Nonsteroidal Immunomodulators Are Preferred to Treat Pediatric NIU Long Term

While systemic corticosteroids are often the first option for treating pediatric noninfectious uveitis (NIU), they cannot be used over the long term due to their side effect profile.

Study Design

This article is a review of the current published literature on and current treatment algorithms for systemic therapy for pediatric NIU. The authors conducted this literature search in June 2022.

Outcomes

Pediatric uveitis is rare. However, unlike adults, many children with NIU have minimal symptoms but can present with severe structural complications and advanced disease by the time of diagnosis. A stepwise approach to treatment is usually taken, beginning with systemic corticosteroids to gain quick control of disease. However, due to their high rates of complications, including weight gain, growth limitation, osteoporosis and sleep disorders, these agents are not recommended for long-term use. Nonsteroidal options include conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), such as methotrexate, and biological disease-modifying antirheumatic drugs (bDMARDs), such as adalimumab (the only agent in this class specifically indicated for pediatric NIU).

Limitations

For many available drugs, data are lacking in the current literature regarding their use in children. Each of these medications carries a unique side effect profile and requires long-term monitoring. The risk of vision loss must be considered in combination with the treatment complexities and individualized for each patient.

Clinical Significance

Transitioning to nonsteroidal immunomodulators is recommended for children whose uveitis recurs after treatment with 1–2 topical steroid drops per day or for those who are unable to taper down from systemic corticosteroids. Methotrexate is well established as the first line csDMARD in pediatric NIU. Other csDMARDs have limited evidence to support their use in pediatric uveitis. Mycophenolate mofetil is used second line (after methotrexate) in juvenile idiopathic arthritis–associated uveitis; however, it is recommended in conjunction with a bDMARD to prevent arthritis flare even when uveitis is under good control. In cases refractory to treatment with a csDMARD for 3 months, addition of a bDMARD is recommended as the next step. There is high-quality evidence to support adalimumab as the first-line bDMARD for pediatric NIU. Adding a second csDMARD instead of a bDMARD has not been shown to control disease and has a higher rate of side effects.

Financial Disclosures: Dr. Allison Umfress discloses no financial relationships.