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Maccora I, Soldovieri S, Oliverio T, de Masi S, Marrani E, Pagnini I, Mastrolia MV, Simonini G. To switch or to swap? Evidence from a meta-analysis for the best treatment approach in childhood chronic uveitis resistant to the I anti-TNF. J Transl Autoimmun 2024; 9:100247. [PMID: 39027719 PMCID: PMC11254593 DOI: 10.1016/j.jtauto.2024.100247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 06/20/2024] [Accepted: 06/22/2024] [Indexed: 07/20/2024] Open
Abstract
Objective Since adalimumab approval in childhood chronic non-infectious uveitis (cNIU), the prognosis has been dramatically changed, but the 25 % failed to achieve inactivity. There is not accordance if it is better to switch to another anti-TNF or to swap to another category of biologic. Thus, we aim to summarize evidence regarding the best treatment of cNIU refractory to the first anti-TNF. Methods A systematic literature review and meta-analysis, according to PRISMA Guidelines, was performed(Jan2000-Aug2023). Studies investigating the efficacy of treatment in cNIU refractory to the first anti-TNF were considered for inclusion. The primary outcome was the improvement of intraocular inflammation according to SUN. A combined estimation of the proportion of children responding to switch or swap and for each drug was performed. Results 23 articles were eligible, reporting 150 children of whom 109 switched anti-TNF (45 adalimumab, 49 infliximab, 9 golimumab) and 41 swapped to another biologics (31 abatacept, 8 tocilizumab and 1 rituximab). The proportion of responding children was 46 %(95 % CI 23-70) for switch and 38 %(95 % CI 8-73) for swap (χ20.02, p = 0.86). Instead analysing for each drug, the proportion of responding children was the 24 %(95 % CI 2-55) for adalimumab, 43 %(95 % CI 2-80) for abatacept, 79 %(95 % CI 61-93) for infliximab, 56 %(95 % CI 14-95) for golimumab and 96 %(95 % CI 58-100) for tocilizumab. We evaluated a superiority of tocilizumab and infliximab compared to the other drugs(χ2 27.5 p < 0.0001). Conclusion Although non-conclusive, this meta-analysis suggests that, after the first anti-TNF failure, tocilizumab and infliximab are the best available treatment for the management of cNIU.
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Affiliation(s)
- Ilaria Maccora
- Rheumatology Unit, ERN ReCONNET Centre, Meyer Children's Hospital IRCCS, Florence, Italy
- NeuroFARBA Department, University of Florence, Florence, Italy
| | - Sara Soldovieri
- Rheumatology Unit, ERN ReCONNET Centre, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Teodoro Oliverio
- Rheumatology Unit, ERN ReCONNET Centre, Meyer Children's Hospital IRCCS, Florence, Italy
| | | | - Edoardo Marrani
- Rheumatology Unit, ERN ReCONNET Centre, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Ilaria Pagnini
- Rheumatology Unit, ERN ReCONNET Centre, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Maria Vincenza Mastrolia
- Rheumatology Unit, ERN ReCONNET Centre, Meyer Children's Hospital IRCCS, Florence, Italy
- NeuroFARBA Department, University of Florence, Florence, Italy
| | - Gabriele Simonini
- Rheumatology Unit, ERN ReCONNET Centre, Meyer Children's Hospital IRCCS, Florence, Italy
- NeuroFARBA Department, University of Florence, Florence, Italy
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Tao T, Yang S, He D, Peng X, Wang Z, Jiang Q, Wang T, Su W. The Efficacy of Adalimumab in Children with Chronic Non-infectious Posterior Uveitis and Panuveitis: A Retrospective Cohort Study. Ophthalmol Ther 2024; 13:1239-1253. [PMID: 38498278 DOI: 10.1007/s40123-024-00884-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 09/06/2023] [Indexed: 03/20/2024] Open
Abstract
INTRODUCTION This study aimed to assess the efficacy and safety of adalimumab in pediatric patients with chronic non-infectious posterior uveitis and panuveitis (not associated with juvenile idiopathic arthritis). METHODS The medical records of children (< 18 years old) with chronic non-infectious posterior uveitis and panuveitis were collected and analyzed in this retrospective cohort study. Children were allocated to a conventional adalimumab-free treatment (CT) or adalimumab (ADA) group based on whether they additionally received adalimumab. RESULTS In total, 69 children (138 eyes) were included, with 21 (42 eyes) and 48 (96 eyes) in the CT and ADA groups, respectively. During the average follow-up period of 24 months, the improvement in all ocular parameters (best-corrected visual acuity, intraocular inflammation, fluorescein angiography score) was better in the ADA group than in the CT group, except for changes in central macular thickness, which did not significantly differ between the groups. The mean time of first alleviation, which was after 1.03 ± 0.12 months of therapy, was earlier in the ADA group than in the CT group (2.30 ± 0.46 months). In the ADA group, 90.6% of children had remission within 3 months, and 47.9% had no relapse during follow-up. Cough and cold were the most common adverse events in the ADA group; however, the number of adverse events was similar between both the groups. CONCLUSIONS Adalimumab was effective in the treatment of chronic noninfectious posterior uveitis and panuveitis in pediatric patients, and disease inactivity was accomplished in the majority of the patients, thereby improving visual outcomes and maintaining disease stability. Adverse events were limited and tolerable.
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Affiliation(s)
- Tianyu Tao
- State Key Laboratory of Ophthalmology, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Zhongshan Ophthalmic Center, Sun Yat-Sen University, No 54, Xianlie S. Rd, Yuexiu Dist., Guangzhou, 510000, China
| | - Shizhao Yang
- State Key Laboratory of Ophthalmology, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Zhongshan Ophthalmic Center, Sun Yat-Sen University, No 54, Xianlie S. Rd, Yuexiu Dist., Guangzhou, 510000, China
- Department of Ophthalmology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Daquan He
- State Key Laboratory of Ophthalmology, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Zhongshan Ophthalmic Center, Sun Yat-Sen University, No 54, Xianlie S. Rd, Yuexiu Dist., Guangzhou, 510000, China
| | - Xuening Peng
- State Key Laboratory of Ophthalmology, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Zhongshan Ophthalmic Center, Sun Yat-Sen University, No 54, Xianlie S. Rd, Yuexiu Dist., Guangzhou, 510000, China
| | - Zhenyu Wang
- State Key Laboratory of Ophthalmology, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Zhongshan Ophthalmic Center, Sun Yat-Sen University, No 54, Xianlie S. Rd, Yuexiu Dist., Guangzhou, 510000, China
| | - Qi Jiang
- State Key Laboratory of Ophthalmology, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Zhongshan Ophthalmic Center, Sun Yat-Sen University, No 54, Xianlie S. Rd, Yuexiu Dist., Guangzhou, 510000, China
| | - Tianfu Wang
- State Key Laboratory of Ophthalmology, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Zhongshan Ophthalmic Center, Sun Yat-Sen University, No 54, Xianlie S. Rd, Yuexiu Dist., Guangzhou, 510000, China
| | - Wenru Su
- State Key Laboratory of Ophthalmology, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Zhongshan Ophthalmic Center, Sun Yat-Sen University, No 54, Xianlie S. Rd, Yuexiu Dist., Guangzhou, 510000, China.
- Guangdong Provincial Clinical Research Center for Ocular Diseases, No 54, Xianlie S. Rd, Yuexiu Dist., Guangzhou, 510000, China.
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Nguyen AT, Koné-Paut I, Dusser P. Diagnosis and Management of Non-Infectious Uveitis in Pediatric Patients. Paediatr Drugs 2024; 26:31-47. [PMID: 37792254 DOI: 10.1007/s40272-023-00596-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2023] [Indexed: 10/05/2023]
Abstract
Uveitis in children accounts for 5-10% of all cases. The causes vary considerably. Classically, uveitis is distinguished according to its infectious or inflammatory origin and whether it is part of a systemic disease or represents an isolated ocular disease. It is important to highlight the specificity of certain etiologies among children such as juvenile idiopathic arthritis. The development of visual function can potentially be hindered by amblyopia (children aged < 7 years), in addition to the usual complications (synechiae, macular edema) seen in adult patients. Moreover, the presentation of uveitis in children is often "silent" with few warning signs and few functional complaints from young children, which frequently leads to a substantial diagnostic delay. The diagnostic approach is guided by the presentation of the uveitis, which can be characterized by its location, and corresponds to the initial and main site of intraocular inflammation; its presentation, whether acute or chronic, granulomatous or not; and the response to treatment. Pediatricians have an important role to play and must be aware of the various presentations and etiologies of uveitis in children. Juvenile idiopathic arthritis is the most common etiology of pediatric non-infectious uveitis, but other causes must be recognized. Promptly initiated treatment before complications arise requires early diagnosis, recognition, and treatment. Any dependence on prolonged local corticosteroid therapy justifies discussing the introduction of a corticosteroid-sparing treatment considering the risk to develop corticoid-induced glaucoma and cataracts. Systemic corticosteroid therapy can be required for urgent control of inflammation in the case of severe uveitis. Long-lasting immunosuppressive treatment and biotherapies are most often prescribed at the same time to reinforce treatment efficacy and to prevent relapse and corticosteroid dependency. We review the different causes of uveitis, excluding infection, and the diagnostic and therapeutic management aimed at limiting the risk of irreversible sequelae.
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Affiliation(s)
- Ai Tien Nguyen
- Department of Pediatric Rheumatology, CeReMAIA, CHU Bicêtre, Assistance Publique-Hôpitaux de Paris, Université de Paris Saclay, 78 Rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, Le Kremlin-Bicêtre, France.
| | - Isabelle Koné-Paut
- Department of Pediatric Rheumatology, CeReMAIA, CHU Bicêtre, Assistance Publique-Hôpitaux de Paris, Université de Paris Saclay, 78 Rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, Le Kremlin-Bicêtre, France
| | - Perrine Dusser
- Department of Pediatric Rheumatology, CeReMAIA, CHU Bicêtre, Assistance Publique-Hôpitaux de Paris, Université de Paris Saclay, 78 Rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, Le Kremlin-Bicêtre, France
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Khochtali S, Ozdal P, AlBloushi AF, Nabi W, Khairallah M. Pediatric Pars Planitis: A Review. Ocul Immunol Inflamm 2023; 31:1915-1929. [PMID: 37976519 DOI: 10.1080/09273948.2023.2279683] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 10/31/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE To provide an overview of pediatric pars planitis. METHODS Narrative literature review. RESULTS Pars planitis refers to the idiopathic subset of intermediate uveitis in which there is vitritis along with snowball or snowbank formation occurring in the absence of an associated infection or systemic disease. It is thought to be a T-cell mediated disease with a genetic predisposition. Pars planitis accounts for 5-26.7% of pediatric uveitis cases. Presentation is commonly bilateral but asymmetric, often with insidious onset of floaters and blurred vision. Although pars planitis is known to be a benign form of uveitis in most cases, severe complications secondary to chronic inflammation may arise, with cystoid macular edema being the most common cause of visual morbidity. Mild vitritis in the absence of symptoms, vision loss, or macular edema may be observed. Patients with severe vitritis and/or associated vision-threatening complications require prompt aggressive treatment. A stepladder approach including corticosteroids, immunosuppressive agents, anti‑tumor necrosis factor‑alpha and pars plana vitrectomy and/or laser photocoagulation is the most commonly used method for treatment of pars planitis. CONCLUSION Timely diagnosis and adequate treatment of pediatric pars planitis and associated complications are crucial in order to improve visual outcomes.
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Affiliation(s)
- Sana Khochtali
- Department of Ophthalmology, Faculty of Medicine, Fattouma Bourguiba University Hospital, University of Monastir, Monastir, Tunisia
| | - Pinar Ozdal
- Service of Uveitis and Retinal Diseases, Ankara Ulucanlar Eye Research Hospital, Ankara, Turkiye
| | - Abdulrahman F AlBloushi
- Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Wijdène Nabi
- Department of Ophthalmology, Faculty of Medicine, Fattouma Bourguiba University Hospital, University of Monastir, Monastir, Tunisia
| | - Moncef Khairallah
- Department of Ophthalmology, Faculty of Medicine, Fattouma Bourguiba University Hospital, University of Monastir, Monastir, Tunisia
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Batu ED, Sener S, Cam V, Aktay Ayaz N, Ozen S. Treatment with Biologic Drugs in Pediatric Behçet's Disease: A Comprehensive Analysis of the Published Data. BioDrugs 2023; 37:813-828. [PMID: 37382804 DOI: 10.1007/s40259-023-00613-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND AND OBJECTIVE Behçet's disease (BD) is a variable vessel vasculitis. Biologic drugs are increasingly used in the treatment of BD. We aimed to analyze biologic drug use in the treatment of pediatric BD. METHODS MEDLINE/PubMed and Scopus databases were searched from the inception of these databases until 15 November 2022, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Only reports presenting data of pediatric patients with BD (BD diagnosis < 18 years of age) treated with biologic drugs were included. The demographic features, clinical characteristics, and data on treatment were extracted from the included papers. RESULTS We included 87 articles including 187 pediatric patients with BD treated with biologic drugs (215 biologic treatments). Tumor necrosis factor (TNF)-α inhibitors (176 treatments) were the most frequently used biologic drugs followed by interferons (21 treatments). Other reported biologic treatments were anti-interleukin-1 agents (n = 11), tocilizumab (n = 4), daclizumab (n = 2), and rituximab (n = 1). The most common indication for biologic drug use was ocular involvement (93 treatments) followed by multisystem active disease (29 treatments). Monoclonal TNF-α inhibitors, adalimumab and infliximab, were preferred over etanercept in ocular and gastrointestinal BD. The improvement rates with any TNF-α inhibitor, adalimumab, infliximab, etanercept, and interferons were 78.5%, 86.1%, 63.4%, 87.5%, and 70%; respectively. The organ-specific improvement rate with TNF-α inhibitors was 76.7% and 70% for ocular and gastrointestinal system involvement. Adverse events have been reported for TNF-α inhibitors, interferons, and rituximab. Six of these were severe [TNF-α inhibitors (n = 4); interferons (n = 2)]. CONCLUSIONS The presented systematic literature search revealed that TNF-α inhibitors followed by interferons were the most frequently used biologic drugs in pediatric BD. Both group of biologic treatments appeared to be effective and have an acceptable safety profile in pediatric BD. However, controlled studies are required for analyzing indications for biologic treatments in pediatric BD.
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Affiliation(s)
- Ezgi Deniz Batu
- Division of Rheumatology, Department of Pediatrics, Hacettepe Üniversitesi İhsan Doğramacı Çocuk Hastanesi, Çocuk Romatoloji Bölümü, Kat: 3 Sıhhiye, 06100, Ankara, Turkey.
| | - Seher Sener
- Division of Rheumatology, Department of Pediatrics, Hacettepe Üniversitesi İhsan Doğramacı Çocuk Hastanesi, Çocuk Romatoloji Bölümü, Kat: 3 Sıhhiye, 06100, Ankara, Turkey
| | - Veysel Cam
- Division of Rheumatology, Department of Pediatrics, Hacettepe Üniversitesi İhsan Doğramacı Çocuk Hastanesi, Çocuk Romatoloji Bölümü, Kat: 3 Sıhhiye, 06100, Ankara, Turkey
| | - Nuray Aktay Ayaz
- Division of Rheumatology, Department of Pediatrics, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Seza Ozen
- Division of Rheumatology, Department of Pediatrics, Hacettepe Üniversitesi İhsan Doğramacı Çocuk Hastanesi, Çocuk Romatoloji Bölümü, Kat: 3 Sıhhiye, 06100, Ankara, Turkey
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Kobak S. Treat to target and tight control: Could be a new approach in the treatment of sarcoidosis? Intractable Rare Dis Res 2023; 12:22-28. [PMID: 36873668 PMCID: PMC9976097 DOI: 10.5582/irdr.2022.01123] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/30/2023] [Accepted: 02/19/2023] [Indexed: 02/23/2023] Open
Abstract
Sarcoidosis is a chronic granulomatous disease with multisystemic involvement. Although it is accepted as a benign disease, it can sometimes cause life-threatening organ (heart, brain) involvement that determines the prognosis of the disease. There are conflicting opinions about the treatment of the disease. In the generally accepted treatment approach the "step-by-step" model has gained weight. According to this approach, corticosteroids (CS) drugs alone are preferred in the first step in patients who require treatment. In the second step, immunosuppressive drugs (IS) are used in patients who do not respond to CS and/or have contraindications to CS use, and biologics (TNF-alpha inhibitors) are used in the third step. This treatment approach may be valid in cases with mild sarcoidosis. However, although sarcoidosis is considered a benign and self-limiting disease in some major organ involvement, the "step-by-step" approach may be a treatment option that puts the patient's life in danger. In such selected patients, much more rigorous, early and combined treatment approaches that definitely include CS, IS or biologic drugs may be required. In selected sarcoidosis patients with high risk, early diagnosis, "treat-to-target" (T2T) and "tight control" follow-up of patients seems to be a rational approach. This article reviews the "step-down" treatment regimens in light of recent literature data and hypothesizes that the T2T model may be a probable new treatment approach in patients with sarcoidosis.
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Affiliation(s)
- Senol Kobak
- Istinye University Faculty of Medicine, Liv Hospital, Department of Internal Medicine and Rheumatology, WASOG Sarcoidosis Clinic, Istanbul,Turkey
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7
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Anti-tumor necrosis factor-alpha treatment in pediatric patients with pars planitis: a single-center experience from Turkey. Int Ophthalmol 2023; 43:155-166. [PMID: 35780435 DOI: 10.1007/s10792-022-02398-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 06/14/2022] [Indexed: 02/07/2023]
Abstract
AIM To evaluate the effectiveness and safety of anti-tumor necrosis factor-alpha (anti-TNF-alpha) treatment (Adalimumab [ADA]) combined with immunomodulatory agents (IMAs) in the treatment of pars planitis (PP). METHODS The patients with PP who were treated with anti-TNF-alpha agents for at least six months were qualified for the chart review. The outcome parameters were the steroid-free remission state, the best-corrected visual acuity (BCVA) and the central macular thickness (CMT) of the patients at the last visit. RESULTS After a mean total follow-up time of 15.5 ± 5.8 months (8-24 months), all the cases were in steroid-free remission at the last visit. The mean BCVA increased, and the mean CMT decreased significantly at the last visit (p < 0.001, p < 0.001, respectively). CONCLUSION ADA combined with IMAs offers effective and safe treatment modalities in the control of chronic intraocular inflammation in PP cases.
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Mandarelli G, Iannone F, Ferracuti S, Grattagliano I, Benevento M, Solarino B, Ferorelli D, Catanesi R. Informed consent and biological agents in rheumatology and internal medicine. Eur J Clin Invest 2022; 52:e13805. [PMID: 35488744 PMCID: PMC9539695 DOI: 10.1111/eci.13805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/19/2022] [Accepted: 04/23/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND The need for highly effective therapies in rheumatologic diseases has led to the widespread and growing use of a heterogeneous class of molecules called biological agents. The increasing experience with biological agents has raised concerns about safety and efficacy issues that need to be discussed in the informed consent acquisition process. METHODS The authors performed a review of the literature on biological agents focusing on their most important characteristics concerning the informed consent procedures. RESULTS No studies specifically addressed the issue of informed consent in patients receiving biological agents. Several studies reported data about off-label use of biological agents usually with no obvious attention to informed consent shortcomings. CONCLUSION The reported association between biological agents and serious infections or malignancies, including reactivation of latent tuberculosis, needs specific disclosure in informed consent acquisition, together with information about the possible efficacy in clinical contexts often characterized by resistance to previous treatments. Ethical and clinical issues bound to the need for experimenting with new agents with potentially serious adverse effects deserve specific attention. Studies aimed at evaluating mental capacity to consent in subjects receiving biological agents are required.
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Lambuk L, Ahmad S, Sadikan MZ, Nordin NA, Kadir R, Nasir NAA, Chen X, Boer J, Plebanski M, Mohamud R. Targeting Differential Roles of Tumor Necrosis Factor Receptors as a Therapeutic Strategy for Glaucoma. Front Immunol 2022; 13:857812. [PMID: 35651608 PMCID: PMC9149562 DOI: 10.3389/fimmu.2022.857812] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 04/19/2022] [Indexed: 11/13/2022] Open
Abstract
Glaucoma is an irreversible sight-threatening disorder primarily due to elevated intraocular pressure (IOP), leading to retinal ganglion cell (RGC) death by apoptosis with subsequent loss of optic nerve fibers. A considerable amount of empirical evidence has shown the significant association between tumor necrosis factor cytokine (TNF; TNFα) and glaucoma; however, the exact role of TNF in glaucoma progression remains unclear. Total inhibition of TNF against its receptors can cause side effects, although this is not the case when using selective inhibitors. In addition, TNF exerts its antithetic roles via stimulation of two receptors, TNF receptor I (TNFR1) and TNF receptor II (TNFR2). The pro-inflammatory responses and proapoptotic signaling pathways predominantly mediated through TNFR1, while neuroprotective and anti-apoptotic signals induced by TNFR2. In this review, we attempt to discuss the involvement of TNF receptors (TNFRs) and their signaling pathway in ocular tissues with focus on RGC and glial cells in glaucoma. This review also outlines the potential application TNFRs agonist and/or antagonists as neuroprotective strategy from a therapeutic standpoint. Taken together, a better understanding of the function of TNFRs may lead to the development of a treatment for glaucoma.
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Affiliation(s)
- Lidawani Lambuk
- Department of Immunology, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
| | - Suhana Ahmad
- Department of Immunology, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
| | - Muhammad Zulfiqah Sadikan
- Centre for Neuroscience Research (NeuRon), Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh, Malaysia
| | - Nor Asyikin Nordin
- Department of Immunology, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
| | - Ramlah Kadir
- Department of Immunology, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
| | - Nurul Alimah Abdul Nasir
- Centre for Neuroscience Research (NeuRon), Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh, Malaysia
| | - Xin Chen
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macau SAR, China
| | - Jennifer Boer
- School of Health and Biomedical Sciences, Royal Melbourne Institute Technology (RMIT) University, Bundoora, VIC, Australia
| | - Magdalena Plebanski
- School of Health and Biomedical Sciences, Royal Melbourne Institute Technology (RMIT) University, Bundoora, VIC, Australia
| | - Rohimah Mohamud
- Department of Immunology, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
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Gupta S, Shyamsundar K, Agrawal M, Vichare N, Biswas J. Current Knowledge of Biologics in Treatment of Noninfectious Uveitis. J Ocul Pharmacol Ther 2022; 38:203-222. [DOI: 10.1089/jop.2021.0098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Simple Gupta
- Department of Ophthalmology, Command Hospital, Pune, India
| | - K. Shyamsundar
- Department of Ophthalmology, Command Hospital, Pune, India
| | - Mohini Agrawal
- Department of Ophthalmology, Command Hospital, Pune, India
| | - Nitin Vichare
- Department of Ophthalmology, Command Hospital, Pune, India
| | - Jyotirmay Biswas
- Department of Uveitis and Ocular Pathology, Sankara Netralaya, Chennai, India
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Abstract
Juvenile idiopathic arthritis (JIA) is an umbrella term for arthritis of unknown origin, lasting for >6 weeks with onset before 16 years of age. JIA is the most common chronic inflammatory rheumatic condition of childhood. According to the International League Against Rheumatism (ILAR) classification, seven mutually exclusive categories of JIA exist based on disease manifestations during the first 6 months of disease. Although the ILAR classification has been useful to foster research, it has been criticized mainly as it does not distinguish those forms of chronic arthritis observed in adults and in children from those that may be unique to childhood. Hence, efforts to provide a new evidence-based classification are ongoing. Similar to arthritis observed in adults, pathogenesis involves autoimmune and autoinflammatory mechanisms. The field has witnessed a remarkable improvement in therapeutic possibilities of JIA owing to the availability of new potent drugs and the possibility to perform controlled trials with support from legislative interventions and large networks availability. The goal of drug therapy in JIA is to rapidly reduce disease activity to inactive disease or clinical remission, minimize drug side effects and achieve a quality of life comparable to that of healthy peers. As JIA can influence all aspects of a child's and their family's life, researchers increasingly recognize improvement of health-related quality of life as a key treatment goal.
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Salido Olivares M, Loza Santamaría E. Efficacy and safety of the optimisation of biological therapy in non-infectious uveitis: Systematic review. Semin Arthritis Rheum 2022; 52:151944. [PMID: 35027247 DOI: 10.1016/j.semarthrit.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/04/2021] [Accepted: 11/10/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To conduct a systematic critical review of the literature on the efficacy and safety of biological therapy (BT) optimisation in non-infectious uveitis (NIU). METHODS Searches were conducted (PubMed, Embase, Cochrane and conference abstracts) up to March 2021. The study population comprised patients with NIU in remission after BT. We analysed BT optimisation strategies. The main outcome measures were efficacy and safety. To assess the risk of bias, the ROBINS-1 tool was used. A qualitative review of the data was performed to assess heterogeneity and bias. Evidence tables (study characteristics and outcomes) were generated, and quantitative synthesis was performed if data were homogeneous. RESULTS We selected 11 studies (prospective and retrospective) including 513 patients. The studies were at moderate/high risk of bias and there was considerable variability between studies in sample size, underlying diseases, definitions and outcome variables. Criteria for starting optimisation were not uniform. All BTs optimised were TNF inhibitors. Optimisation could be attempted after 3-6 months in remission. Relapse occurred in 25-50% of patients but was controlled after dose re-escalation or BT switching. No safety issues were identified. CONCLUSIONS The optimization of BT (with TNF inhibitors) has been applied in patients with NIU in remission. There is no consensus on criteria for attempting BT optimisation and protocols are heterogeneous. There is a least moderate risk of bias, so no robust conclusions on efficacy and safety of optimization can be reached. Preliminary evidence suggests that relapses might be controlled using standard doses. Larger studies using uniform criteria are needed.
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13
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Systemic Immunosuppression for the Treatment of Pediatric Uveitis. Int Ophthalmol Clin 2022; 62:155-175. [PMID: 34965233 DOI: 10.1097/iio.0000000000000402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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14
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Abstract
Childhood noninfectious uveitis leads to sight-threatening complications. Idiopathic chronic anterior uveitis and juvenile idiopathic arthritis-associated uveitis are most common. Inflammation arises from an immune response against antigens within the eye. Ophthalmic work-up evaluates anatomic involvement, disease activity, ocular complications, and disease course. Local and/or systemic glucocorticoids are initial treatment, but not as long-term sole therapy to avoid glucocorticoids-induced toxicity or persistent ocular inflammation. Children with recurrent, refractory, or severe disease require systemic immunosuppression with methotrexate and/or anti-tumor necrosis factor monoclonal antibody medications (adalimumab, infliximab). Goals of early detection and treatment are to optimize vision in childhood uveitis.
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Affiliation(s)
- Margaret H Chang
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Fegan 6, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Jessica G Shantha
- Department of Ophthalmology, Emory University, Emory Eye Center, 1365 Clifton Road, Clinic Building B, Atlanta, GA 30326, USA
| | - Jacob J Fondriest
- Department of Internal Medicine, Summa Health System, Internal Medicine Center, 55 Arch Street, Suite 1B, Akron, OH 44304, USA; Rush Eye Center, 1725 West Harrison Street, Suite 945, Chicago, IL 60612, USA
| | - Mindy S Lo
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Fegan 6, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Sheila T Angeles-Han
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, 3333 Burnett Avenue, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA; Division of Ophthalmology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Ophthalmology, University of Cincinnati, Cincinnati, OH, USA.
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15
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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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16
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Maleki A, Anesi SD, Look-Why S, Manhapra A, Foster CS. Pediatric uveitis: A comprehensive review. Surv Ophthalmol 2021; 67:510-529. [PMID: 34181974 DOI: 10.1016/j.survophthal.2021.06.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 06/15/2021] [Accepted: 06/21/2021] [Indexed: 12/14/2022]
Abstract
Pediatric uveitis accounts for 5-10% of all uveitis. Uveitis in children differs from adult uveitis in that it is commonly asymptomatic and can become chronic and cause damage to ocular structures. The diagnosis might be delayed for multiple reasons, including the preverbal age and difficulties in examining young children. Pediatric uveitis may be infectious or noninfectious in etiology. The etiology of noninfectious uveitis is presumed to be autoimmune or autoinflammatory. The most common causes of uveitis in this age group are idiopathic and juvenile idiopathic arthritis-associated uveitis. The stepladder approach for the treatment of pediatric uveitis is based on expert opinion and algorithms proposed by multidisciplinary panels. Uveitis morbidities in pediatric patients include cataract, glaucoma, and amblyopia. Pediatric patients with uveitis should be frequently examined until remission is achieved. Once in remission, the interval between follow-up visits can be extended; however, it is recommended that even after remission the child should be seen every 8-12 weeks depending on the history of uveitis and the medications used. Close follow up is also necessary as uveitis can flare up during immunomodulatory therapy. It is crucial to measure the impact of uveitis, its treatment, and its complications on the child and the child's family. Visual acuity can be considered as an acceptable criterion for assessing visual function. Additionally, the number of cells in the anterior chamber can be a measure of disease activity. We review different aspects of pediatric uveitis. We discuss the mechanisms of noninfectious uveitis, including autoimmune and autoinflammatory etiologies, and the risks of developing uveitis in children with systemic rheumatologic diseases. We address the risk factors for developing morbidities, the Standardization of Uveitis Nomenclature (SUN) criteria for timing and anatomical classifications, and describe a stepladder approach in the treatment of pediatric uveitis based on expert opinion and algorithms proposed by multi-disciplinary panels. In this review article, We describe the most common entities for each type of anatomical classification and complications of uveitis for the pediatric population. Additionally, we address monitoring of children with uveitis and evaluation of Quality of Life.
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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
| | - Stephen D Anesi
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA; The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
| | - Sydney Look-Why
- 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
| | - C Stephen Foster
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA; The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA; Harvard Medical School, Department of Ophthalmology, Boston, MA, USA.
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17
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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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18
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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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19
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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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20
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Ogbue OD, Malhotra P, Akku R, Jayaprakash T, Khan S. Biologic Therapies in Sarcoidosis and Uveitis: A Review. Cureus 2020; 12:e9057. [PMID: 32782876 PMCID: PMC7413313 DOI: 10.7759/cureus.9057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Sarcoidosis and uveitis are chronic inflammatory conditions with potentially debilitating effects on quality of life. Steroids form the mainstay standard therapy in both conditions. Biologic agents are considered to be appropriate alternatives for treatment in steroid-refractory sarcoidosis and uveitis due to the role of tumor necrosis factor (TNF) in mediating the inflammatory cascade seen in both conditions. We performed a thorough literature search using PubMed to compare the extent of use, efficacy, and safety profile of individual anti-TNF agents in the management of these conditions. Our review consists of two systematic reviews with meta-analysis, thirteen observational studies, and fifteen case series/reports. Infliximab had the widest range of organ-system usage in extra-pulmonary sarcoidosis but is equivalent to adalimumab in terms of efficacy. In uveitis, adalimumab was found to be the most efficacious agent for maintaining disease remission in adults and children with chronic non-infectious uveitis. Etanercept was neither used widely, nor was it efficacious in the management of either condition. In terms of safety profile, biologic agents were found to be well tolerated and have a similar safety profile. More randomized clinical trials are needed to inform evidence-based use of biologic agents in these conditions.
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21
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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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22
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Butbul Aviel Y, Batu ED, Sözeri B, Aktay Ayaz N, Baba L, Amarilyo G, Şimşek S, Harel L, Karadag SG, Bilginer Y, Özen S. Characteristics of pediatric Behçet's disease in Turkey and Israel: A cross-sectional cohort comparison. Semin Arthritis Rheum 2020; 50:515-520. [DOI: 10.1016/j.semarthrit.2020.01.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 12/03/2019] [Accepted: 01/03/2020] [Indexed: 12/14/2022]
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23
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Valenzuela RA, Flores I, Urrutia B, Fuentes F, Sabat PE, Llanos C, Cuitino L, Urzua CA. New Pharmacological Strategies for the Treatment of Non-Infectious Uveitis. A Minireview. Front Pharmacol 2020; 11:655. [PMID: 32508634 PMCID: PMC7250389 DOI: 10.3389/fphar.2020.00655] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 04/22/2020] [Indexed: 12/14/2022] Open
Abstract
Non-infectious uveitis (NIU) is a group of disorders characterized by intraocular inflammation at different levels of the eye. NIU is a leading cause of irreversible blindness in working-age population in the developed world. The goal of uveitis treatment is to control inflammation, prevent recurrences, and preserve vision, as well as minimize the adverse effects of medications. Currently, the standard of care for NIU includes the administration of corticosteroids (CS) as first-line agents, but in some cases a more aggressive therapy is required. This includes synthetic immunosuppressants, such as antimetabolites (methotrexate, mycophenolate mofetil, and azathioprine), calcineurinic inhibitors (cyclosporine, tacrolimus), and alkylating agents (cyclophosphamide, chlorambucil). In those patients who become intolerant or refractory to CS and conventional immunosuppressive treatment, biologic agents have arisen as an effective therapy. Among the most evaluated treatments, TNF-α inhibitors, IL blockers, and anti-CD20 therapy have emerged. In this regard, anti-TNF agents (infliximab and adalimumab) have shown the strongest results in terms of favorable outcomes. In this review, we discuss latest evidence concerning to the effectiveness of biologic therapy, and present new therapeutic approaches directed against immune components as potential novel therapies for NIU.
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Affiliation(s)
- Rodrigo A Valenzuela
- Laboratory of Ocular and Systemic Autoimmune Diseases, Faculty of Medicine, University of Chile, Santiago, Chile.,Department of Chemical and Biological Sciences, Faculty of Health, Universidad Bernardo O Higgins, Santiago, Chile
| | - Iván Flores
- Laboratory of Ocular and Systemic Autoimmune Diseases, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Beatriz Urrutia
- Rheumatology Service, Department of Medicine, Hospital Clinico Universidad de Chile, Santiago, Chile
| | - Francisca Fuentes
- Laboratory of Ocular and Systemic Autoimmune Diseases, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Pablo E Sabat
- Department of Ophthalmology, University of Chile, Santiago, Chile.,Department of Ophthalmology, Clínica las Condes, Santiago, Chile
| | - Carolina Llanos
- Departamento de Inmunología Clínica y Reumatología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Loreto Cuitino
- Laboratory of Ocular and Systemic Autoimmune Diseases, Faculty of Medicine, University of Chile, Santiago, Chile.,Servicio de Oftalmología, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Cristhian A Urzua
- Laboratory of Ocular and Systemic Autoimmune Diseases, Faculty of Medicine, University of Chile, Santiago, Chile.,Department of Ophthalmology, University of Chile, Santiago, Chile.,Faculty of Medicine, Clinica Alemana-Universidad del Desarrollo, Santiago, Chile
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24
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Heiligenhaus A, Klotsche J, Tappeiner C, Sengler C, Niewerth M, Liedmann I, Hoeft S, Walscheid K, Lavric M, Foell D, Minden K. Predictive factors and biomarkers for the 2-year outcome of uveitis in juvenile idiopathic arthritis: data from the Inception Cohort of Newly diagnosed patients with Juvenile Idiopathic Arthritis (ICON-JIA) study. Rheumatology (Oxford) 2020; 58:975-986. [PMID: 30590748 PMCID: PMC6532445 DOI: 10.1093/rheumatology/key406] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 11/01/2018] [Indexed: 11/25/2022] Open
Abstract
Objective To define predictors for the 2-year outcome in terms of achieving inactivity, subsequent uveitis reactivation and occurrence of uveitis-related complications of JIA-associated uveitis. Methods Demographic and clinical parameters and serum samples of JIA-associated uveitis patients enrolled in ICON at ⩽1 year of JIA diagnosis were collected at study enrolment, every 3 months during the first year and subsequently every 6 months. Predictors for the 2-year outcome were evaluated by linear mixed models. Results Of 954 JIA patients included, uveitis occurred in 106 up to the first 2-year follow-up, with 98 of them having complete ophthalmological documentation. In 81.8% and 80.0% of patients, uveitis inactivity was achieved at the 1- and 2-year follow-up after uveitis onset, respectively. JIA onset after the age of 5 years, no use of topical corticosteroids, and adalimumab treatment were significantly associated with an inactive uveitis for at least 6 months (n = 57). Correlates for subsequent uveitis reactivation (n = 16, 30.2%) were age at uveitis onset ⩽5 years and active disease (clinical Juvenile Arthritis Disease Activity Score >4.5). Uveitis-related complications were present in 29.8% of patients at first uveitis documentation and in 30.7% and 32.8% at 1- and 2-year follow-up, respectively. Older age at JIA onset, short duration between JIA and uveitis onset, high anterior chamber (AC) cell grades, poor visual acuity, and topical steroid use at first uveitis documentation correlated with uveitis-related complications. Conclusion In addition to demographic risk factors, JIA disease and uveitis activity scores and adalimumab are significant predictors for the 2-year outcome of JIA-associated uveitis patients.
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Affiliation(s)
- Arnd Heiligenhaus
- Department of Ophthalmology at St Franziskus Hospital, University of Duisburg-Essen, Münster
| | - Jens Klotsche
- German Rheumatism Research Center, a Leibniz Institute, Berlin.,Institute for Social Medicine, Epidemiology and Health Economics, Charité - University Medicine Berlin, Berlin, Germany
| | - Christoph Tappeiner
- Department of Ophthalmology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Claudia Sengler
- German Rheumatism Research Center, a Leibniz Institute, Berlin
| | | | - Ina Liedmann
- German Rheumatism Research Center, a Leibniz Institute, Berlin
| | | | - Karoline Walscheid
- Department of Ophthalmology at St Franziskus Hospital, University of Duisburg-Essen, Münster
| | - Miha Lavric
- Department of Paediatric Rheumatology and Immunology, University of Muenster, Münster
| | - Dirk Foell
- Department of Paediatric Rheumatology and Immunology, University of Muenster, Münster
| | - Kirsten Minden
- German Rheumatism Research Center, a Leibniz Institute, Berlin.,Department of Rheumatology and Clinical Immunology Charité - University Medicine Berlin, Berlin, Germany
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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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26
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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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Szepessy Z, Barboni MTS, Farkas A, Nagy ZZ, Németh J. Retinal Function in Patients with Adalimumab Treatment: Long-term Follow-up with Microperimetry. Ocul Immunol Inflamm 2019; 29:370-375. [PMID: 31697184 DOI: 10.1080/09273948.2019.1672198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Purpose: To examine the effects of a biological treatment (adalimumab) on visual function in patients with ankylosing spondylitis and in uveitic patients without macular edema during one-year treatment with adalimumab.Methods: Sixteen eyes of eight consecutive Caucasian patients treated with adalimumab were followed up using microperimetry (MAIA; CenterVue, Padova, Italy). Five patients had ankylosing spondylitis without uveitis, three patients had panuveitis without macular edema. Macular sensitivity and macular integrity were recorded.Results: During six-month follow-up, the average threshold did not change significantly (p = .649). Macular integrity was stable (p = .225). The macular sensitivity point analysis showed no significant effects (examination F(3,56) = 0.494 and p = .688; point*examination F(108,2016) = 0.688 and p = .994) during the follow-up.Conclusions: During one-year follow-up, adalimumab did not affect macular function, unlike the well-established maculopathy induced by hydroxychloroquine. Microperimetry may be considered when following-up macular function in patients undertaking adalimumab.
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Affiliation(s)
- Zsuzsanna Szepessy
- Department of Ophthalmology, Semmelweis University, Budapest, Hungary.,Bionics Innovation Center, Budapest, Hungary
| | - Mirella T S Barboni
- Department of Ophthalmology, Semmelweis University, Budapest, Hungary.,Bionics Innovation Center, Budapest, Hungary.,Department of Experimental Psychology, Institute of Psychology, University of Sao Paulo, São Paulo, Brazil
| | - Alexandra Farkas
- Department of Ophthalmology, Semmelweis University, Budapest, Hungary
| | - Zoltán Zsolt Nagy
- Department of Ophthalmology, Semmelweis University, Budapest, Hungary
| | - János Németh
- Department of Ophthalmology, Semmelweis University, Budapest, Hungary.,Bionics Innovation Center, Budapest, Hungary
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Frequency and Identification of Risk Factors of Uveitis in Juvenile Idiopathic Arthritis: A Long-term Follow-up Study in a Cohort of Italian Children. J Clin Rheumatol 2019; 26:285-288. [PMID: 31609817 DOI: 10.1097/rhu.0000000000001104] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease of childhood. The JIA-associated uveitis represents the most common extra-articular manifestation. OBJECTIVES The main aim of this study was to evaluate frequency and risk factors of uveitis in a pediatric population affected by JIA. METHODS One hundred eight Italian children with JIA were followed during a follow-up period of 13 years. Association between uveitis, antinuclear antibodies (ANAs), and subtype of arthritis has been estimated, and Kaplan-Meier curves were generated to assess the probability of ocular complications during the follow-up period. RESULTS Twenty-one patients developed uveitis, after 96.5 ± 50.4 months from the enrollment. According to JIA subtypes, the oligoarthritis subtype was characterized by the highest prevalence (39%) of uveitis. The greatest risk of uveitis has been detected in oligoarthritis patients associated to ANA positivity (risk ratio, 8.6; 95% confidence interval, 2.27-32.9; χ = 20.4), whereas the worst evolution was revealed in patients with oligoarthritis and high levels of ANAs, with a progression time of 36 months (log-rank χ = 16.39; p < 0.0001; risk ratio, 18; 95% confidence interval, 7.3-44.2). CONCLUSIONS Patients with early-onset ANA-positive oligoarticular JIA have the highest risk of developing uveitis. A routine ophthalmological follow-up is required at regular intervals, even though the joint disease is clinically quiescent.
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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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Adalimumab in the treatment of pediatric Behçet’s disease: case-based review. Rheumatol Int 2019; 39:1107-1112. [PMID: 30976833 DOI: 10.1007/s00296-019-04300-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 04/02/2019] [Indexed: 12/18/2022]
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31
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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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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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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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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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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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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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Carreño E, Portero A, Herreras JM, García-Vázquez C, Whitcup SM, Stern ME, Calonge M, Enríquez-de-Salamanca A. Cytokine and chemokine tear levels in patients with uveitis. Acta Ophthalmol 2017; 95:e405-e414. [PMID: 27873479 DOI: 10.1111/aos.13292] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 09/13/2016] [Indexed: 12/14/2022]
Abstract
PURPOSE To determine whether the levels of cytokines and chemokines in tears differ in uveitis patients and healthy subjects. METHODS Ninety-two uveitis patients (mean age 46.4 years) and 157 control healthy subjects (mean age 49.5 years) were recruited. Subjects with ocular surface diseases such as dry eye were excluded from the study. Using multiplex bead-based assays, tears (4 μl) were analysed for the concentration of interleukin (IL)-1β, IL-1RA, IL-2, IL-6, IL-7, IL-8/CXCL8, IL-10, IL-12p70, IL-15, IL-17A, IL-23, epidermal growth factor (EGF), fractalkine/CX3CL1, interferon-γ, IP-10/CXCL10, monocyte chemo-attractant protein (MCP)-1/CCL2, tumour necrosis factor-α, vascular endothelial growth factor (VEGF), transforming growth factor (TGF)-β1, TGF-β2 and TGF-β3. Tear molecule levels were compared between the groups and among the different forms of uveitis and disease severity. RESULTS Epidermal growth factor, IL-1RA, IL-7, IL-8/CXCL8, IP-10/CXCL10, MCP-1/CCL2, TGF-β2 and VEGF were detected in more than 75% of the samples in both groups. Statistically significant differences in percentage of detection between control and patient groups were found for IL-23, IL-1β, IL-15, EGF, fractalkine/CX3CL1 and MCP-1/CCL2. The concentrations of IL-1RA, IL-8/CXCL8, fractalkine/CX3CL1, IP-10/CXCL10, VEGF and TGF-β2 in uveitis tear samples were elevated compared to controls (p < 0.05). Significant differences in tear levels of those molecules and also EGF were also present depending on the anatomic classification of uveitis. CONCLUSION There were significant differences in the levels of several cytokines and chemokines in tears of patients with uveitis compared with healthy subjects. These results can help understand the underlying pathophysiology of the uveitis and could potentially aid in diagnosis.
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Affiliation(s)
- Ester Carreño
- IOBA (Institute of Applied OphthalmoBiology); University of Valladolid; Valladolid Spain
| | - Alejandro Portero
- IOBA (Institute of Applied OphthalmoBiology); University of Valladolid; Valladolid Spain
| | - José M. Herreras
- IOBA (Institute of Applied OphthalmoBiology); University of Valladolid; Valladolid Spain
- University Clinic Hospital; Valladolid Spain
- CIBER-BBN (Biomedical Research Networking Center in Bioengineering, Biomaterials and Nanomedicine); Valladolid Spain
| | - Carmen García-Vázquez
- IOBA (Institute of Applied OphthalmoBiology); University of Valladolid; Valladolid Spain
| | | | | | - Margarita Calonge
- IOBA (Institute of Applied OphthalmoBiology); University of Valladolid; Valladolid Spain
- CIBER-BBN (Biomedical Research Networking Center in Bioengineering, Biomaterials and Nanomedicine); Valladolid Spain
| | - Amalia Enríquez-de-Salamanca
- IOBA (Institute of Applied OphthalmoBiology); University of Valladolid; Valladolid Spain
- CIBER-BBN (Biomedical Research Networking Center in Bioengineering, Biomaterials and Nanomedicine); Valladolid Spain
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Abstract
PURPOSE OF REVIEW The review provides updates on novel risk markers for the development of pediatric inflammatory uveitis and a severe disease course, on treatment of refractory disease, and on the measurement of visual outcomes. RECENT FINDINGS There are several new genetic markers, biomarkers, and clinical factors that may influence a child's uveitis disease course. It is important to identify children at risk for poor visual outcomes and who are refractory to traditional therapy. Racial disparities have recently been reported. We describe agents of potential benefit. In addition, we discuss the importance of patient reported outcomes in this population. SUMMARY Uveitis can lead to vision-threatening complications. Timely and aggressive treatment of children identified to be at risk for a severe uveitis course may lead to improved outcomes.
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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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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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Birolo C, Zannin ME, Arsenyeva S, Cimaz R, Miserocchi E, Dubko M, Deslandre CJ, Falcini F, Alessio M, La Torre F, Denisova E, Martini G, Nikishina I, Zulian F. Comparable Efficacy of Abatacept Used as First-line or Second-line Biological Agent for Severe Juvenile Idiopathic Arthritis-related Uveitis. J Rheumatol 2016; 43:2068-2073. [DOI: 10.3899/jrheum.151389] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2016] [Indexed: 11/22/2022]
Abstract
Objective.Abatacept (ABA) has recently been proposed as second-line treatment in patients with juvenile idiopathic arthritis (JIA)–associated uveitis refractory to anti–tumor necrosis factor-α (anti-TNF) agents, but little is known about its efficacy as a first-line approach. The aim of the present study was to compare the safety and efficacy of ABA as a first-line biological agent (ABA-1) with that of ABA as a second-line treatment after 1 or more anti-TNF agents (ABA-2), in patients with severe JIA-related uveitis.Methods.In this multicenter study, we collected data on patients with severe JIA-related uveitis treated with ABA as a first-line or second-line biological agent. Changes in frequency of uveitis flares/year and ocular complications before and after ABA treatment, clinical remission, and side effects were recorded.Results.Thirty-five patients with a mean age of 10.8 years were treated with ABA for a mean period of 19.6 months. In 4 patients, ABA administration was discontinued, owing to inefficacy on arthritis in 3 cases and allergic reaction in 1. Thirty-one patients, 14 in the ABA-1 group and 17 in the ABA-2 group, completed the 12-month followup period; of these, 17 (54.8%) had clinical remission. The mean frequency of uveitis flares decreased from 4.1 to 1.2 in the ABA-1 group (p = 0.002) and from 3.7 to 1.2 in the ABA-2 group (p = 0.004). Preexisting ocular complications improved or remained stable in all but 5 patients, all in the ABA-2 group. No significant difference was found between the efficacy of the 2 treatment modalities. ABA confirmed its good safety profile.Conclusion.ABA, used as first-line biological treatment or after 1 or more anti-TNF agents, induces a comparable improvement in severe refractory JIA-related uveitis.
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Application of multiplex immunoassay technology to investigations of ocular disease. Expert Rev Mol Med 2016; 18:e15. [PMID: 27577534 DOI: 10.1017/erm.2016.15] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Eye-derived fluids, including tears, aqueous humour and vitreous humour often contain molecular signatures of ocular disease states. These signatures can be composed of cytokines, chemokines, growth factors, proteases and soluble receptors. However, the small quantities (<10 µl) of these fluids severely limit the detection of these proteins by traditional enzyme-linked immunosorbent assay or Western blot. To maximise the amount of information generated from the analysis of these specimens, many researchers have employed multiplex immunoassay technologies for profiling the expression or modification of multiple proteins from minute sample volumes.
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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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Foeldvari I. Ocular Involvement in Juvenile Idiopathic Arthritis: Classification and Treatment. Clin Rev Allergy Immunol 2016; 49:271-7. [PMID: 25081063 DOI: 10.1007/s12016-014-8436-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Juvenile idiopathic arthritis (JIA) is one of the most common rheumatic diseases in childhood with a prevalence of 4 in 1,000 children. Anterior uveitis is a well-known threatening comorbid condition of JIA and affects around 10 % of the patients depending on JIA subtype. A large proportion of children with JIA develop uveitis in the first year of disease and 73 to 90 % after 4 years. Uveitis can progress into adulthood and usually occurs as 'white uveitis', while in the JIA related to the enthesitis subtype that is symptomatic. Current studies reinforced the previous observations that early age of JIA onset, oligoarticular subtype and ANA reactivity are the main risk factors for the development of uveitis. Factors associated to worse prognosis are as follows: findings of 1+ or more vitreous cells at presentation and initial visual acuity of 20/200 or worse. The Standardization of Uveitis Nomenclature (SUN) Group took the first step to define outcome measures for uveitis, but it was established for adults. The Multinational Interdisciplinary Working Group for Uveitis in Childhood (MIWGUC) proposed outcome measures for JIA-associated uveitis incorporating the SUN criteria in 2011. The current suggested management recommends to start early a steroid-sparing effective immunomodulatory systemic treatment. Methylprednisolone intravenous pulse therapy, rituximab, tocilizumab and abatacept are promising agents. Because JIA-associated uveitis is a potentially threatening comorbidity, it is important to recognize and treat it early to prevent any visual damage that could impair visual acuity.
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Affiliation(s)
- Ivan Foeldvari
- Hamburger Zentrum für Kinder- und Jugendrheumatologie am Klinikum Eilbek, Dehnhaide 120, 22081, Hamburg, Germany.
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Adalimumab for the treatment of refractory noninfectious paediatric uveitis. Int Ophthalmol 2016; 37:719-725. [PMID: 27432171 DOI: 10.1007/s10792-016-0293-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Accepted: 07/12/2016] [Indexed: 01/04/2023]
Abstract
To report the experience of our center with the use of adalimumab (ADA) for the treatment of severe refractory noninfectious paediatric uveitis. The study is a retrospective case series of all paediatric patients with refractory uveitis who were treated with ADA at the Paediatric Uveitis Unit of our center from 2008 to 2015. We present 12 patients (6 Juvenile idiopathic arthritis-associated uveitis, 4 idiopathic panuveitis, 1 early-onset sarcoidosis-associated panuveitis, and 1 intermediate uveitis), with uveitis in 19/24 eyes. Once ADA therapy was started, all the patients presented improved activity according to Standardization of Uveitis Nomenclature (SUN) criteria. Nine out of the 12 patients had structural damage before ADA could be started: cataract (n = 4), glaucoma (n = 2), cystic macular edema (n = 1), exudative retinal detachment (n = 1), and optic disk edema (n = 5). Visual acuity improved or maintained stable in 17/19 affected eyes, and only 2 eyes decreased its visual acuity because of structural damage, which was already present before ADA therapy. In our experience, ADA presents a good safety profile and is efficacious in the treatment of paediatric patients with different forms of refractory noninfectious uveitis.
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Ozdal PC, Berker N, Tugal-Tutkun I. Pars Planitis: Epidemiology, Clinical Characteristics, Management and Visual Prognosis. J Ophthalmic Vis Res 2016; 10:469-80. [PMID: 27051493 PMCID: PMC4795398 DOI: 10.4103/2008-322x.176897] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Pars planitis is an idiopathic chronic intermediate uveitis which predominantly affects children and adolescents, and accounts for 5-26.7% of pediatric uveitis. Although an autoimmune process with a genetic predisposition has been suggested, its etiology still remains unknown. The most common presenting symptoms are floaters and blurred vision. Diffuse vitreous cells, haze, snowballs and snowbanks are typical findings of pars planitis. Peripheral retinal vasculitis, optic disc edema and anterior segment inflammation are other well-known findings. Although pars planitis is known to be a benign form of uveitis in most cases, it may become a potentially blinding disease due to complications including cataract, cystoid macular edema, vitreous opacities and optic disc edema. Cystoid macular edema is the most common cause of visual morbidity. Band keratopathy, epiretinal membrane formation, vitreous condensation, neovascularizations, vitreous hemorrhage, retinal detachment, cyclitic membranes, glaucoma and amblyopia may develop as a consequence of the chronic course of the disease. Exclusion of infectious and non-infectious causes which may present with intermediate uveitis is of utmost importance before starting treatment. Treatment of pars planitis has been a controversial issue. There is no consensus specifically for treatment of cases with minimal inflammation and relatively good visual acuity. However, current experience shows that pars planitis may cause severe inflammation and needs an aggressive treatment. A stepladder approach including corticosteroids, immunosupressive agents, anti-tumor necrosis factor-alpha and pars plana vitrectomy and/or laser photocoagulation is the most commonly used method for treatment of pars planitis. Adequate control of inflammation and prompt detection of associated complications are crucial in order to improve the overall prognosis of the disease.
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Affiliation(s)
- Pinar Cakar Ozdal
- Service of Uveitis and Retinal Diseases, Ankara Ulucanlar Eye Research Hospital, Ankara, Turkey
| | - Nilufer Berker
- Service of Uveitis and Retinal Diseases, Ankara Ulucanlar Eye Research Hospital, Ankara, Turkey
| | - Ilknur Tugal-Tutkun
- Department of Ophthalmology, Istanbul University Faculty of Medicine, Istanbul, Turkey
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Maleki A, Meese H, Sahawneh H, Foster CS. Progress in the understanding and utilization of biologic response modifiers in the treatment of uveitis. Expert Rev Clin Immunol 2016; 12:775-86. [PMID: 26972783 DOI: 10.1586/1744666x.2016.1166052] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Uveitis is the third most common cause of blindness in developed countries. Considering the systemic and local complications of long-term corticosteroid therapy and the intolerance due to side effects and ineffectiveness of conventional chemotherapy, use of biologic response modifiers is a reasonable alternative in the treatment of non-infectious uveitis and persistent uveitic macular edema. The majority of the evidence presented here comes from open uncontrolled analyses. Based on these studies, tumor necrosis factor alpha inhibitors, especially infliximab and adalimumab, have been shown to be effective in the treatment of non-infectious uveitis in numerous studies. More research is necessary, particularly multi-center randomized clinical trials, to address the choice of biologic response modifier agent and the length of treatment as we employ biologic response modifiers in different types of uveitis and persistent uveitic macular edema.
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Affiliation(s)
- Arash Maleki
- a Massachusetts Eye Research and Surgery Institution , Waltham , MA , USA.,b Ocular Immunology & Uveitis Foundation , Waltham , MA , USA
| | - Halea Meese
- a Massachusetts Eye Research and Surgery Institution , Waltham , MA , USA.,b Ocular Immunology & Uveitis Foundation , Waltham , MA , USA
| | - Haitham Sahawneh
- a Massachusetts Eye Research and Surgery Institution , Waltham , MA , USA.,b Ocular Immunology & Uveitis Foundation , Waltham , MA , USA
| | - C Stephen Foster
- a Massachusetts Eye Research and Surgery Institution , Waltham , MA , USA.,b Ocular Immunology & Uveitis Foundation , Waltham , MA , USA.,c Department of Ophthalmology , Harvard Medical School , Boston , MA , USA
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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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