• Methotrexate Versus Mycophenolate Mofetil for Uveitis

    By Lynda Seminara
    Selected By: Deepak P. Edward, MD

    Journal Highlights

    JAMA
    2019;322(10):936-945

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    Corticosteroids are standard first-line treatment for noninfectious uveitis, but local and systemic side effects are common with these drugs. Alterna­tively, patients may receive antimetab­olite treatment with methotrexate or mycophenolate mofetil, sparing them the adverse effects of steroids. In the FAST (First-line Antimetabolites as Steroid-sparing Treatment) trial, Rathinam et al. compared the efficacy of these two agents in patients with active noninfectious uveitis and found methotrexate to be noninferior to my­cophenolate mofetil.

    FAST was a randomized, parallel, observer-masked clinical trial conduct­ed in six diverse countries. Patients with noninfectious intermediate uveitis, posterior uveitis, or panuveitis were as­signed randomly to receive methotrex­ate (25 mg weekly) or mycophenolate mofetil (1.5 g twice daily); both agents were administered orally. Patients also were given oral prednisone, with the goal of tapering to 7.5 mg daily by six months. Topical corticosteroids were allowed if needed, and they were to be reduced to <2 drops/day of 1% pred­nisolone acetate.

    The primary outcome, treatment success, was determined at months 6 and 12. Treatment success was defined as inflammation control, achievement of the target corticosteroid dosage, and acceptable safety and tolerability. Pa­tients with treatment failure at month 6 received the other antimetabolite for the next six months.

    Of the 216 patients enrolled, 194 had follow-up through six months, at which time the treatment success rate was 66.7% for methotrexate (64 of 96 patients) and 57.1% for mycophenolate mofetil (56 of 98 patients). Subgroup analysis of patients with posterior uve­itis or panuveitis showed that metho­trexate was more effective.

    The 12-month evaluation was completed by 163 patients. About three-fourths of those with treatment success at six months continued to have control of inflammation at 12 months, and approximately half discontinued prednisone by this time. Among the 49 patients who switched treatment after the initial six months, those who tran­sitioned to methotrexate had greater treatment success. Relatively few pa­tients in either group had intolerability or safety issues, although liver function tests were more likely to be abnormal in those patients given methotrexate.

    In summary, methotrexate was noninferior to mycophenolate mofetil as steroid-sparing immunosuppressive therapy for uveitis. Anatomic subtype may affect the success of either treat­ment; this possibility warrants further exploration, said the authors.

    The original article can be found here.