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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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Maccora I, Simonini G, Guly CM, Ramanan AV. Management of JIA associated uveitis. Best Pract Res Clin Rheumatol 2024:101979. [PMID: 39048481 DOI: 10.1016/j.berh.2024.101979] [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: 03/07/2024] [Revised: 05/14/2024] [Accepted: 07/17/2024] [Indexed: 07/27/2024]
Abstract
Juvenile Idiopathic Arthritis (JIA) is the most common chronic rheumatic disease in childhood, and is associated with uveitis in up to 20-25% of cases. Typically, the uveitis is chronic, asymptomatic, non-granulomatous and anterior. For this reason, screening for uveitis is recommended to identify uveitis early and allow treatment to prevent sight-threatening complications. The management of JIA associated uveitis requires a multidisciplinary approach and a close collaboration between paediatric rheumatologist and ophthalmologist. Starting the appropriate treatment to control uveitis activity and prevent ocular complications is crucial. Current international recommendations advise a step-wise approach, starting with methotrexate and moving on to adalimumab if methotrexate alone is not sufficient to control the disease. If the uveitis remains active despite standard treatment other therapeutic options may be considered including anti-IL6 or other anti-TNF agents such as infliximab, although the evidence for these agents is limited.
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Affiliation(s)
- Ilaria Maccora
- NeuroFARBA Department, University of Florence, Florence, Italy; Rheumatology Unit, ERN ReCONNET Center, Meyer Children's Hospital IRCCS, Florence, Italy.
| | - Gabriele Simonini
- NeuroFARBA Department, University of Florence, Florence, Italy; Rheumatology Unit, ERN ReCONNET Center, Meyer Children's Hospital IRCCS, Florence, Italy.
| | - Catherine M Guly
- Bristol Eye Hospital, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK.
| | - Athimalaipet V Ramanan
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK; Translational Health Science, University of Bristol, Bristol, UK.
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Lassoued Ferjani H, Kharrat L, Ben Nessib D, Kaffel D, Maatallah K, Hamdi W. Management of Blau syndrome: review and proposal of a treatment algorithm. Eur J Pediatr 2024; 183:1-7. [PMID: 37735224 DOI: 10.1007/s00431-023-05204-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/16/2023] [Accepted: 09/13/2023] [Indexed: 09/23/2023]
Abstract
Blau syndrome is a rare genetic granulomatosis affecting children. It could be responsible for vision-threatening complications and articular deformation. Due to the rarity of this disease, there are no standardized guidelines for its management. This work aimed to provide an updated overview of the different therapeutic options for Blau syndrome. We conducted research in the PubMed database for the different treatments used in Blau syndrome patients, and we proposed a therapeutic algorithm for disease management. High doses of corticosteroids are considered as a bridging therapy in Blau syndrome. Methotrexate should be initiated if the patient has articular or ocular involvement. An anti-tumor necrosis factor α should be added for patients with uveitis or residual arthritis. If the patient remains symptomatic, a switch to another anti-tumor necrosis factor α is the best option. In non-responders to the first- and second-line biotherapies, a switch to an anti-interleukin 1, an anti-interleukin 6, or tofacitinib is necessary. CONCLUSION This article suggested an algorithm for the treatment of Blau syndrome. Other studies are necessary to confirm the efficacy of these treatments. WHAT IS KNOWN • Blau syndrome is a rare but severe granulomatosis that could be responsible for vision-threatening complications and articular deformation. • Blau syndrome seems to be refractory to treatments. WHAT IS NEW • High doses of corticosteroids are usually insufficient and should be considered only as a bridging therapy. • Blau syndrome could be considered as a poor factor for uveitis, thus, an anti-tumor necrosis factor α should be initiated for patients with uveitis or with residual arthritis.
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Affiliation(s)
- Hanene Lassoued Ferjani
- Rheumatology Department, Kassab Orthopedics Institute, Ksar Saïd, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Research Unit UR17SP04, 2010, Ksar Said, 2010, Tunis, Tunisia
| | - Lobna Kharrat
- Rheumatology Department, Kassab Orthopedics Institute, Ksar Saïd, Tunisia.
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia.
| | - Dorra Ben Nessib
- Rheumatology Department, Kassab Orthopedics Institute, Ksar Saïd, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Research Unit UR17SP04, 2010, Ksar Said, 2010, Tunis, Tunisia
| | - Dhia Kaffel
- Rheumatology Department, Kassab Orthopedics Institute, Ksar Saïd, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Research Unit UR17SP04, 2010, Ksar Said, 2010, Tunis, Tunisia
| | - Kaouther Maatallah
- Rheumatology Department, Kassab Orthopedics Institute, Ksar Saïd, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Research Unit UR17SP04, 2010, Ksar Said, 2010, Tunis, Tunisia
| | - Wafa Hamdi
- Rheumatology Department, Kassab Orthopedics Institute, Ksar Saïd, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Research Unit UR17SP04, 2010, Ksar Said, 2010, Tunis, Tunisia
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Burlo F, Tumminelli C, Pastore S, Stocco G, Curci D, Lucafò M, Tommasini A, Taddio A. Subcutaneous tocilizumab in the management of non-infectious uveitis in children: a brief report. Pediatr Rheumatol Online J 2023; 21:99. [PMID: 37700264 PMCID: PMC10496382 DOI: 10.1186/s12969-023-00883-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 08/28/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Tocilizumab is a humanized monoclonal antibody that acts as an IL-6 receptor antagonist. Intravenous tocilizumab is considered an option for children with anti-TNF refractory juvenile idiopathic arthritis-associated uveitis. In contrast, the potential of subcutaneous drug use with this indication is more controversial. Due to the decreased availability of intravenous tocilizumab during the COVID-19 pandemic, we started using the subcutaneous formulation of the drug in children with anti-TNF refractory uveitis. The study analyzes the serum concentration of tocilizumab and its clinical response in patients with anti-TNF refractory uveitis who started or switched to subcutaneous administration from intravenous use. METHODS Five patients with non-infectious uveitis were treated with subcutaneous tocilizumab. Ocular inflammation was evaluated on slit lamp examination during clinical control. Serum tocilizumab concentrations were determined by ELISA. RESULTS The mean blood concentration of tocilizumab was 61.4 µg/mL (range 2.7-137.0.), with higher values than levels recorded in adult patients with rheumatoid arthritis treated with intravenous tocilizumab. Three patients entered clinical remission. One patient developed a mild relapse and was treated with topical steroids. Only one patient did not respond to therapy. The medication was well tolerated without severe infection or other adverse events. CONCLUSION Our results support a possible role of subcutaneous tocilizumab in anti-TNF refractory uveitis.
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Affiliation(s)
- Francesca Burlo
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy
| | - Cristina Tumminelli
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy
| | - Serena Pastore
- Institute for Maternal and Child Health "IRCCS Burlo Garofolo", Trieste, Italy.
- Institute for Maternal and Child Health "IRCCS Burlo Garofolo", Trieste, Italy.
| | - Gabriele Stocco
- Institute for Maternal and Child Health "IRCCS Burlo Garofolo", Trieste, Italy
- Department of Life Sciences, University of Trieste, Trieste, Italy
| | - Debora Curci
- Institute for Maternal and Child Health "IRCCS Burlo Garofolo", Trieste, Italy
| | - Marianna Lucafò
- Department of Life Sciences, University of Trieste, Trieste, Italy
| | - Alberto Tommasini
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy
- Institute for Maternal and Child Health "IRCCS Burlo Garofolo", Trieste, Italy
| | - Andrea Taddio
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy
- Institute for Maternal and Child Health "IRCCS Burlo Garofolo", Trieste, Italy
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Maccora I, Marrani E, Pagnini I, Mastrolia MV, de Libero C, Caputo R, Simonini G. Challenges and management of childhood non-infectious chronic uveitis. Expert Rev Clin Immunol 2023; 19:599-611. [PMID: 36996498 DOI: 10.1080/1744666x.2023.2198210] [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: 04/01/2023]
Abstract
INTRODUCTION Childhood uveitis is a sight-threatening condition, because if not properly recognized and treated can lead to several ocular complications and blindness. It represents a real challenge not only from an etiologic/diagnostic point of view, but also for management and therapy. AREAS COVERED In this review we will discuss the main etiologies, the diagnostic approach, risk factors associated to childhood non-infectious uveitis (cNIU), and the difficulties in eye examination in childhood. Moreover, we will discuss the treatment of cNIU in term of therapeutic choice, timing of initiation and withdrawal. EXPERT OPINION Identification of specific diagnosis is mandatory to prevent severe complications, thus a thorough differential diagnosis is essential. Pediatric eye examination may be extremely challenging due to the scarce collaboration, but novel techniques and biomarkers will help in identify low grade of inflammation, eventually modify long-term outcomes. Once identified the appropriate diagnosis, recognition of children who may benefit of a systemic treatment is crucial. What, When and how long are the key questions to address in this field. Current evidence and future results of ongoing clinical trials will help in driving treatment. A proper ocular screening, not only in the context of systemic disease, should be discussed by experts.
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Affiliation(s)
- Ilaria Maccora
- Pediatric Rheumatology Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- NeuroFARBA department, University of Florence, Florence, Italy
| | - Edoardo Marrani
- Pediatric Rheumatology Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Ilaria Pagnini
- Pediatric Rheumatology Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | | | | | - Roberto Caputo
- Ophthalmology Unit, Meyer Children's Hospital, Florence, Italy
| | - Gabriele Simonini
- Pediatric Rheumatology Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- NeuroFARBA department, University of Florence, Florence, Italy
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Wilson L, Lewis KE, Evans LS, Dillon SR, Pepple KL. Systemic Administration of Acazicolcept, a Dual CD28 and Inducible T cell Costimulator Inhibitor, Ameliorates Experimental Autoimmune Uveitis. Transl Vis Sci Technol 2023; 12:27. [PMID: 36976157 PMCID: PMC10064916 DOI: 10.1167/tvst.12.3.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 02/21/2023] [Indexed: 03/29/2023] Open
Abstract
Purpose Combined inhibition of CD28 and inducible T cell costimulator (ICOS) pathways with acazicolcept (ALPN-101) represents a potential new treatment for uveitis. Here, we evaluate preclinical efficacy using experimental autoimmune uveitis (EAU) in Lewis rats. Methods Efficacy was tested in 57 Lewis rats treated with either systemic (subcutaneous) or local (intravitreal) administration of acazicolcept and compared to treatment with a matched Fc-only control or corticosteroid. Impact of treatment on uveitis was assessed using clinical scoring, optical coherence tomography (OCT), and histology. Ocular effector T cell populations were determined using flow cytometry, and multiplex ELISA used to measure aqueous cytokine concentrations. Results When compared to Fc control treatment, systemic acazicolcept led to statistically significant decreases in clinical score (P < 0.01), histologic score (P < 0.05), and number of ocular CD45+ cells (P < 0.01). Number of ocular CD4+ and CD8+ T cells expressing IL-17A+ and IFNγ+ were also decreased with statistical significance (P < 0.01). Similar results were achieved with corticosteroids. Intravitreal acazicolcept decreased inflammation scores when compared to untreated fellow eyes and to Fc control treated eyes, although not statistically significant. Systemic toxicity, measured by weight loss, occurred in the corticosteroid-treated, but not in the acazicolcept-treated animals. Conclusions Systemic treatment with acazicolcept statistically significantly suppressed EAU. Acazicolcept was well-tolerated without the weight loss associated with corticosteroids. Acazicolcept may be an effective alternative to corticosteroids for use in treating autoimmune uveitis. Additional studies are needed to clarify the optimal dose and route for use in humans. Translational Relevance We show that T cell costimulatory blockade could be an effective mechanism for treating uveitis.
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Affiliation(s)
- Leslie Wilson
- Department of Ophthalmology, University of Washington, Seattle, WA, USA
- Roger and Angie Karalis Johnson Retina Center, University of Washington School of Medicine, Seattle, WA, USA
| | | | | | - Stacey R. Dillon
- Translational Medicine, Alpine Immune Sciences, Seattle, WA, USA
| | - Kathryn L. Pepple
- Department of Ophthalmology, University of Washington, Seattle, WA, USA
- Roger and Angie Karalis Johnson Retina Center, University of Washington School of Medicine, Seattle, WA, USA
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Zhang M, Zhang X. T cells in ocular autoimmune uveitis: Pathways and therapeutic approaches. Int Immunopharmacol 2023; 114:109565. [PMID: 36535124 DOI: 10.1016/j.intimp.2022.109565] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/29/2022] [Accepted: 12/06/2022] [Indexed: 12/23/2022]
Abstract
Autoimmune uveitis is a non-infectious intraocular condition that affects the uveal tract of the eye and threatens vision if not treated properly. Increasing evidence suggests that activated CD4+ T cells are associated with progressive and permanent destruction of photoreceptors in ocular autoimmune diseases. As such, the purpose of this review is to offer an overview of the role of CD4+ T cells in autoimmune uveitis as well as a justification for the current development and assessment of innovative autoimmune uveitis medications targeting CD4+ T cells. With an emphasis on T helper (Th)17, Th1, and Th2 cells, follicular helper CD4+ T cells, and regulatory T cells, this review presents a summary of recent research related to the pathways and signaling that encourage CD4+ T cells to develop into specialized effector cells. We also describe immunotherapeutic approaches based on CD4+ T cell subsets and their potential as therapeutic agents for autoimmune disorders.
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Affiliation(s)
- Mi Zhang
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
| | - Xiaomin Zhang
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China.
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Patel S, Belamkar A, Hajrasouliha AR, Jusufbegovic D, Ciulla TA. Progress in the pharmacotherapy of uveitis: the art of personalized care. Expert Opin Pharmacother 2022; 23:1445-1455. [PMID: 35880543 DOI: 10.1080/14656566.2022.2104637] [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: 11/04/2022]
Abstract
INTRODUCTION Uveitis is a heterogeneous group of inflammatory intraocular disorders which can lead to blindness, but prompt diagnosis and management can improve visual outcomes and reduce treatment burden. AREAS COVERED In this review, the authors provide an overview of commonly used treatments of the management of non-infectious uveitis. EXPERT OPINION Initially, the treatment of non-infectious uveitis was limited to corticosteroids which have a broad range of adverse ocular and systemic effects. Now new options, such as biological response modulators, are a novel yet exciting addition to this armory and have the potential to change the course of treatment as well as prognostic outcomes for uveitis patients. Additionally, further research is needed to evaluate the efficacy of this novel class of immunomodulators in uveitis therapy.
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Affiliation(s)
- Shivam Patel
- Department of Ophthalmology, Indiana University School of Medicine, 1160 W Michigan St, Indianapolis, IN 46202
| | - Aditya Belamkar
- Department of Ophthalmology, Indiana University School of Medicine, 1160 W Michigan St, Indianapolis, IN 46202
| | - Amir R Hajrasouliha
- Department of Ophthalmology, Indiana University School of Medicine, 1160 W Michigan St, Indianapolis, IN 46202
| | - Denis Jusufbegovic
- Department of Ophthalmology, Indiana University School of Medicine, 1160 W Michigan St, Indianapolis, IN 46202
| | - Thomas A Ciulla
- Department of Ophthalmology, Indiana University School of Medicine, 1160 W Michigan St, Indianapolis, IN 46202.,Midwest Eye Institute, Springmill Medical Building, 10300 N. Illinois St., Suite 1000, Carmel, IN 46290, USA.,Clearside Biomedical, 900 North Point Pkwy # 200, Alpharetta, GA 30005
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