The outcomes of Mycophenolate Mofetil therapy combined with systemic corticosteroids in acute uveitis associated with Vogt‐Koyanagi‐Harada Disease

Abstract

To study the effectiveness of mycophenolate mofetil (MMF) combined with systemic corticosteroids in acute uveitis associated with Vogt‐Koyanagi‐Harada (VKH) disease. The outcomes in this group were compared with those of another group of patients with VKH disease who were treated with corticosteroid monotherapy. Nineteen patients (38 eyes) were studied prospectively. Mean follow‐up period was 27.011.1 months. Corticosteroid‐sparing effect was achieved in all patients. Mean interval between starting treatment and tapering prednisone to 10 mg or less daily was 5.11.2 months. Ten (53%) patients discontinued treatment without relapse of inflammation. Mean time observed off of treatment was 17.311.9 months. Visual acuity of 20/20 was achieved by 38% of the eyes in the corticosteroid group and by 74% in the corticosteroid + MMF group (p<0.001). Recurrent inflammation of 3 times was reduced significantly (p=0.0383) in the corticosteroid + MMF group (3%) as compared to corticosteroid group ( 18%). Development of all complications was significantly higher in the corticosteroid group (43%) compared to the corticosteroid + MMF group (8%) (p<0.001). None of the eyes in the corticosteroid + MMF group developed “sunset glow fundus”.

Vogt-Koyanagi-Harada Disease

“…[1][2][3][4][5][6] While corticosteroids are the mainstay of therapy and are required to control active inflammation during episodes of acute or recurrent inflammation, cumulative evidence supports the first-line use of corticosteroid-sparing immunosuppressive agents to reduce the risk of recurrence, decrease the development of late complications, and improve long-term vision. [16][17][18][19][20] Multimodal imaging studies, particularly fluorescein angiography and spectral domain-ocular coherence tomography (SD-OCT), are important adjuncts for initial diagnosis and early monitoring of treatment response. 5 Indocyanine green angiography (ICGA) appears to be especially useful for detecting suboptimal or incomplete control of choroidal inflammation in patients with longstanding or chronic/recurrent disease.…”

Catching the therapeutic window of opportunity in early initial-onset Vogt–Koyanagi–Harada uveitis can cure the disease

“…Subclinical evolution of choroidal inflammation has also been clearly documented by several groups investigating smoldering disease with the help of ICGA [28][29][30][31][32][33], explaining that the development of SGF despite corticosteroid therapy results from the progressive loss of stromal melanocytes due to the ongoing insufficiently controlled immunological process [19,32]. This is a strong incentive to maintain sufficiently dosed therapy including first-line nonsteroidal immunosuppressive drugs, even in the subacute phase and during the corticosteroid tapering process, to be sure to eradicate choroidal inflammation [24][25][26][27][28][29][30][31][32][33]. An Indian group proposed early and highdose triple agent immunosuppression in 2006 and reported favorable outcomes with disease remission in all five reported patients [34].…”

“…None of the patients developed SGF, suggesting that it was also effective in controlling progressive subclinical choroidal inflammation. Mycophenolate mofetil was also effective in preventing the development of vitiligo, poliosis, alopecia, and sensory hearing loss [24,26]. In a series [26] of 38 patients with initial-onset acute uveitis associated with VKH disease, 22 (57.9%) patients were able to discontinue treatment without relapse of inflammation.…”

“…Abu El-Asrar et al [24] determined the effectiveness of mycophenolate mofetil (Cellcept Ò ) combined with systemic corticosteroids as first-line therapy for very early initial-onset acute VKH disease without AC inflammatory signs [26]. They compared the outcomes in this group with those of a group of patients with acute VKH uveitis treated with corticosteroid monotherapy or with the previously reported delayed addition of immunomodulatory therapy [35].…”

“…Combination of steroidal and non-steroidal immunosuppression is required to treat initialonset acute VKH disease in order to prevent chronic evolution Because numerous studies have shown that corticosteroid monotherapy is insufficient to prevent chronic evolution, combinations of corticosteroids with firstline non-steroidal immunosuppressive therapies such as cyclosporine, azathioprine, mycophenolate mofetil, anti-tumor necrosis factor-a agents, or others have been proposed to achieve better control of the uveitis, facilitate earlier tapering of corticosteroids, and avoid chronic evolution in acute initial-onset disease [17,[24][25][26][27]. First-line immunosuppression is defined here as the initiation of immunosuppression at the onset of disease concomitant to corticosteroids and not thereafter, as is the case in most studies speaking of first-line immunosuppressive therapy.…”