POSITIVE RESULTS FOR UVEITIS IN CHILDREN

TNFα-inhibitors, commonly known as biologicals, have become a key component of treatment of uveitis in children, particularly when steroids are no longer desired and when steroid-sparing treatments fail, according to Joke de Boer MD, a uveitis specialist in Utrecht, the Netherlands. She provided an update on behalf of Dr Manfred Zierhut during a Joint Symposium on Paediatric Uveitis, organised by WSPOS and EURETINA. She reviewed the most important studies to date that looked at the use of the three main biologicals (etanercept, infliximab and adalimumab) in paediatric uveitis. The first with etanercept were published as early as 2001, with the drug being used for treatment-resistant chronic uveitis in children. The results were encouraging, but etanercept has since been abandoned in favour of infliximab and adalimumab. A 2005 study by Kotaniemi et al. suggested that infliximab was superior to etanercept in the treatment of chronic uveitis associated with refractory juvenile idiopathic arthritis (JIA).

Dr Zierhut and his team studied the use of adalimumab in children with chronic anterior uveitis in whom previous therapy had been ineffective. A main inclusion criterion was the unsuccessful use of at least one additional immunosuppressant besides steroids. Indeed, all 18 patients had been previously treated with cyclosporine and methotrexate. Of these 18 patients, many had also undergone treatment with azathioprine (12) mycophenolate mofetil (4) cyclophosphamide (2) and even other biologicals, including etanercept (8) and infliximab (5). “The extent of the previous treatment characterised the severity of the uveitis seen in the patients included in the study,†said Dr de Boer.

The results were very encouraging. Adalimumab was considered “effective†in 16 of the 18 patients (88.8 per cent), mildly effective in one (5.6 per cent) and not effective in one (5.6 per cent). No worsening of the uveitis was seen during the study. However, Dr de Boer emphasised the potential for adverse events, including production of autoantibodies. To prevent this problem, the recommendation was to continue methotrexate during treatment with biologicals. All patients must be screened for latent tuberculosis and, using MRI, for demyelinating disease. Regarding the risk of tumours after biologicals, Dr de Boer said that studies have shown no higher incidence than with the traditional disease-modifying anti-rheumatic drugs (DMARDs). Dr de Boer also introduced delegates to a less well-known drug, rituximab. This is a chimeric monoclonal antibody that binds the CD20 protein found on the surface of B cells, leading to the cells’ death. This biological agent, primarily used to treat hematologic neoplasia, might see use in uveitis treatment in the future.