - Paraskevi V Voulgari
- Department of Rheumatology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Greece
| | - Andreas Katsanos
- Department of Ophthalmology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Greece
| | - Constantina Gartzonika
- Laboratory of Microbiology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Chris Kalogeropoulos
- Department of Ophthalmology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Greece
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2
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Juvenile Idiopathic Arthritis-associated Uveitis: Diagnosis, Management, Sequelae. Int Ophthalmol Clin 2022; 62:143-154. [PMID: 34965232 DOI: 10.1097/iio.0000000000000391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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3
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Lazăr C, Spîrchez M, Ştefan M, Predeţeanu D, Nicoară S, Crişan M, Man O. Diagnosis and treatment of uveitis associated with juvenile idiopathic arthritis. Med Pharm Rep 2021; 94:S28-S32. [PMID: 34527905 DOI: 10.15386/mpr-2224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in pediatric population, with uveitis as the most common and severe extra-articular manifestation. Eye damage (bilateral in 70-80% of cases) is usually anterior, chronic and asymptomatic. Young age, female gender, oligoarticular form and ANA positivity are risk factors for chronic anterior uveitis (CAU). Acute anterior uveitis (AAU) frequently occurs in HLA-B27 positive boys with enthesitis-related arthritis. The onset is on average 1.8 years after the onset of JIA, but it may also precede the articular manifestations. Ophthalmological screening for JIA is recommended every 3 or 6-12 months depending on the combination of risk factors for associated uveitis. The major purpose of the treatment is to minimize the loss of visual acuity. The treatment is topical (corticosteroids, cycloplegics) and systemic (short-term glucocorticoids, methotreexate, biological drugs). Biological therapy (indicated if previous treatments are ineffective) is using anti-TNF drugs as first choice (most studies are indicating sup erior efficiency for Adalimumab). Usually AAU is treated promptly and no systemic treatment is needed. In some cases the evolution of CAU can lead to severe complications (synechiaes, cataract, glaucoma, even blindness). Interdisciplinary approach involving the pediatric rheumatologist and ophthalmologist is essential for correct monitoring of this disease.
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Affiliation(s)
- Călin Lazăr
- Department of Pediatrics Clinic I, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Department of Pediatrics Clinic I, Emergency Clinical Hospital for Children, Cluj-Napoca, Romania
| | - Mihaela Spîrchez
- Department of Pediatrics Clinic II, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Department of Pediatrics Clinic II, Emergency Clinical Hospital for Children, Cluj-Napoca, Romania
| | | | - Denisa Predeţeanu
- Rheumatology Clinic, "Sfânta Maria" Clinical Hospital, Bucharest, Romania
| | - Simona Nicoară
- Department of Ophthalmology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Mirela Crişan
- Department of Pediatrics Clinic I, Emergency Clinical Hospital for Children, Cluj-Napoca, Romania
| | - Oana Man
- Department of Pediatrics Clinic I, Emergency Clinical Hospital for Children, Cluj-Napoca, Romania
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4
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Gunzinger J, Moore P, Athimalaipet R, Dick A. Adalimumab in the treatment of pediatric patients with chronic noninfectious anterior uveitis. EXPERT REVIEW OF OPHTHALMOLOGY 2021. [DOI: 10.1080/17469899.2021.1935240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
| | - Phoebe Moore
- Department of Uveitis, Bristol Eye Hospital, Bristol, UK
| | - Ramanan Athimalaipet
- Bristol Royal Hospital for Children, Upper Maudlin St, Bristol BS2 8BJ, University Hospitals Bristol NHs Foundation Trust & Translational Health Sciences, University of Bristol, Bristol, UK
| | - Andrew Dick
- Bristol Eye Hospital, Institute of Ophthalmology and the National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital and University College London, London, UK
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5
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Sadhu S, Dutta Majumder P, Biswas J. Biological therapy in refractory cases of uveitis and scleritis: An analysis of 18 cases from a tertiary eye care center from South India. Indian J Ophthalmol 2021; 68:1929-1933. [PMID: 32823417 PMCID: PMC7690551 DOI: 10.4103/ijo.ijo_966_20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Purpose To evaluate the effectiveness of biologic therapy in a cohort of patients with various types of refractory non-infectious uveitis and scleritis. Methods A retrospective observational study on patients with non-infectious uveitis and scleritis who were not responding or had a high recurrence rate with the conventional treatment and had received biologic therapy. Results We studied 18 patients (33 eyes) who received biological therapy between January 2017 and November 2019. The mean age was 30 ± 17 years and mean duration of uveitis was 36.8 months (range 1-120 months). Anterior uveitis (27.7%) was most commonly observed followed by scleritis, panuveitis, posterior, and intermediate uveitis. The most common etiology was Behçet's disease (4 patients, 22.2%) followed by juvenile idiopathic arthritis (3 patients, 16.6%), granulamotosis polyangitis, and idiopathic (2 patients each, 11.1%). Majority had trialled one or more immunosuppressive and were refractory in nature. Maximum patients had received adalimumab (61%) followed by infliximab (22%), rituximab (12%), and golimumab (6%). The median prednisolone dose was reduced from 30 mg (range 7.5-60 mg) to 5 mg (range 0-10 mg) after biological therapy (P = 0.002). Significant visual improvement was observed post biologic therapy (mean log mar VA 0.41 ± 0.62 improved to 0.23 ± 0.48 at the final visit, P = 0.008). Maximum number of patients (16 patients, 89%) responded well with biological therapy. Three patients developed recurrence and systemic complications were observed in two patients. Conclusion Biologic therapy is effective in non-infectious refractory uveitis who were resistant to conventional therapy and may prolong disease recurrence.
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Affiliation(s)
- Soumen Sadhu
- Department of Uvea, Medical and Vision Research Foundations, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | | | - Jyotirmay Biswas
- Department of Uvea, Medical and Vision Research Foundations, Sankara Nethralaya, Chennai, Tamil Nadu, India
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6
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Powierza K, Sawicka-Powierza J, Urban B, Żelazowska-Rutkowska B, Cylwik B, Mikołuć B, Kowalewska O, Bakunowicz-Łazarczyk A. Endothelin-1 Serum Concentration in Pediatric Chronic Idiopathic Uveitis. Clin Ophthalmol 2021; 15:157-164. [PMID: 33469261 PMCID: PMC7811460 DOI: 10.2147/opth.s276109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 11/13/2020] [Indexed: 12/14/2022] Open
Abstract
Purpose The aim of our study was to determine endothelin-1 (ET-1) concentration in chronic idiopathic uveitis in children and adolescents depending on anatomical location and grade of inflammation. Methods The cross-sectional study was conducted among 17 patients with chronic idiopathic uveitis and 22 healthy controls. Concentration of ET-1 in serum was determined using a commercially available ELISA kit. The concentration of C reactive protein (CRP) in serum was determined by immunoturbidimetric method using CRP4 reagent kit (Roche Diagnostics GmbH, Mannheim, Germany). Results Statistically significant difference between ET-1 concentration in patients with chronic idiopathic uveitis and controls was found 1.33 (1.22; 1.48) vs 1.93 (1.1; 3.11), p = 0.008). No correlations were found between ET-1 concentration and age, either in chronic idiopathic uveitis patients or controls. Nine out of 17 patients presented with anterior uveitis, 5 with posterior and 3 with panuveitis. There were no differences in ET-1 concentration between anterior, posterior and panuveitis (p = 0.634), and in terms of grade of inflammation. Conclusion ET-1 expression is disturbed in pediatric chronic idiopathic uveitis irrespective of the anatomical location and grade of inflammation. Lower expression of ET-1 plays a crucial role in disturbed vascular tone control and can result in permanent visual impairment in chronic non-infectious uveitis.
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Affiliation(s)
- Katarzyna Powierza
- University Clinical Hospital in Bialystok, Medical University of Bialystok, Bialystok 15-276, Poland
| | | | - Beata Urban
- Department of Pediatric Ophthalmology and Strabismus, Medical University of Bialystok, Bialystok 15-274, Poland
| | - Beata Żelazowska-Rutkowska
- Department of Pediatric Laboratory Diagnostics, Medical University of Bialystok, Bialystok 15-274, Poland
| | - Bogdan Cylwik
- Department of Pediatric Laboratory Diagnostics, Medical University of Bialystok, Bialystok 15-274, Poland
| | - Bożena Mikołuć
- Department of Pediatrics, Rheumatology, Immunology and Metabolic Bone Diseases, Medical University of Bialystok, Bialystok 15-274, Poland
| | - Olga Kowalewska
- Psychiatric Clinic, Lund, Division of Psychiatry, Lund 222 40, Sweden
| | - Alina Bakunowicz-Łazarczyk
- Department of Pediatric Ophthalmology and Strabismus, Medical University of Bialystok, Bialystok 15-274, Poland
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7
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Ponti R, Mastrolia MV, Simonini G. Non-infectious Chronic Uveitis in Childhood: Assessment and Treatment in the Biological Era. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2021. [DOI: 10.1007/s40674-020-00166-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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8
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Petty RE, Zheng Q. Uveitis in juvenile idiopathic arthritis. World J Pediatr 2020; 16:562-565. [PMID: 31965444 DOI: 10.1007/s12519-019-00331-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 12/17/2019] [Indexed: 02/07/2023]
Affiliation(s)
- Ross E Petty
- Division of Rheumatology, Department of Pediatrics, University of British Columbia, 4480 Oak Street, Vancouver, BC, V6H 3V4, Canada.
| | - Qi Zheng
- Department of Rheumatology Immunology and Allergy, Children's Hospital, Zhejiang University School of Medicine, 57# Zhu Gan Road Zhejiang Province, Hangzhou, 310000, China
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9
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Maccora I, Fusco E, Marrani E, Ramanan AV, Simonini G. Changing evidence over time: updated meta-analysis regarding anti-TNF efficacy in childhood chronic uveitis. Rheumatology (Oxford) 2020; 60:568-587. [DOI: 10.1093/rheumatology/keaa595] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 07/19/2020] [Accepted: 07/31/2020] [Indexed: 12/14/2022] Open
Abstract
Abstract
Objective
To summarize evidence regarding efficacy of anti-TNFα in childhood chronic uveitis, refractory to common DMARDs.
Methods
An updated systematic search was conducted between November 2012 and January 2020. Studies investigating the efficacy of anti-TNFα therapy, in children of ages <16 years, as the first biologic treatment for childhood chronic uveitis, refractory to topical and/or systemic steroid and at least one DMARD were eligible for inclusion. The primary outcome measure was the improvement of intraocular inflammation according to Standardization of Uveitis Nomenclature Working Group criteria. A combined estimate of the proportion of children responding to etanercept (ETA), infliximab (INF), and adalimumab (ADA) was determined.
Results
We identified 1677 articles of which 37 articles were eligible. Three were randomized controlled trials, one on ETA and two on ADA, and were excluded from pooled analysis. From the observational studies, a total of 487 children were identified: 226 received ADA, 213 INF and 48 ETA. The proportion of responding children was 86% (95% CI: 76%, 95%) for ADA, 68% (95% CI: 50%, 85%) for INF and 36% (95% CI: 9%, 67%) for ETA. Pooled analysis showed clear differences (χ2 = 32.2, P < 0.0001): ADA and INF were both significantly superior to ETA (χ2 = 26.8, P < 0.0001, and χ2 = 7.41, P < 0.006, respectively), ADA significantly superior to INF (χ2 = 13.4, P < 0.0002).
Conclusion
This meta-analysis, consistent with recent randomized controlled trial data, suggests the efficacy of ADA and INF in childhood chronic uveitis treatment. However, ADA results were superior to those of INF in this clinical setting.
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Affiliation(s)
- Ilaria Maccora
- Rheumatology Unit, Meyer Children's Hospital, School of Human Health Science, University of Florence, Florence, Italy
| | - Eleonora Fusco
- Rheumatology Unit, Meyer Children's Hospital, School of Human Health Science, University of Florence, Florence, Italy
| | - Edoardo Marrani
- Rheumatology Unit, Meyer Children's Hospital, School of Human Health Science, University of Florence, Florence, Italy
| | - Athimalaipet V Ramanan
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK
- Translational Health Sciences, University of Bristol, Bristol, UK
| | - Gabriele Simonini
- Rheumatology Unit, NEUROFARBA Department, Meyer Children's Hospital, University of Florence, Florence, Italy
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10
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Maleki A, Manhapra A, Asgari S, Chang PY, Foster CS, Anesi SD. Tocilizumab Employment in the Treatment of Resistant Juvenile Idiopathic Arthritis Associated Uveitis. Ocul Immunol Inflamm 2020; 29:14-20. [PMID: 33021415 DOI: 10.1080/09273948.2020.1817501] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM To determine the efficacy and safety of intravenous tocilizumab in refractory juvenile idiopathic arthritis associated uveitis. PATIENTS AND METHODS This was a retrospective observational case series. Patients with refractory juvenile idiopathic arthritis associated uveitis, who had received tocilizumab were included in this study. RESULTS 8 patients (14 eyes) were included in this study. The average age of the patients at the first visit was 16.8 ± 11.2 years (7-40). The average duration of follow-up period after starting treatment was 28.6 ± 24.6 months (9-70). Intravenous tocilizumab infusions induced and maintained remission in 5 patients (8 eyes). Vasculitis was resolved within 8 months in all but one patient. The presence of papillitis before starting treatment was directly correlated with visual acuity improvement. No side effects were observed. CONCLUSION Intravenous tocilizumab infusion can be an effective and safe method of treatment to induce and maintain remission in resistant juvenile idiopathic arthritis associated uveitis.
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Affiliation(s)
- Arash Maleki
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA.,The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
| | - Ambika Manhapra
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA.,The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
| | - Soheila Asgari
- Noor Ophthalmology Research Center, Noor Eye Hospital, Tehran, Iran
| | - Peter Y Chang
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA.,The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
| | - C Stephen Foster
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA.,The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA.,Department of Ophthalmology, Harard Medical School, Boston, MA, USA
| | - Stephen D Anesi
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA.,The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
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11
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Non-Infectious Chronic Uveitis in Childhood: Assessment and Treatment in the Biological Era. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2020. [DOI: 10.1007/s40674-020-00151-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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12
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Drug Retention Rate and Causes of Discontinuation of Adalimumab in Uveitis. Ophthalmology 2020; 127:814-825. [DOI: 10.1016/j.ophtha.2019.11.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 11/11/2019] [Accepted: 11/25/2019] [Indexed: 12/16/2022] Open
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13
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Jari M, Shiari R, Salehpour O, Rahmani K. Epidemiological and advanced therapeutic approaches to treatment of uveitis in pediatric rheumatic diseases: a systematic review and meta-analysis. Orphanet J Rare Dis 2020; 15:41. [PMID: 32019589 PMCID: PMC7001204 DOI: 10.1186/s13023-020-1324-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 01/28/2020] [Indexed: 12/14/2022] Open
Abstract
Background Despite the low prevalence of uveitis in pediatric rheumatic diseases, potential problems as well as high disease burden can complicate its management. In this review, we systematically assessed the epidemiological, etiological, and managerial aspects of uveitis in pediatric rheumatic diseases. Methods This current study was conducted in accordance with the established methods and the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). We searched the manuscript databases, including Medline, Web of Knowledge, Google Scholar, Scopus, and Cochrane for all eligible studies in line with the considered keywords. We also conducted the statistical analysis using the Stata software. Results Considering studies focusing on uveitis in Juvenile Idiopathic Arthritis (JIA) yielded a pooled prevalence of 11.8% (95%CI: 11.2 to 12.4%) for uveitis following JIA. In this regard, the prevalence rate of uveitis related to Behçet,s disease and Systemic Lupus Erythematosus (SLE( was estimated to be 15.0 and 0.8%, respectively. The pooled response rate to Adalimumab and Infliximab was estimated to be 68.0% (95%CI: 65.4 to 70.6%), 64.7% (95%CI: 59.8 to 69.3%), respectively. The documents for the systematical assessment of other biological medications (e.g. Tocilizumab, Daclizumab and Rituximab) were inadequate; however, the mean response rate for these drugs was 59, 75 and 80%, respectively. Our meta-analysis showed a pooled response rate of 40.0% (95%CI, 36.0% to 44.2) to Methotrexate. Significant heterogeneity and significant diffusion bias were demonstrated by reviewing studies. Conclusions The pooled prevalence of uveitis in pediatric rheumatic diseases widely varied based on the underlying disease requiring more investigations in different subtypes of rheumatic diseases. The biologic medications, especially Adalimumab are the most effective treatments for uveitis in pediatric rheumatic diseases; however, a combination of the safe, available alternatives is preferred to achieve the most desirable treatment response.
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Affiliation(s)
- Mohsen Jari
- Department of Pediatric Rheumatology, Imam Hossein Children's Hospital. Isfahan University of Medical Sciences, Isfahan, Iran. .,Child Growth and Development Research Center, Research Institute for Primordial prevention of non-communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Reza Shiari
- Department of Pediatric Rheumatology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Omid Salehpour
- Negah Specialty Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Khosro Rahmani
- Department of Pediatric Rheumatology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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14
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Malcová H, Dallos T, Bouchalova K, Brejchová I, Brichová M, Bušányová B, Fabianová J, Fráňová J, Furdová A, Jarošová K, Kobrová K, Kostolná B, Košková E, Lokaj M, Macků M, Melocíková J, Michaličková M, Minxová L, Moravčíková D, Němcová D, Pískovský T, Říhová E, Schüller M, Skalická E, Svozílková P, Tomčíková D, Vargová V, Vrtíková E, Doležalová P, Heissigerová J. Recommendations for the Management of Uveitis Associated With Juvenile Idiopathic Arthritis: The Czech and Slovak adaptation of SHARE Initiative. CESKA A SLOVENSKA OFTALMOLOGIE : CASOPIS CESKE OFTALMOLOGICKE SPOLECNOSTI A SLOVENSKE OFTALMOLOGICKE SPOLECNOSTI 2020; 76:1-15. [PMID: 33086847 DOI: 10.31348/2020/7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in children and uveitis is its most important extra-articular manifestation. Evidence-based recommendations are available only to a limited extent and therefore JIA associated uveitis management is mostly based on physicians experience. Consequently, treatment practices differ widely, both nationally and internationally. Therefore, an effort to optimize and publish recommendations for the care of children and young adults with rheumatic diseases was launched in 2012 as part of the international project SHARE (Single Hub and Access Point for Pediatric Rheumatology in Europe) to facilitate clinical practice for paediatricians and (paediatric) rheumatologists. The aim of this work was to translate published international SHARE recommendations for the diagnosis and treatment of JIA associated uveitis and to adapt them for use in the Czech and Slovak Republics. International recommendations were developed according to the standard methodology of the European League against Rheumatism (EULAR) by a group of nine experienced paediatric rheumatologists and three experts in ophthalmology. It was based on a systematic literature review and evaluated in the form of an online survey and subsequently discussed using a nominal group technique. Recommendations were accepted if > 80% agreement was reached (including all three ophthalmologists). A total of 22 SHARE recommendations were accepted: 3 on diagnosis, 5 on disease activity assessment, 12 on treatment and 2 on future recommendations. Translation of the original text was updated and modified with data specific to the czech and slovak health care systems and supplemented with a proposal for a protocol of ophthalmological dispensarization of paediatric JIA patients and a treatment algorithm for JIA associated uveitis. Conclusion: The aim of the SHARE initiative is to improve and standardize care for paediatric patients with rheumatic diseases across Europe. Therefore, recommendations for the diagnosis and treatment of JIA-associated uveitis have been formulated based on the evidence and agreement of leading European experts in this field.
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15
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Ho M, Chen LJ, Sin HPY, Iu LPL, Brelen M, Ho ACH, Lai TYY, Young AL. Experience of using adalimumab in treating sight-threatening paediatric or adolescent Behcet's disease-related uveitis. J Ophthalmic Inflamm Infect 2019; 9:14. [PMID: 31367810 PMCID: PMC6669227 DOI: 10.1186/s12348-019-0181-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 07/19/2019] [Indexed: 12/14/2022] Open
Abstract
Purpose To report the clinical outcomes of adalimumab in treating refractory Behcet’s disease (BD)-related uveitis in paediatric or adolescent patients. Methods Retrospective review of five paediatric or adolescent patients with BD-related uveitis with a minimum follow-up of 24 months. Results Disease quiescence was observed in 9 (90%) of 10 eyes at 12 months. The mean number of relapses per year per patient was 5 (range, 3–7) before initiation of adalimumab treatment. This was reduced to 0.2 relapse per patient per year among the five patients during the first 24 months after starting adalimumab treatment. At baseline, 5 eyes had active retinal vasculitis. Retinal vasculitis resolved in all cases (100%) after starting adalimumab. The mean time to complete resolution of inflammation was 3.4 weeks. The mean ± standard deviation logMAR best-corrected visual acuity was 0.711 ± 0.63 at baseline and improved to 0.172 ± 1.04 at 12 months (P < 0.001). None of the patients developed any adverse events associated with adalimumab treatment. Conclusion Adalimumab was effective in preventing irreversible sight-threatening BD-related uveitis in paediatric or adolescent patients. Adalimumab appears to be a promising treatment option for young patients with recalcitrant BD-related uveitis and has a favourable safety profile.
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Affiliation(s)
- Mary Ho
- Department of Ophthalmology & Visual Sciences, Prince of Wales Hospital, the Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - Li Jia Chen
- Department of Ophthalmology & Visual Sciences, Prince of Wales Hospital, the Chinese University of Hong Kong, Shatin, Hong Kong SAR.,Department of Ophthalmology & Visual Sciences, Hong Kong Eye Hospital, the Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - Helena P Y Sin
- Department of Ophthalmology & Visual Sciences, Prince of Wales Hospital, the Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - Lawrence P L Iu
- Department of Ophthalmology & Visual Sciences, Prince of Wales Hospital, the Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - Marten Brelen
- Department of Ophthalmology & Visual Sciences, Prince of Wales Hospital, the Chinese University of Hong Kong, Shatin, Hong Kong SAR.,Department of Ophthalmology & Visual Sciences, Hong Kong Eye Hospital, the Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - Assunta C H Ho
- Department of Paediatrics, Faculty of Medicine, the Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - Timothy Y Y Lai
- Department of Ophthalmology & Visual Sciences, Prince of Wales Hospital, the Chinese University of Hong Kong, Shatin, Hong Kong SAR.,Department of Ophthalmology & Visual Sciences, Hong Kong Eye Hospital, the Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - Alvin L Young
- Department of Ophthalmology & Visual Sciences, Prince of Wales Hospital, the Chinese University of Hong Kong, Shatin, Hong Kong SAR. .,Department of Ophthalmology & Visual Sciences, Hong Kong Eye Hospital, the Chinese University of Hong Kong, Shatin, Hong Kong SAR.
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16
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Angeles-Han ST, Lo MS, Henderson LA, Lerman MA, Abramson L, Cooper AM, Parsa MF, Zemel LS, Ronis T, Beukelman T, Cox E, Sen HN, Holland GN, Brunner HI, Lasky A, Rabinovich CE. Childhood Arthritis and Rheumatology Research Alliance Consensus Treatment Plans for Juvenile Idiopathic Arthritis-Associated and Idiopathic Chronic Anterior Uveitis. Arthritis Care Res (Hoboken) 2019; 71:482-491. [PMID: 29806733 PMCID: PMC6261704 DOI: 10.1002/acr.23610] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 05/22/2018] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Systemic immunosuppressive treatment of pediatric chronic anterior uveitis (CAU), both juvenile idiopathic arthritis-associated and idiopathic anterior uveitis, varies, making it difficult to identify best treatments. The Childhood Arthritis and Rheumatology Research Alliance (CARRA) developed consensus treatment plans (CTPs) for CAU for the purpose of reducing practice variability and allowing future comparison of treatments using comparative effectiveness analysis techniques. METHODS A core group of pediatric rheumatologists, ophthalmologists with uveitis expertise, and a lay advisor comprised the CARRA uveitis workgroup that performed a literature review on pharmacologic treatments, held teleconferences, and developed a case-based survey administered to the CARRA membership to delineate treatment practices. We held 3 face-to-face consensus meetings using nominal group technique to develop CTPs. RESULTS The survey identified areas of treatment practice variability. We developed 2 CTPs for the treatment of CAU, case definitions, and monitoring parameters. The first CTP is directed at children who are naive to steroid-sparing medication, and the second at children initiating biologic therapy, with options for methotrexate, adalimumab, and infliximab. We defined a core data set and outcome measures, with data collection at 3 and 6 months after therapy initiation. The CARRA membership voted to accept the CTPs with a >95% approval (n = 233). CONCLUSION Using consensus methodology, 2 standardized CTPs were developed for systemic immunosuppressive treatment of CAU. These CTPs are not meant as treatment guidelines, but are designed for further pragmatic research within the CARRA research network. Use of these CTPs in a prospective comparison effectiveness study should improve outcomes by identifying best practice options.
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Affiliation(s)
- Sheila T. Angeles-Han
- Division of Rheumatology, Cincinnati Children’s Hospital Medical Center and Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Mindy S. Lo
- Division of Immunology, Boston Children’s Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Lauren A. Henderson
- Division of Immunology, Boston Children’s Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA
| | | | - Leslie Abramson
- Vermont Children’s Hospital at University of Vermont Medical Center, Burlington, VT
| | | | | | | | - Tova Ronis
- Children’s National Health System, Washington, DC
| | | | | | - H. Nida Sen
- National Eye Institute, National Institutes of Health, Bethesda, Maryland
| | - Gary N. Holland
- UCLA Stein Eye Institute and David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA
| | - Hermine I. Brunner
- Division of Rheumatology, Cincinnati Children’s Hospital Medical Center and Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Andrew Lasky
- Randall Children’s Hospital at Legacy Emmanuel, Portland, OR
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17
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Heiligenhaus A, Minden K, Tappeiner C, Baus H, Bertram B, Deuter C, Foeldvari I, Föll D, Frosch M, Ganser G, Gaubitz M, Günther A, Heinz C, Horneff G, Huemer C, Kopp I, Lommatzsch C, Lutz T, Michels H, Neß T, Neudorf U, Pleyer U, Schneider M, Schulze-Koops H, Thurau S, Zierhut M, Lehmann HW. Update of the evidence based, interdisciplinary guideline for anti-inflammatory treatment of uveitis associated with juvenile idiopathic arthritis. Semin Arthritis Rheum 2018; 49:43-55. [PMID: 30595409 DOI: 10.1016/j.semarthrit.2018.11.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 11/27/2018] [Accepted: 11/29/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Uveitis in juvenile idiopathic arthritis (JIAU) is frequently associated with the development of complications and visual loss. Topical corticosteroids are the first line therapy, and disease modifying anti-rheumatic drugs (DMARDs) are commonly used. However, treatment has not been standardized. METHODS Interdisciplinary guideline were developed with representatives from the German Ophthalmological Society, Society for Paediatric Rheumatology, Professional Association of Ophthalmologists, German Society for Rheumatology, parents' group, moderated by the Association of the Scientific Medical Societies in Germany. A systematic literature analysis in MEDLINE was performed, evidence and recommendations were graded, an algorithm for anti-inflammatory treatment and final statements were discussed in a consensus meeting (Nominal Group Technique), a preliminary draft was fine-tuned and discussed thereafter by all participants (Delphi procedure). RESULTS Consensus was reached on recommendations, including a standardized treatment strategy according to uveitis severity in the individual patient. Thus, methotrexate shall be introduced for uveitis not responding to low-dose (≤ 2 applications/day) topical corticosteroids, and a TNFalpha antibody (preferably adalimumab) used, if uveitis inactivity is not achieved. In very severe active uveitis with uveitis-related deterioration of vision, systemic corticosteroids should be considered for bridging until DMARDs take effect. If TNFalpha antibodies fail to take effect or lose effect, another biological should be selected (tocilizumab, abatacept or rituximab). De-escalation of DMARDs should be preceded by a period of ≥ 2 years of uveitis inactivity. CONCLUSIONS An interdisciplinary, evidence-based treatment guideline for JIAU is presented.
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Affiliation(s)
- A Heiligenhaus
- Department of Ophthalmology, Guideline of the German Ophthalmological Society (DOG), St. Franziskus Hospital, Hohenzollernring 74, 48145 Muenster, Germany.
| | - K Minden
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - C Tappeiner
- Department of Ophthalmology, Guideline of the German Ophthalmological Society (DOG), St. Franziskus Hospital, Hohenzollernring 74, 48145 Muenster, Germany
| | - H Baus
- The Participation of the Following Bodies: Parents' Group for Children with Uveitis and their Families, Germany
| | - B Bertram
- Professional Association of Ophthalmologists (BVA), Germany
| | - C Deuter
- Department of Ophthalmology, Guideline of the German Ophthalmological Society (DOG), St. Franziskus Hospital, Hohenzollernring 74, 48145 Muenster, Germany
| | - I Foeldvari
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - D Föll
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - M Frosch
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - G Ganser
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - M Gaubitz
- German Society of Rheumatology (DGRh), Germany
| | - A Günther
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - C Heinz
- Department of Ophthalmology, Guideline of the German Ophthalmological Society (DOG), St. Franziskus Hospital, Hohenzollernring 74, 48145 Muenster, Germany
| | - G Horneff
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - C Huemer
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - I Kopp
- Association of the Scientific Medical Societies in Germany (AWMF), Germany
| | - C Lommatzsch
- Department of Ophthalmology, Guideline of the German Ophthalmological Society (DOG), St. Franziskus Hospital, Hohenzollernring 74, 48145 Muenster, Germany
| | - T Lutz
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - H Michels
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - T Neß
- Department of Ophthalmology, Guideline of the German Ophthalmological Society (DOG), St. Franziskus Hospital, Hohenzollernring 74, 48145 Muenster, Germany
| | - U Neudorf
- The Society for Paediatric Rheumatology (GKJR), Germany
| | - U Pleyer
- Department of Ophthalmology, Guideline of the German Ophthalmological Society (DOG), St. Franziskus Hospital, Hohenzollernring 74, 48145 Muenster, Germany
| | - M Schneider
- German Society of Rheumatology (DGRh), Germany
| | | | - S Thurau
- Department of Ophthalmology, Guideline of the German Ophthalmological Society (DOG), St. Franziskus Hospital, Hohenzollernring 74, 48145 Muenster, Germany
| | - M Zierhut
- Department of Ophthalmology, Guideline of the German Ophthalmological Society (DOG), St. Franziskus Hospital, Hohenzollernring 74, 48145 Muenster, Germany
| | - H W Lehmann
- The Society for Paediatric Rheumatology (GKJR), Germany
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18
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Timing of infliximab and adalimumab initiation despite methotrexate in children with chronic non-infectious anterior uveitis. Eye (Lond) 2018; 33:629-639. [PMID: 30487588 DOI: 10.1038/s41433-018-0283-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 07/24/2018] [Accepted: 11/05/2018] [Indexed: 12/14/2022] Open
Abstract
AIMS Methotrexate (MTX) is standard treatment in pediatric chronic anterior uveitis (CAU). Addition of tumor necrosis factor-α inhibitors (TNFi) is often needed. We describe the timing and risk factors for TNFi use in children with CAU on MTX. METHODS In this retrospective study, we reviewed 51 records, and 46 met inclusion criteria. Primary outcome was the addition of TNFi due to active CAU per Standardization of Uveitis Nomenclature criteria. Time to TNFi and factors associated with their addition were assessed using survival analysis models. RESULTS Of 46 children treated with MTX for uveitis (36 juvenile idiopathic arthritis-associated uveitis, 10 idiopathic CAU), 72% had ocular complications. MTX was started a median of 5.0 months, and TNFi 43 months from uveitis diagnosis. Kaplan-Meier estimates suggest that cumulatively, 12% (95% CI: 4-23%) start TNFi within 6 months of MTX, 21% (12-37%) within 1 year, and 39% (24-54%) within 2 years. On Cox Proportional Hazard regression analysis, children with idiopathic CAU required TNFi earlier in their uveitis course (at 3 months (Hazard Ratio 6.06; 95% confidence interval (1.25-29.41))). Females appeared less likely to require TNFi early. Children treated in 2012 and later were more likely to receive TNFi earlier than those treated before 2012. CONCLUSION Little is known about optimal time to initiate treatment or factors associated with the need to add TNFi in children on MTX. Children with idiopathic CAU and males required TNFi earlier in their course. Factors associated with these potential risk factors for TNFi warrant further investigation.
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Leinonen S, Immonen I, Kotaniemi K. Fluocinolone acetonide intravitreal implant (Retisert ® ) in the treatment of sight threatening macular oedema of juvenile idiopathic arthritis-related uveitis. Acta Ophthalmol 2018; 96:648-651. [PMID: 29655222 DOI: 10.1111/aos.13744] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 02/07/2018] [Indexed: 12/12/2022]
Abstract
PURPOSE We describe eight patients with juvenile idiopathic arthritis-related chronic uveitis, who received a fluocinolone acetonide implant (FAI, Retisert®, Bausch&Lomb) in one eye. All patients had poor visual acuity (VA) due to persistent macular oedema in one or both eyes despite treatment with antirheumatic medication. METHODS Median age of the patients was 22.9 years (range, 14.1-39.7) and duration of uveitis 13.0 years (range, 6.8-28.4) at FAI implantation. Median preoperative best-corrected visual acuity (BCVA) was 0.1 (range, 0.05-0.4) and Standardization of Uveitis Nomenclature, SUN-grade was SUN 2+ (range, 0.5-4.0). All patients had been treated extensively with systemic corticosteroids and antirheumatic drugs by the time of FAI implantation. The median follow-up time was 5.3 years (range, 4.4-6.3). RESULTS Macular edema resolved in a median time of 0.2 years (range, 0.04-0.39) after the FAI implantation. The median BCVA was 0.5-0.63 (range, 0.1-1.0) from 1 to 5 years of follow-up. Macular edema did not recur in 5 eyes after the implantation. In three eyes, the macular oedema relapsed at 2.7, 2.9 and 5.5 years of follow-up. All our patients needed antirheumatic drugs in addition to the FAI to treat their macular edema. During the follow-up, 7 eyes required further intraocular operations: 4 cataract operations, 4 intraocular pressure -lowering operations and 1 retinal detachment surgery were performed. CONCLUSION Fluocinolone acetonide implant is a valuable option in the treatment of persistent macular edema associated with JIA-related uveitis refractory to systemic treatments.
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Affiliation(s)
- Sanna Leinonen
- Department of Ophthalmology; Helsinki University Hospital; University of Helsinki; Helsinki Finland
| | - Ilkka Immonen
- Department of Ophthalmology; Helsinki University Hospital; University of Helsinki; Helsinki Finland
| | - Kaisu Kotaniemi
- Department of Ophthalmology; Helsinki University Hospital; Helsinki Finland
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20
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Constantin T, Foeldvari I, Anton J, de Boer J, Czitrom-Guillaume S, Edelsten C, Gepstein R, Heiligenhaus A, Pilkington CA, Simonini G, Uziel Y, Vastert SJ, Wulffraat NM, Haasnoot AM, Walscheid K, Pálinkás A, Pattani R, Györgyi Z, Kozma R, Boom V, Ponyi A, Ravelli A, Ramanan AV. Consensus-based recommendations for the management of uveitis associated with juvenile idiopathic arthritis: the SHARE initiative. Ann Rheum Dis 2018; 77:1107-1117. [PMID: 29592918 PMCID: PMC6059050 DOI: 10.1136/annrheumdis-2018-213131] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 03/07/2018] [Accepted: 03/11/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND In 2012, a European initiative called Single Hub and Access point for pediatric Rheumatology in Europe (SHARE) was launched to optimise and disseminate diagnostic and management regimens in Europe for children and young adults with rheumatic diseases. Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in children and uveitis is possibly its most devastating extra-articular manifestation. Evidence-based guidelines are sparse and management is mostly based on physicians' experience. Consequently, treatment practices differ widely, within and between nations. OBJECTIVES To provide recommendations for the diagnosis and treatment of JIA-associated uveitis. METHODS Recommendations were developed by an evidence-informed consensus process using the European League Against Rheumatism standard operating procedures. A committee was constituted, consisting of nine experienced paediatric rheumatologists and three experts in ophthalmology from Europe. Recommendations derived from a validated systematic literature review were evaluated by an Expert Committee and subsequently discussed at two consensus meetings using nominal group techniques. Recommendations were accepted if >80% agreement was reached (including all three ophthalmologists). RESULTS In total, 22 recommendations were accepted (with >80% agreement among experts): 3 on diagnosis, 5 on disease activity measurements, 12 on treatment and 2 on future recommendations. CONCLUSIONS The SHARE initiative aims to identify best practices for treatment of patients suffering from JIA-associated uveitis. Within this remit, recommendations for the diagnosis and treatment of JIA-associated uveitis have been formulated by an evidence-informed consensus process to suggest a standard of care for JIA-associated uveitis patients throughout Europe.
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Affiliation(s)
- Tamas Constantin
- 2nd Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Ivan Foeldvari
- Klinikum Eilbek, Hamburger Zentrum für Kinder- und Jugendrheumatologie, Hamburg, Germany
| | - Jordi Anton
- Department of Pediatric Rheumatology, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - Joke de Boer
- Department of Ophthalmology, University Hospital Utrecht, Utrecht, The Netherlands
| | | | - Clive Edelsten
- Department of Ophthalmology, Great Ormond Street Hospital, London, UK
| | - Raz Gepstein
- Department of Ophthalmology, Meir Medical Center, Kfar Sava, Israel
| | - Arnd Heiligenhaus
- Department of Ophthalmology, Uveitis-Center, and Ophtha Lab, at St. Franziskus Hospital, Muenster, Germany
- University of Duisburg-Essen, Duisburg, Germany
| | | | - Gabriele Simonini
- Department of Paediatrics, Rheumatology Unit, Anna Meyer Children's Hospital, University of Florence, Florence, Italy
| | - Yosef Uziel
- Department of Paediatrics, Meir Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Sebastian J Vastert
- Department of Pediatric Rheumatology and Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht and University of Utrecht, Utrecht, The Netherlands
| | - Nico M Wulffraat
- Department of Pediatric Rheumatology and Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht and University of Utrecht, Utrecht, The Netherlands
| | - Anne-Mieke Haasnoot
- Department of Ophthalmology, University Hospital Utrecht, Utrecht, The Netherlands
| | - Karoline Walscheid
- Department of Ophthalmology, Uveitis-Center, and Ophtha Lab, at St. Franziskus Hospital, Muenster, Germany
| | | | - Reshma Pattani
- Department of Ophthalmology, Great Ormond Street Hospital, London, UK
| | - Zoltán Györgyi
- 2nd Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Richárd Kozma
- 2nd Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Victor Boom
- Department of Internal Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Andrea Ponyi
- 2nd Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Angelo Ravelli
- Università degli Studi di Genova and Istituto Giannina Gaslini, Genoa, Italy
| | - Athimalaipet V Ramanan
- University Hospitals Bristol NHS Foundation Trust & Bristol Medical School, University of Bristol, Bristol, UK
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21
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Ming S, Xie K, He H, Li Y, Lei B. Efficacy and safety of adalimumab in the treatment of non-infectious uveitis: a meta-analysis and systematic review. Drug Des Devel Ther 2018; 12:2005-2016. [PMID: 30013320 PMCID: PMC6037408 DOI: 10.2147/dddt.s160431] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To summarize updated evidences on the efficacy and safety of adalimumab (ADA) in the treatment of patients with non-infectious uveitis. PATIENTS AND METHODS A systematic search between January 2000 and September 2017 was conducted using PubMed, Embase, and Cochrane libraries. We investigated control of inflammation, improvement of visual acuity (VA), corticosteroid-sparing effect, and adverse events (AEs) or serious adverse events. RESULTS Three randomized clinical trials (RCTs) and 20 non-RCTs were included and analyzed. The pooled proportions of inflammation control were 74% (95% CI 64%-82%) and 79% (95% CI 69%-87%) in groups of ≤6- and ≥12-months follow-up durations. No significant difference was found between the two groups (χ2 = 0.920, p = 0.337). Analysis of subgroups classified by degree of being treatment-naïve for anti-TNFα agents showed the inflammation control reached a high of 87% (95% CI 80%-92%) when subjects were "almost naïve" to anti-TNFα before ADA treatment. VA was improved by three or more lines in 41.3% (52/126) eyes, and was equal to or better than the baseline in 88.8% (142/160) eyes. Corticosteroid sparing was observed in 82.0% (91/111) of the patients; among them, 48.8% (40/82) discontinued use of corticosteroid completely. Minor drug-related adverse events were reported. The treatment effects of ADA were generally consistent in the three RCTs, and ADA reduced the risk of treatment failure by 43%-75%. CONCLUSION The current review provided evidences that ADA might be a promising choice in reducing inflammatory activity, gaining VA, and sparing corticosteroid use with minor AEs when applied in treating non-infectious uveitis.
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Affiliation(s)
- Shuai Ming
- Clinical Research Center, Henan Eye Institute, Henan Eye Hospital,
- Department of Ophthalmology, Henan Provincial People's Hospital,
| | - Kunpeng Xie
- Clinical Research Center, Henan Eye Institute, Henan Eye Hospital,
- Department of Ophthalmology, Henan Provincial People's Hospital,
| | - Huijuan He
- Clinical Research Center, Henan Eye Institute, Henan Eye Hospital,
- Department of Ophthalmology, Henan Provincial People's Hospital,
| | - Ya Li
- Clinical Research Center, Henan Eye Institute, Henan Eye Hospital,
- Department of Ophthalmology, Henan Provincial People's Hospital,
| | - Bo Lei
- Clinical Research Center, Henan Eye Institute, Henan Eye Hospital,
- Department of Ophthalmology, Henan Provincial People's Hospital,
- Department of Ophthalmology, People's Hospital of Zhengzhou University, Zhengzhou, China,
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22
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Shepherd J, Cooper K, Harris P, Picot J, Rose M. The clinical effectiveness and cost-effectiveness of abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis: a systematic review and economic evaluation. Health Technol Assess 2018; 20:1-222. [PMID: 27135404 DOI: 10.3310/hta20340] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Juvenile idiopathic arthritis (JIA) is characterised by joint pain, swelling and a limitation of movement caused by inflammation. Subsequent joint damage can lead to disability and growth restriction. Treatment commonly includes disease-modifying antirheumatic drugs (DMARDs), such as methotrexate. Clinical practice now favours newer drugs termed biologic DMARDs where indicated. OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of four biologic DMARDs [etanercept (Enbrel(®), Pfizer), abatacept (Orencia(®), Bristol-Myers Squibb), adalimumab (Humira(®), AbbVie) and tocilizumab (RoActemra(®), Roche) - with or without methotrexate where indicated] for the treatment of JIA (systemic or oligoarticular JIA are excluded). DATA SOURCES Electronic bibliographic databases including MEDLINE, EMBASE, The Cochrane Library and the Database of Abstracts of Reviews of Effects were searched for published studies from inception to May 2015 for English-language articles. Bibliographies of related papers, systematic reviews and company submissions were screened and experts were contacted to identify additional evidence. REVIEW METHODS Systematic reviews of clinical effectiveness, health-related quality of life and cost-effectiveness were undertaken in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. A cost-utility decision-analytic model was developed to compare the estimated cost-effectiveness of biologic DMARDs versus methotrexate. The base-case time horizon was 30 years and the model took a NHS perspective, with costs and benefits discounted at 3.5%. RESULTS Four placebo-controlled randomised controlled trials (RCTs) met the inclusion criteria for the clinical effectiveness review (one RCT evaluating each biologic DMARD). Only one RCT included UK participants. Participants had to achieve an American College of Rheumatology Pediatric (ACR Pedi)-30 response to open-label lead-in treatment in order to be randomised. An exploratory adjusted indirect comparison suggests that the four biologic DMARDs are similar, with fewer disease flares and greater proportions of ACR Pedi-50 and -70 responses among participants randomised to continued biologic DMARDs. However, confidence intervals were wide, the number of trials was low and there was clinical heterogeneity between trials. Open-label extensions of the trials showed that, generally, ACR responses remained constant or even increased after the double-blind phase. The proportions of adverse events and serious adverse events were generally similar between the treatment and placebo groups. Four economic evaluations of biologic DMARDs for patients with JIA were identified but all had limitations. Two quality-of-life studies were included, one of which informed the cost-utility model. The incremental cost-effectiveness ratios (ICERs) for adalimumab, etanercept and tocilizumab versus methotrexate were £38,127, £32,526 and £38,656 per quality-adjusted life year (QALY), respectively. The ICER for abatacept versus methotrexate as a second-line biologic was £39,536 per QALY. LIMITATIONS The model does not incorporate the natural history of JIA in terms of long-term disease progression, as the current evidence is limited. There are no head-to-head trials of biologic DMARDs, and clinical evidence for specific JIA subtypes is limited. CONCLUSIONS Biologic DMARDs are superior to placebo (with methotrexate where permitted) in children with (predominantly) polyarticular course JIA who have had an insufficient response to previous treatment. Randomised comparisons of biologic DMARDs with long-term efficacy and safety follow-up are needed to establish comparative effectiveness. RCTs for JIA subtypes for which evidence is lacking are also required. STUDY REGISTRATION This study is registered as PROSPERO CRD42015016459. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Jonathan Shepherd
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
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23
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Ku WN, Lin CJ, Tsai YY. The rescue effect of adalimumab in the treatment of refractory pediatric panuveitis complicated with steroid-induced glaucoma. Taiwan J Ophthalmol 2018; 8:164-167. [PMID: 30294530 PMCID: PMC6169335 DOI: 10.4103/tjo.tjo_63_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
We report the rescue effects of adalimumab (HUMIRA®) therapy in a case of refractory pediatric panuveitis complicated with steroid-induced glaucoma. A 13-year-old girl had suffered from blurred vision since January 2013. Bilateral idiopathic panuveitis with macular edema (ME) was diagnosed. She had previously been treated with systemic steroids, methotrexate, cyclosporine, and mycophenolate. All treatments had failed to suppress the ocular inflammation and ME persisted. Intravitreal dexamethasone implant injections were given to both eyes and ME subsided; however, complications with steroid-induced glaucoma and cataract occurred. ME also recurred following absorbance of the dexamethasone implant. After administration of subcutaneous adalimumab injections every 2 weeks, inflammatory activity was well controlled and ME subsided. Phacoemulsification and posterior intraocular lens implantation were performed in both eyes. Menorrhagia and anemia were noted 9 months after adalimumab treatment. Thereafter, adalimumab was reduced and her anemia improved. Her vision had remained 20/20 for 33 months. Refractory pediatric uveitis usually requires more aggressive treatment. Intraocular glucocorticoid releasing implant could be used to lessen the possible systemic side effects in children. Intravitreal dexamethasone implant was effective in treating the inflammatory ME but could be complicated with steroid glaucoma and cataract. Tumor necrosis factor-blocking agents have been used to treat chronic, refractory uveitis in adults as well as children. Adalimumab was a favorable biological agent in steroid-responding pediatric patient of refractory noninfectious uveitis but could be complicated with menorrhagia. Long-term follow-up and more cases are mandatory.
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Affiliation(s)
- Wei-Ning Ku
- Department of Ophthalmology, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Chun-Ju Lin
- Department of Ophthalmology, China Medical University Hospital, China Medical University, Taichung, Taiwan.,School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Yi-Yu Tsai
- Department of Ophthalmology, China Medical University Hospital, China Medical University, Taichung, Taiwan.,School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
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Quartier P, Baptiste A, Despert V, Allain-Launay E, Koné-Paut I, Belot A, Kodjikian L, Monnet D, Weber M, Elie C, Bodaghi B. ADJUVITE: a double-blind, randomised, placebo-controlled trial of adalimumab in early onset, chronic, juvenile idiopathic arthritis-associated anterior uveitis. Ann Rheum Dis 2017; 77:1003-1011. [PMID: 29275333 DOI: 10.1136/annrheumdis-2017-212089] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 11/24/2017] [Accepted: 11/29/2017] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To assess the efficacy and safety of adalimumab on uveitis in patients with early onset, chronic, juvenile idiopathic arthritis (JIA)-associated or idiopathic anterior uveitis and an inadequate response to topical steroids and methotrexate (MTX). METHODS Patients aged 4 years or more with ocular inflammation quantified by laser flare photometry (LFP) ≥30 photon units/ms were double-blindly randomised (1:1) to 2 groups, one treated with placebo and one with adalimumab subcutaneously at a dose of 24 mg/m2 in patients aged <13 years, 40 mg in the others, every other week. The primary outcome was response at month 2 (M2) defined as a 30% reduction of inflammation on LFP in the assessable eye with more severe baseline inflammation and no worsening on slit lamp examination. From M2 to M12, all patients received adalimumab. RESULTS At M2, among 31 patients included in intention-to-treat analysis, there were 9/16 responders on adalimumab and 3/15 on placebo (P=0.038, Χ2 test; relative risk=2.81, 95% CI 0.94 to 8.45; risk difference: 36.3%, 95% CI 2.1 to 60.6); there was no significant difference using the Standardised Uveitis Nomenclature classification criteria of improvement. Thirty patients continued the trial after M2 and received adalimumab (open-label phase), 29 reached M12. There were seven serious adverse events none related to study treatment. CONCLUSIONS This trial is in favour of using adalimumab in patients with early onset, chronic anterior uveitis, which is in most cases associated with JIA, in case of inadequate response to topical therapy and MTX. LFP could be a valuable tool to assess early treatment efficacy. TRIAL REGISTRATION NUMBER NCT01385826.
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Affiliation(s)
- Pierre Quartier
- Pediatric Immunology-Hematology and Rheumatology Unit, Necker-Enfants Malades University Hospital, Assistance Publique-Hopitaux de Paris, Paris, France.,Imagine Institute, Paris, France.,Paris Descartes University, Paris, France.,Pediatric Rheumatology and Systemic Auto-immune Diseases, RAISE National Reference Centre, Rennes, France
| | - Amandine Baptiste
- Clinical Research Unit/CIC Paris Descartes, Necker-Enfants Malades-Cochin University Hospital, Paris, France
| | | | | | - Isabelle Koné-Paut
- Pediatric Rheumatology Department, Kremlin-Bicêtre, Assistance Publique-Hopitaux de Paris, University of Paris-Sud, Orsay, France
| | - Alexandre Belot
- Pediatric Rheumatology and Systemic Auto-immune Diseases, RAISE National Reference Centre, Rennes, France.,Pediatric Nephrology, Rheumatology, Dermatology, University of Lyon, INSERM U1111, Lyon, France
| | | | - Dominique Monnet
- Paris Descartes University, Paris, France.,UMR-CNRS 52, University Hospital Cochin, Assistance Publique-Hopitaux de Paris, Nantes, France
| | - Michel Weber
- Department of Ophthalmology, University Hospital Hotel Dieu, Nantes, France
| | - Caroline Elie
- Clinical Research Unit/CIC Paris Descartes, Necker-Enfants Malades-Cochin University Hospital, Paris, France
| | - Bahram Bodaghi
- Department of Ophthalmology, University Hospital Pitie-Salpetriere, Paris, France
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Asproudis I, Katsanos A, Kozeis N, Tantou A, Konstas AG. Update on the Treatment of Uveitis in Patients with Juvenile Idiopathic Arthritis: A Review. Adv Ther 2017; 34:2558-2565. [PMID: 29143927 DOI: 10.1007/s12325-017-0635-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Indexed: 12/11/2022]
Abstract
Chronic uveitis is a common extra-articular manifestation of juvenile idiopathic arthritis. The classic clinical picture is one of chronic anterior uveitis, which usually remains asymptomatic until ocular complications arise. The risk of uveitis is increased in girls with an early onset of oligoarthritis and positive antinuclear antibodies. Even though the inflammation in patients with juvenile idiopathic arthritis is initially limited in the anterior part of the eye, chronic active inflammation may eventually cause significant damage to the posterior pole. Complications may include band keratopathy, cataract, secondary glaucoma, posterior synechiae, cystoid macular edema, and hypotony. The cooperation of ophthalmologists with rheumatologists may help define the best treatment plan. The ophthalmic therapeutic regimen includes topical corticosteroids and mydriatics, while in severe cases immunosuppressive and biological agents are introduced. Surgical management of complications might be needed.
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Abstract
The past two decades have brought immense satisfaction to pediatric rheumatologists and families of children with rheumatologic diseases. We have been able to better classify, recognize, and diagnose rheumatologic diseases, but most importantly, the discovery of biologic therapies and their efficacy and relative safety in treating multiple rheumatologic conditions, improving quality of life for the patients we care for. We will review the advances of the past two decades and discuss potential areas for new discoveries.
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Affiliation(s)
- Yonit Sterba
- Division of Pediatric Rheumatology, The Children's Hospital at Montefiore, 3415 Bainbridge Avenue, Bronx, NY, 10467, USA.
| | - Norman Ilowite
- Division of Pediatric Rheumatology, The Children's Hospital at Montefiore, 3415 Bainbridge Avenue, Bronx, NY, 10467, USA
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Abstract
INTRODUCTION Adalimumab, an inhibitor of tumor necrosis factor-alpha (TNFα), is the only systemic non-corticosteroid agent which has been approved by the US Food and Drug Administration (FDA) for the treatment of non-infectious uveitis. Areas covered: The aim of this review is to summarize the research which demonstrated the effectiveness of adalimumab in the treatment of intraocular inflammation and helped to establish its side effect profile, ultimately leading to its FDA approval. Expert commentary: Adalimumab is a useful second-line agent in the treatment of non-infectious uveitis. While it is only approved in the United States for use in intermediate, posterior, and panuveitis in adults, I find it to be effective in off-label treatment of pediatric uveitis and scleritis as well.
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Affiliation(s)
- Kara C LaMattina
- a Department of Ophthalmology , Northwestern University Feinberg School of Medicine , Chicago , IL , USA
| | - Debra A Goldstein
- a Department of Ophthalmology , Northwestern University Feinberg School of Medicine , Chicago , IL , USA
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Sood AB, Angeles-Han ST. An Update on Treatment of Pediatric Chronic Non-Infectious Uveitis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2017; 3:1-16. [PMID: 28944162 PMCID: PMC5604477 DOI: 10.1007/s40674-017-0057-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
There are no standardized treatment protocols for pediatric non-infectious uveitis. Topical corticosteroids are the typical first-line agent, although systemic corticosteroids are used in intermediate, posterior and panuveitic uveitis. Corticosteroids are not considered to be long-term therapy due to potential ocular and systemic side effects. In children with severe and/or refractory uveitis, timely management with higher dose disease-modifying antirheumatic drugs (DMARDs) and biologic agents is important. Increased doses earlier in the disease course may lead to improved disease control and better visual outcomes. In general, methotrexate is the usual first-line steroid-sparing agent and given as a subcutaneous weekly injection at >0.5 mg/kg/dose or 10-15 mg/m2 due to better bioavailability. Other DMARDs, for instance mycophenolate, azathioprine, and cyclosporine are less common treatments for pediatric uveitis. Anti-tumor necrosis factor-alpha agents, primarily infliximab and adalimumab are used as second line agents in children refractory to methotrexate, or as first-line treatment in those with severe complicated disease at presentation. Infliximab may be given at a minimum of 7.5 mg/kg/dose every 4 weeks after loading doses, up to 20 mg/kg/dose. Adalimumab may be given up to 20 or 40 mg weekly. In children who fail anti-tumor necrosis factor-alpha agents, develop anti-tumor necrosis factor-alpha antibodies, experience adverse effects, or have difficulty with tolerance, there is less data available regarding subsequent treatment. Promising results have been noted with tocilizumab infusions every 2-4 weeks, abatacept monthly infusions and rituximab.
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Calvo-Río V, Santos-Gómez M, Calvo I, González-Fernández MI, López-Montesinos B, Mesquida M, Adán A, Hernández MV, Maíz O, Atanes A, Bravo B, Modesto C, Díaz-Cordovés G, Palmou-Fontana N, Loricera J, González-Vela MC, Demetrio-Pablo R, Hernández JL, González-Gay MA, Blanco R. Anti-Interleukin-6 Receptor Tocilizumab for Severe Juvenile Idiopathic Arthritis-Associated Uveitis Refractory to Anti-Tumor Necrosis Factor Therapy: A Multicenter Study of Twenty-Five Patients. Arthritis Rheumatol 2017; 69:668-675. [DOI: 10.1002/art.39940] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 09/20/2016] [Indexed: 11/08/2022]
Affiliation(s)
- Vanesa Calvo-Río
- Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Marqués de Valdecilla (IDIVAL), and University of Cantabria; Santander Spain
| | - Montserrat Santos-Gómez
- Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Marqués de Valdecilla (IDIVAL), and University of Cantabria; Santander Spain
| | | | | | | | | | | | | | - Olga Maíz
- Hospital Universitario Donostia; San Sebastian Spain
| | | | - Beatriz Bravo
- Hospitalario Universitario Virgen de las Nieves; Granada Spain
| | | | | | - Natalia Palmou-Fontana
- Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Marqués de Valdecilla (IDIVAL), and University of Cantabria; Santander Spain
| | - Javier Loricera
- Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Marqués de Valdecilla (IDIVAL), and University of Cantabria; Santander Spain
| | - M. C. González-Vela
- Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Marqués de Valdecilla (IDIVAL), and University of Cantabria; Santander Spain
| | - Rosalía Demetrio-Pablo
- Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Marqués de Valdecilla (IDIVAL), and University of Cantabria; Santander Spain
| | - J. L. Hernández
- Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Marqués de Valdecilla (IDIVAL), and University of Cantabria; Santander Spain
| | - Miguel A. González-Gay
- Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Marqués de Valdecilla (IDIVAL), and University of Cantabria; Santander Spain
| | - Ricardo Blanco
- Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Marqués de Valdecilla (IDIVAL), and University of Cantabria; Santander Spain
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Outcome of Juvenile Idiopathic Arthritis Associated Uveitis in Two Disease Subtypes. Arch Rheumatol 2017; 32:26-31. [PMID: 30375520 DOI: 10.5606/archrheumatol.2017.6060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 05/28/2016] [Indexed: 02/07/2023] Open
Abstract
Objectives This study aims to evaluate the efficacy of adalimumab as a first line biologic agent in specific subtypes of juvenile idiopathic arthritis (JIA) patients with associated uveitis. Patients and methods We retrospectively analyzed the data of 11 JIA patients (8 males, 3 females; mean age 14.5 years; range 9 to 18 years) with associated uveitis treated with biologic therapy. All patients were diagnosed as oligoarticular/extended oligoarticular or enthesitis-related JIA subtypes, treated with methotrexate, and had active or previous history of uveitis for which adalimumab was prescribed. We tested all patients for anti-nuclear antibody presence and human leukocyte antigen genotype. We assessed disease activity and therapy efficacy by American College of Rheumatology 50%, 70%, and 100% improvement criteria. We evaluated uveitis activity by slit-lamp biomicroscopy and recorded adverse events. Results Of the JIA patients, three (27.27%) had oligoarticular/extended oligoarticular JIA and eight (72.73%) had enthesitis-related arthritis. Anti-nuclear antibody positivity was present in 27.27% (all females) while human leukocyte antigen-B51 was determined in 62.5% and human leukocyte antigen-B27 in 12.5% of patients. Mean uveitis duration before adalimumab introduction was 12.3 months. After two years of follow-up, there were no relapses of uveitis and visual acuity was stable while on adalimumab and methotrexate treatment. All patient were gradually tapered and discontinued treatment with topical steroids. Disease activity improved and seven patients (63.64%) achieved American College of Rheumatology 100% response rate (attained remission), while four patients (36.36%) achieved American College of Rheumatology 70% response rate. Conclusion Anti-nuclear antibody positivity with oligoarticular/extended oligoarticular and enthesitis-related arthritis JIA subtypes, which are known for their high risk to develop uveitis, may benefit from adalimumab as a first line anti-tumor necrosis factor agent.
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Advancements in the management of uveitis. Best Pract Res Clin Rheumatol 2016; 30:304-315. [PMID: 27886802 DOI: 10.1016/j.berh.2016.07.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 07/28/2016] [Indexed: 02/08/2023]
Abstract
Uveitis may exist as a clinical manifestation of an underlying systemic disease or may represent an idiopathic entity, sometimes with a very characteristic pattern. Different forms of uveitis have been defined on the basis of three important variables: chronicity, anatomic location, and underlying etiology. The evolving understanding of the immune system has resulted in a more targeted approach to manage patients with different forms of uveitis, although clearly this approach is at a very early stage. Altered patterns of cellular processing and different cytokine expression, including TNF, IL-1, IL-2, IL-6, and IL17, have been defined in uveitis, and this has laid the pathway for targeted therapy. Furthermore, approved biologic therapies for some of the more common autoimmune illnesses have now been tested in uveitis. Adalimumab and infliximab have been the best studied anti-TNF agents and indeed have now been recommended by an expert panel as the first line of treatment for ocular manifestations of Behçet's disease and the second line of treatment for other forms of uveitis. Adalimumab has been recently approved for intermediate uveitis, posterior uveitis, and panuveitis. Other biologic agents have been tested, including daclizumab, a monoclonal antibody directed against IL-2, anti-IL1, and anti-IL-6 receptor agents and therapies that block antigen-presenting cell and T-cell interaction, such as abatacept. In small case series, other biologics such as interferon and rituximab have also been evaluated. Although these biologic therapies have provided a larger armamentarium to treat uveitis, challenges remain. Uveitis is not a disease, but a manifestation of many potential systemic diseases that may have specific individual therapeutic targets. Identification and characterization of these underlying diseases are not always possible and, more importantly, the most effective therapies for each entity have not been defined. In this study, an approach to manage patients with uveitis is presented and current therapy is reviewed.
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Discontinuation of long-term adalimumab treatment in patients with juvenile idiopathic arthritis-associated uveitis. Graefes Arch Clin Exp Ophthalmol 2016; 255:171-177. [DOI: 10.1007/s00417-016-3497-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 09/09/2016] [Accepted: 09/14/2016] [Indexed: 12/12/2022] Open
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Kearsley-Fleet L, Davies R, Baildam E, Beresford MW, Foster HE, Southwood TR, Thomson W, Hyrich KL. Factors associated with choice of biologic among children with Juvenile Idiopathic Arthritis: results from two UK paediatric biologic registers. Rheumatology (Oxford) 2016; 55:1556-65. [PMID: 26732349 PMCID: PMC4993954 DOI: 10.1093/rheumatology/kev429] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 11/25/2015] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The objectives of this study were to describe patients starting first-line biologics for JIA, to describe characteristics over time among patients starting etanercept, and to describe patterns of second biologic prescribing. METHODS The British Society for Paediatric and Adolescent Rheumatology Etanercept Cohort Study, and the Biologics for Children with Rheumatic Diseases study are ongoing prospective observational cohorts, collecting data on patients starting biologic therapy for JIA. Patients registered from 1 January 2010 starting their first biologic were compared between therapies. Patients starting etanercept before 2010 were included to analyse changes in etanercept prescribing. The pathway of patients starting a second biologic was recorded in all patients. RESULTS To 26 August 2014, 931 patients were recruited starting a first-line biologic (142 Biologics for Children with Rheumatic Diseases; 789 British Society for Paediatric and Adolescent Rheumatology Etanercept Cohort Study). From 2010, patients with systemic JIA (sJIA) were almost exclusively prescribed anakinra or tocilizumab. Choice between anti-TNF therapies was largely driven by history of chronic anterior uveitis (CAU). When investigating trends in patients starting etanercept over time, disease duration at etanercept start, patients with sJIA, a history of CAU, and those who received concomitant oral corticosteroids decreased over time. Patients who started a second biologic from 1 January 2010 showed a similar stratification. CONCLUSION Although etanercept remains the most common biologic prescribed for JIA, there has been a clear shift towards the use of alternative biologics, largely driven by disease subtype and history of CAU. This channelling of children towards specific therapies should be considered carefully in future studies and in clinical guidelines and ongoing research.
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Affiliation(s)
- Lianne Kearsley-Fleet
- Arthritis Research UK Centre for Epidemiology, Manchester Academic Health Science Centre, The University of Manchester, Manchester
| | - Rebecca Davies
- Arthritis Research UK Centre for Epidemiology, Manchester Academic Health Science Centre, The University of Manchester, Manchester
| | | | - Michael W Beresford
- Clinical Academic Department of Paediatric Rheumatology, Institute of Translational Medicine (Child Health), University of Liverpool, Alder Hey Children's NHS Foundation Trust, Liverpool
| | - Helen E Foster
- Musculoskeletal Research Group, Institute Cellular Medicine, Newcastle University, Newcastle upon Tyne
| | - Taunton R Southwood
- Department of Paediatric Rheumatology, Institute of Child Health, Birmingham Children's Hospital - NHS Trust and University of Birmingham, Birmingham
| | - Wendy Thomson
- Arthritis Research UK Centre for Genetics and Genomics, Manchester Academic Health Science Centre and NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust and University of Manchester Partnership, Manchester, UK
| | - Kimme L Hyrich
- Arthritis Research UK Centre for Epidemiology, Manchester Academic Health Science Centre, The University of Manchester, Manchester, NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust and University of Manchester Partnership, Manchester, UK
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Abstract
Therapy for autoimmune ophthalmic disease is currently evolving. The improved understanding of the abnormal immune response in the various forms of uveitis has resulted in targeted therapy. The aberrations of the immune system have been characterized by atypical cell populations, cytokine expression, and cell-cell interactions. Different patterns of cytokine expression have now been delineated in the abnormal uveal tract with exaggerated and/or abnormal expression of TNF, IL-1, IL-2, IL-6, and IL-17. The development of therapies for other conditions in which these cytokines play an important role has resulted in the availability of biological agents that have been adopted for use in the therapy for uveitis. Adalimumab and infliximab have been the best studied anti-TNF agents and indeed have now been recommended by an expert panel as first-line treatment of ocular manifestations of Behçet's disease and second-line treatment for other forms of uveitis (Levy-Clarke et al. (Ophthalmology, 2013). Other anti-TNF agents have been studied as well. Daclizumab, a monoclonal antibody directed against the IL-2 receptor, has also demonstrated utility in treating uveitis as have some of the anti-IL1 agents. Gevokizumab has been granted orphan drug designation for the treatment of resistant forms of uveitis. Therapies affecting IL-6, including tocilizumab are being studied, and available medications that block antigen presenting cell and T cell interaction such as abatacept have been reported to be effective in uveitis. Interferons as well as rituximab have also been evaluated in small studies. Although these biologic therapies have provided a larger armamentarium to treat uveitis, challenges remain. Uveitis is not a single illness; rather, it is a manifestation of many potential systemic diseases that may have very specific individual therapeutic targets. Identifying and characterizing these underlying diseases is not always achieved, and more importantly, the most effective therapies for each entity have not been defined.
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Kheir V, Vaudaux J, Guex-Crosier Y. Review of the latest systemic treatments for chronic non-infectious uveitis. EXPERT REVIEW OF OPHTHALMOLOGY 2016. [DOI: 10.1586/17469899.2016.1153425] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Abu Samra K, Sahawneh H, Foster CS. The role of biologic response modifiers in the management of juvenile idiopathic arthritis associated uveitis: a review. EXPERT REVIEW OF OPHTHALMOLOGY 2016. [DOI: 10.1586/17469899.2016.1162097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kolomeyer AM, Tu Y, Miserocchi E, Ranjan M, Davidow A, Chu DS. Chronic Non-infectious Uveitis in Patients with Juvenile Idiopathic Arthritis. Ocul Immunol Inflamm 2016; 24:377-85. [PMID: 26902465 DOI: 10.3109/09273948.2015.1125509] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE To describe clinical findings and analyze treatment evolution of chronic, non-infectious uveitis in patients with juvenile idiopathic arthritis (JIA). METHODS A total of 82 patients (147 eyes) with JIA-related uveitis treated for ≥2 months were included (78% females; 79% bilateral uveitis; 74% anterior uveitis). Outcome measures were visual acuity (VA), inflammation control, side-effects, and surgical procedures. RESULTS Mean ± SD age at diagnosis was 4.9 ± 3.8 years; mean ± SD follow-up time was 8.7 ± 7.8 years. Mean VA did not significantly change throughout the study. Three (2%) eyes resulted in no light perception (NLP) vision. Thirty (37%) patients underwent 69 procedures. In total, 41 (50%) patients achieved inflammation control. TNF-α inhibitors were significantly associated with inflammation control. Seven (8.5%) patients stopped treatment due to side-effects. CONCLUSIONS JIA is a cause of significant ocular morbidity. TNF-α inhibitor use was associated with inflammation control. Prospective, randomized, double blind clinical trials in this regard are warranted.
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Affiliation(s)
- Anton M Kolomeyer
- a Department of Ophthalmology , University of Pittsburgh Medical Center , Pittsburgh , Pennsylvania , USA
| | - Yufei Tu
- b Institute of Ophthalmology and Visual Science , Rutgers University , Newark , New Jersey , USA
| | - Elisabetta Miserocchi
- c Department of Ophthalmology and Visual Sciences, Scientific Institute San Raffaele , University Vita-Salute , Milan , Italy
| | - Mangala Ranjan
- d Department of Quantitative Methods , Rutgers University , Newark , New Jersey , USA
| | - Amy Davidow
- d Department of Quantitative Methods , Rutgers University , Newark , New Jersey , USA
| | - David S Chu
- b Institute of Ophthalmology and Visual Science , Rutgers University , Newark , New Jersey , USA.,e Metropolitan Eye Research and Surgery Institute , Palisades Park, New Jersey , USA
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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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Llorenç V, Mesquida M, Sainz de la Maza M, Blanco R, Calvo V, Maíz O, Blanco A, de Dios-Jiménez de Aberásturi JR, Adán A. Certolizumab Pegol, a New Anti-TNF-α in the Armamentarium against Ocular Inflammation. Ocul Immunol Inflamm 2014; 24:167-72. [PMID: 25325834 DOI: 10.3109/09273948.2014.967779] [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: 12/14/2022]
Abstract
PURPOSE To study the efficacy and tolerance of certolizumab pegol (CZP) in active uveitis. METHODS Retrospective case series at 4 referral centers. Patients treated with CZP for active uveitis during at least 6 months were eligible. Inflammation by SUN scores, visual acuity (VA) (logMAR), and central macular thickness (CMT) were compared from baseline until final follow-up. Quiescence was defined as 0+ to 0.5+ in anterior chamber and vitreous haze scores and no CMT increase. RESULTS Four males and 3 females (14 eyes) were included, mean age 42.4 ± 8.8 years. All were long-lasting chronic-relapsing uveitis with prior failure to other anti-TNF-α. After a mean follow-up of 10.4 ± 4.8 months, 5/7 patients (71.4%) achieved quiescence with CZP. VA improved significantly from +0.52 ± 0.68 to +0.45 ± 0.68 (p = 0.032) at 1 month and to +0.44 ± 0.64 (p = 0.035) at 6 months. No adverse events were found. CONCLUSION CZP can be an effective alternative in refractory uveitis.
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Affiliation(s)
- Victor Llorenç
- a Clínic Institute of Ophthalmology (ICOF), Hospital Clínic of Barcelona , Barcelona , Spain
| | - Marina Mesquida
- a Clínic Institute of Ophthalmology (ICOF), Hospital Clínic of Barcelona , Barcelona , Spain
| | - Maite Sainz de la Maza
- a Clínic Institute of Ophthalmology (ICOF), Hospital Clínic of Barcelona , Barcelona , Spain
| | - Ricardo Blanco
- b Department of Rheumatology , Marqués de Valdecilla Hospital , Santander , Spain
| | - Vanesa Calvo
- b Department of Rheumatology , Marqués de Valdecilla Hospital , Santander , Spain
| | - Olga Maíz
- c Department of Rheumatology , Donostia Universitary Hospital , San Sebastián , Spain , and
| | - Ana Blanco
- c Department of Rheumatology , Donostia Universitary Hospital , San Sebastián , Spain , and
| | | | - Alfredo Adán
- a Clínic Institute of Ophthalmology (ICOF), Hospital Clínic of Barcelona , Barcelona , Spain
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