This prospective study found that adalimumab seems to be well tolerated and helpful in decreasing inflammatory activity in refractory uveitis and may reduce patient use of steroids.
The authors administered a 40-mg adalimumab subcutaneous injection every other week for six months to 131 patients with chronic, therapy-resistant, noninfectious uveitis. Associated immunosuppressants were tapered after administration of three adalimumab injections at week six.
Inflammation in the anterior chamber was present in 82 percent of patients and in the vitreous cavity in 59 percent of patients. The most common causes were juvenile idiopathic arthritis (JIA) in (29.7 percent), pars planitis (12.2 percent), and Behçet's disease (9.9 percent). Twenty-seven patients had uveitis of idiopathic origin.
Patients showed a significant reduction in anterior chamber and vitreous inflammation, as well as an overall gain in visual acuity, reduction of macular thickness, and decrease of the immunosuppression load. Cystoid macular edema, which was present in 40 eyes at baseline, showed complete resolution in 28 eyes at six months. Only 6.9 percent of patients had severe relapses during six months of follow-up. Patients also benefited from a significant reduction of concomitant immunosuppressive therapies.
Although the overall results were good, 38.2 percent did have a reactivation within the six-month follow-up period. This is not trivial as some diseases, such as juvenile idiopathic arthritis (JIA) and pars planitis, are chronic and six months is not very long. We are not told if this was early in the course of the treatment. A nine-year-old with JIA had a "severe" exacerbation of her uveitis which interestingly improved on infliximab; I have had that experience with patients as well.
The authors write that these results confirm findings from a previous pilot study in 19 patients carried out by their group. However, treatment of refractory uveitis is a challenge requiring weighing the risk of blindness and complications against the toxicity of immunosuppressive and cytotoxic therapy. There is an important concern about the economic impact of anti-TNF-α treatment.
Adalimumab has so far demonstrated some preliminary advantages over infliximab, including its subcutaneous route of administration, lack of need for hospitalization, being less immunogenic and less expensive, and having a more protracted therapeutic response in uveitis. But it is substantially more expensive than many other immunosuppressive drugs and suitable only for select patients because most respond to first-line immunosuppressors.