New treatments for uveitis arsenal

Biologic response modifiers offer new options for third-line treatment

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A growing array of ‘biologics’ offers uveitis specialists potent new weapons in their therapeutic arsenal that may potentially benefit some patients with refractory non-infectious posterior uveitis, according to Emmett T. Cunningham MD, PhD. “While corticosteroids remain the mainstay of therapy, followed by non-corticosteroid immunosuppressive agents such as methotrexate and azathioprine, there is an interesting list of potent third-line treatments that may prove useful when conventional therapies have failed or been poorly tolerated,” Dr Cunningham told delegates attending the 8th EURETINA Winter Meeting in Budapest. Although corticosteroids are inexpensive, fast acting, potent and flexible, they are often used “for too little and too long”, said Dr Cunningham. “They are used too little because people are afraid to use them and they don't want to use high doses. And they are used for too long because patients are frequently undertreated and so have to stay on the medications, which can lead to a long list of complications associated with their long-term use,” he said. Although originally developed to treat systemic inflammatory diseases such as Behçet’s disease, juvenile idiopathic arthritis (JIA), ankylosing spondylitis and similar diseases, biologic response modifiers, or biologics for short, have been increasingly used off label for the treatment of non-infectious uveitis and other ocular inflammatory diseases, said Dr Cunningham. He noted that the most commonly studied systemic biologics for uveitis to date are tumour necrosis factor (TNF)-α inhibitors, primarily infliximab and adalimumab. SECOND AGENT “Infliximab led the vanguard of this approach to treatment and was first approved 20 years ago for rheumatoid arthritis. It is typically a 4-to-6mg/kg dose given intravenously for about two or three hours, so not very convenient for the patient. The fact that the antibody has murine components also means that it must be given concomitantly with a second agent such as methotrexate to prevent host rejection,” he said. Adalimumab is a fully human monoclonal antibody against TNF-α, approved for the treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis and other indications. “It is administered as a subcutaneous injection, first with a loading dose of 80mg, which is then halved every other week, so it is much more convenient than an intravenous infusion. It is the only systemic non-corticosteroid agent that has been approved by the US Food and Drug Administration (FDA) for the treatment of non-infectious uveitis, which was a big hurdle to cross,” he said. Biologics may potentially be used as first-line treatments for uveitis related to Behçet’s disease and JIA, said Dr Cunningham. They are not recommended for the treatment of infectious uveitis, and their use may also initiate or worsen demyelinating disease, he concluded.
Tags: biologic agents, biologics, uveitis