This retrospective study assessed long-term outcomes of tocilizumab therapy for treatment of vision-impacting uveitis-associated macular edema (ME) refractory to traditional immunosuppressive and biological agents.
Data were obtained by chart review of 16 eyes from 12 patients with longstanding ME (mean 13.2 years) whose uveitis was quiescent at initiation of tocilizumab, an interleukin-6 (IL-6) receptor antagonist. Subjects had a range of uveitis diagnoses: JIA (n=6), birdshot chorioretinopathy (n=2), idiopathic panuveitis (n=2), ankylosing spondylitis (n=1) and sympathetic ophthalmia (n=1).
Tocilizumab was administered intravenously at a dose of 8 mg/kg body weight in 4-week intervals, and treatment results were evaluated at month 1, 3, 6, 12, 18 and 24.
Improvement in ME was statistically significant and changed dramatically in some eyes. Mean central foveal thickness (CFT) improved significantly from baseline by month 1 (367 vs. 516 microns, P=0.008), and remained stable at 274 microns from month 12 through month 24 (P=0.00039 compared with baseline). Average BCVA improved from 0.78 to 0.40 logMAR at month 24 (P=0.0002).
All patients maintained inflammatory remission while on tocilizumab. At month 12, withdrawal was attempted in 5 patients who showed fluid resolution. However, their ME relapsed within 1 to 3 months after discontinuation. Encouragingly, ME resolution and improvement of VA was achieved again when tocilizumab was restarted.
There were no serious adverse events. One case each of grade 1 neutropenia and community-acquired pneumonia were recorded.
This study was retrospective and small. Additionally, 8 of 12 patients were on 1 or more concomitant immunomodulatory medication (oral prednisone, cyclosporine A and/or methotrexate), thus treatment regimens were not consistent.
Many of us have given patients tocilizumab following failure of TNF inhibitors. Because of our familiarity with TNF agents after over a decade of use, and the fact that adalimumab (Humira) is approved for posterior uveitis in the U.S., TNF inhibitors are still often used before tocilizumab. However, these findings provide strong evidence for its use in cases where TNF inhibitors are inadequate. Nonetheless, although I have used and will continue to use tociluzimab when TNF inhibition fails, we must remember this is a small series with a mixed bag of diagnoses, and tociluzimab is not a drug to be used lightly. There were not enough patients to comment on the rate of adverse reactions in any meaningful way, including the possibility of severe, even fatal, systemic infections.