Guidance on Noncorticosteroid Systemic Immunomodulatory Therapy in Noninfectious Uveitis

Abstract

Consensus guidelines were developed based on published literature, expert opinion, and practical experience to bridge the gap between clinical needs and medical evidence to support the treatment of patients with noninfectious uveitis with noncorticosteroid immunomodulatory agents.

Rheumatoid arthritis-associated uveitis treated with adalimumab

“…However, interventions such as PPV or peripheral cryotherapy, have late complications and do not resolve the underlying immune issues. Consequently, the gain from surgical procedure might be only temporary (11). Hamam et al reported promising results of direct intravitreal Adalimumab administration, although no reliable conclusions can be drawn from this experimental treatment due to a limited number of subjects included in the study (5).…”

Inflammatory eye and rheumatic disease

“…Combination immunosuppressive therapy is used as a steroid‐sparing approach when inflammation cannot be controlled with oral systemic steroids ≤ 7.5 mg/d within 3 months. Conventional immunosuppressive therapy used to supplement systemic corticosteroid and help reduce the steroid burden include antimetabolites (methotrexate, mycophenolate, azathioprine), T‐cell inhibitors (cyclosporine, tacrolimus), and alkylating agents (cyclophosphamide, chlorambucil), although the latter are rarely used because of higher risk of serious complications and infertility, especially in young patients . We typically use methotrexate or mycophenolate as first‐line agents …”

“…The use of adalimumab as steroid‐sparing systemic therapy was supported and received recommendation level A in a recently published guidance for the treatment of non‐infectious uveitis provided by the Fundamentals of Care for Uveitis (FOCUS) initiative . Infliximab received recommendation level B/C.…”

Acute unilateral red eye in a patient with psoriasis

“…The pathogenesis of ocular inflammation is largely mediated by the actions of T lymphocytes and proinflammatory cytokines such as tumour necrosis factor (TNF)‐α, interleukin (IL)‐17 and IL‐23 …”

“…Our patient improved within 1 week with intensive topical prednisolone acetate 1% on taper and homatropine 2%, without the need for increase in her MTX dose or addition of any other systemic agents (such as oral steroids, azathioprine or sulfasalazine). In severe and refractory cases, biologics such as anti‐tumour necrosis factor‐α blockers (ADA and infliximab), anti‐IL‐12/23 p40 blockade with ustekinumab and high‐dose intravenous secukinumab have shown efficacy in controlling symptoms when other systemic agents have failed . This response to immunosuppression is expected considering the common pathological pathways in both skin and eye disease.…”