PAEDIATRIC UVEITIS

New biologic agents are altering the therapeutic management of paediatric uveitis and increasing the chances of disease control in these patients, although intensive monitoring is needed to avoid systemic and ocular complications. “Biologic agents have certainly given us more treatment options, although the evidence to date suggests that clinical remission is time limited both for methotrexate and the more commonly used biologic agents. What we need is more prospective studies looking at the effect of biologic agents and identification of parameters predicting the efficacy of different treatment regimes,” Lisbeth Sandfeld MD, PhD, told delegates attending the 2013 Congress of the European Society of Ophthalmology (SOE).

Presenting the results of a retrospective study to evaluate the efficacy of systemic treatment in childhood uveitis, Dr Sandfeld said that the treatment of paediatric uveitis is complex and is based on subtype and severity of the condition, and must take account of concomitant systemic disease and side effects. In many patients, corticosteroids alone are not sufficient to control the inflammation and immunomodulatory therapy will be necessary. The study carried out at the Eye Clinic, Rigshospitalet, Copenhagen, Denmark, included children aged younger than 18 years at the time of their uveitis diagnosis between 2007 and 2012. The efficacy of the patients’ systemic treatment and side effects were registered. Treatment was topical/systemic steroid, with clinical remission defined as no uveitis during medical treatment for more than one year. In the event of recurrent uveitis, patients were treated with methotrexate, and biologic response modifiers – adalimumab, infliximab, etanercept – or a combination of methotrexate and one of the biologic agents. The study included a total of 73 children treated for uveitis: 52 were identified as juvenile idiopathic arthritis (JIA)-associated uveitis, 19 were idiopathic uveitis, one patient had sarcoidosis and one had glomerulonephritis. 61of the patients were receiving systemic treatment. Out of these 61 patients, 25 needed three or more different systemic treatments after one year to obtain sufficient disease control. The mean age of the patients at uveitis debut was seven years and four months ranging from one year to 17 years. The mean age at systemic disease debut was four years and six months (range six months to 13 years). In four cases, data was not obtainable regarding previous medication, said Dr Sandfeld.

Dr Sandfeld reported that methotrexate induced and maintained clinical remission for at least one year in 33 of 47 patients, adalimumab in 18 of 23 patients, infliximab in six of nine patients and etanercept in nine of 17 patients. A combination of methotrexate and adalimumab resulted in clinical remission in seven of 18 patients, methotrexate and infliximab in 21 of 26 patients and methotrexate and etanercept in six of seven patients. Severe side effects were noted for infliximab – anaphylaxis in four cases, and for methotrexate – nausea and increasing liver enzymes in seven patients. Putting the overall results into context, Dr Sandfeld said that methotrexate had a limited effect in idiopathic uveitis while etanercept had a limited effect in polyarticular JIA-associated uveitis. The effect of treatment also seemed to be unrelated to antinuclear antibody, rheumatoid factor, HLA-B27 haplotype, sex, anatomic location of uveitis or the patient’s age at uveitis debut. “Going forward we need more prospective, randomised clinical trials to help us define clearer indications for different biologics in refractory paediatric uveitis and criteria for successful outcome prediction,” she concluded.