EXPERT ANALYSIS FROM RWCS 2016
MAUI, HAWAII (FRONTLINE MEDICAL NEWS) – Uveitis is a common, highly destructive manifestation of juvenile idiopathic arthritis that is readily treatable when caught early, Dr. Anne M. Stevens said at the 2016 Rheumatology Winter Clinical Symposium.
Moreover, recent evidence from Germany suggests that uveitis may actually be preventable through early aggressive anti-inflammatory therapy, noted Dr. Stevens, a pediatric rheumatologist at Seattle Children’s Hospital and the University of Washington.
She cited a report from investigators participating in the National Pediatric Rheumatological Database in Germany. This large study included 3,512 juvenile idiopathic arthritis (JIA) patients with a mean age at arthritis onset of 7.8 years, a disease duration of less than 12 months at enrollment, and a mean follow-up of 3.6 years.
Uveitis occurred in 5.1% of patients within the first year after onset of JIA, and in another 7.1% following the first year. The key finding in the German study was that aggressive disease-modifying antirheumatic drug (DMARD) therapy during the year prior to uveitis significantly reduced the likelihood of developing this complication. Children on methotrexate during that time period were 37% less likely to develop uveitis than were those not on a DMARD. Moreover, patients placed on methotrexate within the first year after being diagnosed with JIA had a 71% relative risk reduction.
Patients on a tumor necrosis factor inhibitor during the year prior to uveitis had a 44% reduction in the risk of developing the eye complication. Most impressive of all, children on both methotrexate and a TNF inhibitor during the year prior to uveitis had a whopping 90% reduction in the risk of developing uveitis, compared with those not on a DMARD ( Arthritis Care Res [Hoboken]. 2016 Jan;68:46-54 ).
“I was fascinated by this study showing that treatment with two types of therapy may be preventive,” Dr. Stevens commented. “If this is substantiated in another large population-based cohort, it will be interesting to see if practice moves to treating the ANA [antinuclear antibody]–positive oligo JIA patients very early with TNF [tumor necrosis factor] inhibitors and methotrexate to prevent uveitis.”
The logic behind this aggressive preventive therapy lies in the fact that while uveitis occurs in about 20% of patients with oligoarticular JIA overall, roughly 90% of cases involve ANA-positive patients. For this reason, guidelines recommend slit lamp examinations every 3 months for a year in patients with young-onset, ANA-positive JIA.
“Imagine trying to do a slit lamp exam on a 2-year-old. It really helps to send these kids to a pediatric ophthalmologist who’s done a lot of them,” she advised.
The uveitis of JIA is typically anterior, asymptomatic, and low grade. It’s also a leading cause of blindness in childhood. Complications include band keratopathy, glaucomatous optic neuropathy, cataracts, and maculopathy.
“If we catch uveitis early, we can treat this disease really well now,” according to Dr. Stevens.
The initial therapy is short-term topical steroids. It’s important to keep in touch with the ophthalmologist regarding the slit lamp findings, however, because ophthalmologists generally tend to favor longer-term topical steroid therapy, while rheumatologists are appropriately primed to push on to more aggressive systemic therapy very quickly.
The first-line systemic agent for treatment of uveitis in patients with JIA is methotrexate at 1 mg/kg/week. If that doesn’t achieve satisfactory results, pediatric rheumatologists are quick to move on to second-line therapy with cyclosporine, azathioprine, or mycophenolate (CellCept).
“We move on fairly quickly if need be to TNF inhibitors, and we go with very high doses. The literature for infliximab [Remicade] is supportive of 20 mg/kg every 4 weeks. That’s what I use,” she continued.
High-dose adalimumab (Humira) is another option (J Rheumatol. 2013 Jan;40:74-9). However, etanercept (Enbrel) is not effective for this condition. The use of abatacept (Orencia) or rituximab (Rituxan) in refractory patients is supported by favorable case reports.
Dr. Stevens reported having no financial interests relevant to her presentation.