Uveitis Guidelines: Immunomodulatory Therapy

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Since guidelines for systemic treatment of noninfectious uveitis (NIU) were last published in 2000, treatment with biologic and other non­corticosteroid systemic immunomod­ulatory agents has become widespread. Now, an international, evidence-based consensus initiative has addressed the management of NIU in this new era of noncorticosteroid systemic immuno­modulatory therapy (NCSIT).¹

Rigorous methodology. Janet L. Davis, MD, MA, of the Bascom Palmer Eye Institute in Miami, emphasized the solid methodology behind the new recommendations. The group’s steering committee identified clinical questions, conducted a systematic review, and circulated proposed guidelines among 130 international uveitis experts. Group members met in late 2016 to refine guidelines in a modified Delphi technique and assign Oxford levels of evidence.

INDIVIDUALIZED TX. The guidelines provide recommendations by drug and disease. For instance, for birdshot chorioretinopathy (seen here), infliximab has a grade B recommendation, while intravenous immunoglobulins are grade C. This image was originally published in the ASRS Retina Image Bank. Armando L. Oliver, MD, and Carmen Santos, MD. Birdshot OS. Retina Image Bank. 2016; Image Number 26370. © The American Society of Retina Specialists.

Areas of clinical focus. The com­mittee’s final guidance statements addressed optimal timing for treatment escalation; transitioning among agents, including biologics; and multidisci­plinary team collaboration and safety monitoring.

Key guidelines. Dr. Davis encour­aged ophthalmologists who manage uveitis patients to read the consensus guidelines, and she highlighted the following recommendations:

• NCSIT for NIU may be introduced to control persistent or severe inflam­mation or to prevent ocular structural complications that pose a risk to visual function (see Table 1).
• Collection of historical, laboratory, and clinically relevant radiologic data should take place before initiation of NCSIT. These data document baseline organ functions and test for active or latent infectious diseases.
• Although there is considerable het­erogeneity in the criteria used to judge disease activity—cell counts; flare; haze; deterioration (or lack of response) in visual function; and retinal, choroidal, or optic nerve lesions—they can be in­fluential in decisions to modify therapy.
• Before changing a therapy because of ineffectiveness, consider the follow­ing: treatment nonadherence, infections, and masquerade syndromes.
• If NCSIT is not adequately effective, escalation to the maximally tolerated dose may be considered before introducing an alternative medication, including a biologic agent (see Table 2). Choices for therapy must be individualized based on multiple factors, including the patient’s history, underlying cause of uveitis, and any systemic diseases.
• Withdrawal of NCSIT should be individualized based on tolerance of the current treatment, duration of disease control, and the specific cause of uveitis.
• Effective NCSIT drugs for NIU include mycophenolate mofetil (grade C recommendation), tacrolimus (grade B), cyclosporine (grade B), azathioprine (grade B), and methotrexate (grade B).
• Use of biologic agents for the treat­ment of NIU is supported for adali­mumab (grade A recommendation), infliximab (grade B/C), and interferon alpha-2a (grade B).
• Communication across medical spe­cialties, particularly between ophthal­mologists and rheumatologists, fosters optimal therapy with safe prescribing and monitoring of NCSIT.

—Gabrielle Weiner

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1 Dick AD et al., for the Fundamentals of Care for Uveitis International Consensus Group. Oph­thalmology. Published online Jan. 6, 2018.

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Relevant financial disclosures: Dr. Davis—AbbVie: C; Allergan: C.

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