Background Pediatric uveitis often take a serious course refractory to standard immunosuppression. Biologics provide new options for patients with resistant rheumatic diseases (RD). However, their efficacy in associated uveitis is less known and there is no direct correlation between ocular and joint response.
Objectives To evaluate efficacy of biologics in combined treatment of pediatric RD related uveitis.
Methods 85 children aged 2 – 17 years with uveitis associated with RD (83 with juvenile idiopathic arthritis, 2 with Behcets disease) weretreated with biologics in standard pattern and doses. Infliximab (2.5 – 12 mg/kg) was given in 46 cases, follow up period ranged from 1.5 to 49 month, mean 11. Adalimumab – in 40 patients, 14 were switched to Adalimumab from Infliximab, follow up period – from 3 to 41 month, mean 16. Abatacept – in 20 cases (7 as 2nd, 1 as 3rd, 1 as 4th biologic), follow up period – from 1.5 to 21 month, mean 7.6. Rituximab – in 4 cases (3 as 2nd biologic), 3 patients received 2, 1 child – 3 courses of treatment. Tocilizumab was given to 1 patient as a 5th biologic, follow up period – 8 month. Indication for their use was ineffectiveness of standard therapy of underlying systemic disease. Biologics were usually combined with other immunosuppressive drugs (mostly Methotrexate, its combination with Cyclosporin or low-dose steroids). Topical treatment was also used. Anterior uveitis was in 94%, intermediate in 2%, panuveitis in 3% of cases. Duration of uveitis before biologics ranged from 1 month to 12 years. 60% of uveitis was resistant to standard immunosuppression.
Results Remission of uveitis on current treatment was achieved in 22%, decrease in the degree of inflammation and/or in frequency of relapses in 19% from 37 children with active uveitis, receiving Infliximab. In Adalimumab group – in 50% and 38% from 40, in Abatacept – in 28% and 28% from 18 respectively. In 5 patients uveitis developed during biologic therapy (4 – in Infliximab, 1 – in Abatacept). 6 children had remission of uveitis before and during biologic treatment up to 24 month. After Adalimumab application remission of panuveitis refractory to Cyclosporin and steroids was achieved in both children with Behcets disease. On Adalimumab therapy improvement was seen in 9 out of 10 cases of uveitis resistant to Infliximab. Only 2 out of 9 cases resistant to TNF-α blockers improved on Abatacept. Interestingly, in 8 out of 17 cases with initial response to TNF-α blockers we saw exacerbations of uveitis after 11th and following months of treatment. Likely after 1st course of Rituximab remission of uveitis was seen in 3 children, but before 2nd course 2 relapsed, so steady remission was only in 1. Exacerbation of uveitis was found in the patient treated with Tocilizumab. Surgical interventions (37 operations, 26 eyes, 20 patients) were uncomplicated in most cases. Ocular adverse effects were not observed, systemic – occurred in 14% of the patients so in 7% biologics were discontinued.
Conclusions Biologic therapy was effective in 41 – 88% of children with RD related uveitis that depends on the drug and disease severity. Nowadays Adalimumab is the most effective for pediatric RD associated uveitis. Further investigations are required to define indications for different biologics in pediatric uveitis and criterions for successful outcome prediction.
Disclosure of Interest None Declared
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