1
|
Dick AD, Rosenbaum JT, Al-Dhibi HA, Belfort R, Brézin AP, Chee SP, Davis JL, Ramanan AV, Sonoda KH, Carreño E, Nascimento H, Salah S, Salek S, Siak J, Steeples L. Guidance on Noncorticosteroid Systemic Immunomodulatory Therapy in Noninfectious Uveitis: Fundamentals Of Care for UveitiS (FOCUS) Initiative. Ophthalmology 2018; 125:757-773. [PMID: 29310963 DOI: 10.1016/j.ophtha.2017.11.017] [Citation(s) in RCA: 144] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 10/06/2017] [Accepted: 11/08/2017] [Indexed: 12/14/2022] Open
Abstract
TOPIC An international, expert-led consensus initiative to develop systematic, evidence-based recommendations for the treatment of noninfectious uveitis in the era of biologics. CLINICAL RELEVANCE The availability of biologic agents for the treatment of human eye disease has altered practice patterns for the management of noninfectious uveitis. Current guidelines are insufficient to assure optimal use of noncorticosteroid systemic immunomodulatory agents. METHODS An international expert steering committee comprising 9 uveitis specialists (including both ophthalmologists and rheumatologists) identified clinical questions and, together with 6 bibliographic fellows trained in uveitis, conducted a Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol systematic review of the literature (English language studies from January 1996 through June 2016; Medline [OVID], the Central Cochrane library, EMBASE, CINAHL, SCOPUS, BIOSIS, and Web of Science). Publications included randomized controlled trials, prospective and retrospective studies with sufficient follow-up, case series with 15 cases or more, peer-reviewed articles, and hand-searched conference abstracts from key conferences. The proposed statements were circulated among 130 international uveitis experts for review. A total of 44 globally representative group members met in late 2016 to refine these guidelines using a modified Delphi technique and assigned Oxford levels of evidence. RESULTS In total, 10 questions were addressed resulting in 21 evidence-based guidance statements covering the following topics: when to start noncorticosteroid immunomodulatory therapy, including both biologic and nonbiologic agents; what data to collect before treatment; when to modify or withdraw treatment; how to select agents based on individual efficacy and safety profiles; and evidence in specific uveitic conditions. Shared decision-making, communication among providers and safety monitoring also were addressed as part of the recommendations. Pharmacoeconomic considerations were not addressed. CONCLUSIONS Consensus guidelines were developed based on published literature, expert opinion, and practical experience to bridge the gap between clinical needs and medical evidence to support the treatment of patients with noninfectious uveitis with noncorticosteroid immunomodulatory agents.
Collapse
Affiliation(s)
- Andrew D Dick
- Ophthalmology, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom; Institute of Ophthalmology, University College London, London, United Kingdom; National Institute for Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital and Institute of Ophthalmology, University College London, London, United Kingdom.
| | - James T Rosenbaum
- Legacy Devers Eye Institute, Portland, Oregon; Department of Ophthalmology, Oregon Health & Science University, Portland, Oregon; Departments of Medicine and Cell Biology, Oregon Health & Science University, Portland, Oregon
| | - Hassan A Al-Dhibi
- Division of Vitreoretinal Surgery and Uveitis, King Khaled Eye Specialist Hospital, Riyadh, Kingdom of Saudi Arabia
| | - Rubens Belfort
- Department of Ophthalmology and Visual Sciences, Paulista School of Medicine, Federal University of São Paulo and Vision Institute, São Paulo, Brazil
| | - Antoine P Brézin
- Service d'ophtalmologie, Université Paris Descartes, Hôpital Cochin, Paris, France
| | - Soon Phaik Chee
- Ocular Inflammation and Immunology Service, Singapore National Eye Centre, Singapore, Republic of Singapore; Singapore Eye Research Institute, Singapore, Republic of Singapore; Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Republic of Singapore; Duke-National University of Singapore Medical School, Ophthalmology & Visual Sciences Academic Clinical Program, Singapore, Republic of Singapore
| | - Janet L Davis
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida
| | - Athimalaipet V Ramanan
- Ophthalmology, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom; Pediatric Rheumatology, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Koh-Hei Sonoda
- Department of Ophthalmology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ester Carreño
- Ophthalmology, Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | | | - Sawsen Salah
- Service d'ophtalmologie, Université Paris Descartes, Hôpital Cochin, Paris, France
| | - Sherveen Salek
- Department of Ophthalmology, Oregon Health & Science University, Portland, Oregon; The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jay Siak
- Ocular Inflammation and Immunology Service, Singapore National Eye Centre, Singapore, Republic of Singapore; Singapore Eye Research Institute, Singapore, Republic of Singapore; Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Republic of Singapore; Duke-National University of Singapore Medical School, Ophthalmology & Visual Sciences Academic Clinical Program, Singapore, Republic of Singapore
| | - Laura Steeples
- Ophthalmology, Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom; Manchester Royal Eye Hospital, Central Manchester University Hospitals, and University of Manchester, Manchester Academic Health Sciences Centre, Manchester, United Kingdom
| |
Collapse
|
2
|
Gómez-Gómez A, Loza E, Rosario MP, Espinosa G, de Morales JMGR, Herreras JM, Muñoz-Fernández S, Cordero-Coma M. Efficacy and safety of immunomodulatory drugs in patients with anterior uveitis: A systematic literature review. Medicine (Baltimore) 2017; 96:e8045. [PMID: 29049193 PMCID: PMC5662359 DOI: 10.1097/md.0000000000008045] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 08/15/2017] [Accepted: 08/18/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND To assess the efficacy and safety of immunomodulatory drugs in patients with noninfectious anterior uveitis (AU). METHODS Systematic review of studies were retrieved from Medline (1961 to March 2016), Embase (1961 to March 2016), and Cochrane Library (up to March 2016), and a complementary hand search was also performed. The selection criteria were as follows: (population) noninfectious AU patients, adults; (intervention) immunomodulatory drugs (any dose, regimen, route of administration, duration of treatment); (outcome) control of inflammation, steroid-sparing effect, AU flares, adverse events, and so on; (study design) systematic literature reviews, randomized controlled trials, and observational studies. The study quality was assessed using the Jadad scale and according to The Oxford Centre for Evidence-based Medicine (update 2009). RESULTS We included 13 studies of moderate-poor quality, with a mean duration from 5 months to 20 years, and number of AU patients ranging from 9 to 274. Patient's demographic and clinical characteristics were very heterogeneous. In most cases, uveitis anatomic classification criteria and outcomes definitions were unclear. Some of the studies only included AU patients with a systemic disease associated, mostly spondyloarthritis, others, mixed populations (idiopathic and systemic disease associated patients), and in some articles this data is not described. We found that methotrexate, cyclosporine A, azathioprine, adalimumab, and golimumab might prevent AU flares, improve ocular inflammation and visual acuity, and decrease systemic steroids doses. CONCLUSIONS Although there is a lack of robust evidence, methotrexate, cyclosporine A, azathioprine, adalimumab, and golimumab might be effective in AU patients.
Collapse
Affiliation(s)
- Alejandro Gómez-Gómez
- Reumatología HM Hospitales-Hospital Universitario HM Sanchinarro, Madrid
- Reumatología, Hospital Universitario Infanta Sofía, Madrid
| | | | | | - Gerard Espinosa
- Department of Autoimmune Diseases, Institut Clinic de Medicina i Dermatologia, Hospital Clínic, Barcelona
| | - José M. García Ruiz de Morales
- Unidad de Inmunología, Complejo Asistencial Universitario e Instituto de Biomedicina Universidad de León (IBIOMED), León
| | - Jose M. Herreras
- Instituto Universitario de Oftalmobiología (IOBA), Universitdad de Valladolid, Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Hospital Clínico Universitario de Valladolid
| | | | - Miguel Cordero-Coma
- Unidad de Uveitis, Complejo Asistencial Universitario e Instituto de Biomedicina Universidad de León (IBIOMED), León, Spain
| |
Collapse
|
3
|
Castiblanco C, Meese H, Foster CS. Treatment of pediatric uveitis with adalimumab: the MERSI experience. J AAPOS 2016; 20:145-7. [PMID: 27079596 DOI: 10.1016/j.jaapos.2015.12.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 12/02/2015] [Accepted: 12/04/2015] [Indexed: 01/31/2023]
Abstract
PURPOSE To evaluate adalimumab therapy in children with uveitis. METHODS The electronic health records of pediatric patients diagnosed with uveitis and treated with adalimumab therapy were reviewed retrospectively. Demographic information, site and degree of intraocular inflammation, visual acuity, underlying systemic disorders, duration of therapy, side effects, and ability to obtain steroid-free remission were recorded. RESULTS A total of 17 patients were included, 16 patients with anterior uveitis and 1 with panuveitis; 14 patients had bilateral disease. Juvenile idiopathic arthritis had been diagnosed in 14 patients, sarcoidosis in 1 patient, and idiopathic etiology in 2 patients. Of the 17 patients, 13 (about 77%) achieved steroid-free remission, and 4 did not. Six patients flared after discontinuation of adalimumab, with evidence of inflammation noted 3-7 months later. Adalimumab therapy was of 12-64 months' duration (mean, 36 months). At the time of initiation, 14 patients were using other agents concomitantly with adalimumab; 3 patients were on adalimumab monotherapy. At 1 year's follow-up, 12 patients were using combination therapy, and 3 patients were on adalimumab monotherapy: 11 patients had no evidence of inflammation. Side effects included pain at site of injection in 3 patients, anemia in 1 patient, and depression in 1 patient. CONCLUSIONS In our study cohort, adalimumab was effective in inducing steroid-free remission. It was well tolerated, especially in combination with other immunomodulatory agents. The dosing and the interval can be adjusted to further improve inflammation control.
Collapse
Affiliation(s)
- Claudia Castiblanco
- Massachusetts Eye Research and Surgery Institution (MERSI), Waltham, Massachusetts; Ocular Immunology and Uveitis Foundation (OIUF), Waltham, Massachusetts
| | - Halea Meese
- Massachusetts Eye Research and Surgery Institution (MERSI), Waltham, Massachusetts; Ocular Immunology and Uveitis Foundation (OIUF), Waltham, Massachusetts
| | - C Stephen Foster
- Massachusetts Eye Research and Surgery Institution (MERSI), Waltham, Massachusetts; Ocular Immunology and Uveitis Foundation (OIUF), Waltham, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| |
Collapse
|
4
|
Saboo US, Metzinger JL, Radwan A, Arcinue C, Parikh R, Mohamed A, Foster CS. Risk factors associated with the relapse of uveitis in patients with juvenile idiopathic arthritis: a preliminary report. J AAPOS 2013; 17:460-4. [PMID: 24160963 DOI: 10.1016/j.jaapos.2013.06.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Revised: 05/24/2013] [Accepted: 06/12/2013] [Indexed: 12/17/2022]
Abstract
PURPOSE To identify risk factors associated with relapse of uveitis in patients with recurrent uveitis associated with juvenile idiopathic arthritis (JIA) after treatment with immunomodulatory therapy (IMT) and durable remission of 1 year. METHODS The medical records of 30 patients with JIA-associated uveitis who were successfully treated with IMT to a state of corticosteroid-free remission and subsequently remained in remission after discontinuation of IMT for a period of at least 1 year were retrospectively reviewed. In subsequent follow-up, some patients had relapse of uveitis, whereas others continued to be in remission. Remission was defined as <1 + cells in the anterior chamber and <1 + vitreous haze grading; relapse was defined as ≥ 1 + cell in the anterior chamber or ≥ 1 + vitreous haze grading. RESULTS A total of 30 patients were included. Of these, 17 (56.7%) patients remained in uveitic remission, whereas 13 (43.3%) relapsed. The patients in remission received IMT earlier in the course of disease compared with patients who relapsed (median, 12 months vs 72 months; P = 0.002 [Mann-Whitney test]). Patients in remission had received treatment with IMT at a younger age compared with the relapse group (median age, 7 years vs 13 years; P = 0.02 [Mann-Whitney test]). None of the other factors studied revealed a statistically significant association. CONCLUSIONS Patients with JIA-associated uveitis who were treated with IMT earlier in the course of disease and at a younger age were associated with a lower rate of relapse of uveitis after durable remission and 1 year of quiescence, compared with similar patients who relapsed.
Collapse
Affiliation(s)
- Ujwala S Saboo
- Massachusetts Eye Research and Surgery Institution, Cambridge, Massachusetts; Ocular Immunology and Uveitis Foundation, Cambridge, Massachusetts
| | | | | | | | | | | | | |
Collapse
|
6
|
Siddique SS, Shah R, Suelves AM, Foster CS. Road to remission: a comprehensive review of therapy in uveitis. Expert Opin Investig Drugs 2011; 20:1497-515. [PMID: 21936708 DOI: 10.1517/13543784.2011.617741] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Although uveitis remains the third leading cause of preventable blindness in the US, the care and management of patients with uveitis and ocular inflammatory disease sit poised to make evolutionary if not revolutionary changes in the years ahead. This review serves to highlight important advances in the pharmacologic options available for the treatment of uveitis and ocular inflammation. AREAS COVERED Advances in steroid therapy (both topical and extended delivery), updates in the clinical safety of systemic immune modulation, and the emerging therapies for uveitis and ocular inflammatory disease are some of the areas covered in this review. EXPERT OPINION Corticosteroids have been the mainstay in the care of patients with ocular inflammatory disorders for many years. Indeed, some physicians still use only steroids for treating inflamed eyes. However, the mission is remission of all corticosteroids in order to prevent the complications associated with long-term corticosteroid use. The goal is to achieve quiescence through aggressive use of corticosteroids to extinguish the fire and then move along to achieve steroid-free remission through immunosuppressant agents.
Collapse
Affiliation(s)
- Sana S Siddique
- Massachusetts Eye Research and Surgery Institution, 5 Cambridge Center, 8th floor, Cambridge, MA 02412 , USA.
| | | | | | | |
Collapse
|