Background Anterior uveitis (AU) is the most common pattern of uveitis, that migh lead to important ocular complications including blindness. Immunomodulatory drugs have been used in order to prevent recurrences of uveitis. Nevertheless, it is not clear which drug could be preferred in each patient.
Objectives To generate recommendations on the use of immunomodulators in adult patients with non-infectious, non-neoplastic anterior uveitis (AU) based on best evidence and experience.
Methods Delphi methodology was followed. A multidisciplinary panel of 5 experts (2 ophtalmologists, one immunologist, one rheumatologist, one internist) was established, who, in the first nominal group meeting, defined the scope, users, and chapters of the document. A systematic literature review was performed to assess the efficacy and safety of immunomodulators in patients with non-infectious, non-neoplastic AU. All of the exposed above was discussed in a second nominal group meeting and 33 recommendations were generated. Recommendations agreement grade was tested also in 25 additional experts. Recommendations were voted from 1 (total disagreement) to 10 (total agreement). We defined agreement if at least 70% voted ≥7. The level of evidence and grade or recommendation was assessed using the Oxford Centre for Evidence-based Medicine Levels of Evidence.
Results The 33 recommendations were accepted. They include specific recommendations on patients with non-infectious, non-neoplastic UA, as well as different treatment lines. Methotrexate (MTX) or Sulfasalazine were recommended as a first line drugs in refractory cases to topic treatments in patients with AU and spondyloarthritis, inflammatory bowel disease, psoriasis, idiopathic HLA-B27 positive or negative AU. Etanercept was recommended for patients with TRAPS syndrome, and for those with other autoinflammatory syndromes canakinumab o anakinra. In case of bilateral sarcoidosis, relapsing polychondritis or TINU syndrome, MTX was recommended along with systemic steroids. For patients with a flare of AU and Behçet disease, systemic steroids along with azathioprine or a calcineurin inhibitor were recommended. The indication of an immunomodulatory drug in patitnes with multiple sclerosis was considered to be decided with a neurologist. For patients refractory to all exposed above and or intolerant, depending on AU type, a change to another classical immunomodulatory drug or to an anti-TNF was recommended (adalimumab, infliximab, certolizumab or). Except for patients with TINU, etanercept was not recommended because current evidence does not support the use of it to prevent AU flares.
Conclusions In patients with non-infectious, non-neoplastic AU, these recommendations on the use of immunomodulators might be a guide in order to help in the treatment decision making, due to the lack of robust evidence or other globally accepted algorithms.
Disclosure of Interest G. Espinosa Grant/research support from: GSK, Actelion, S. Muñoz-Fernandez: None declared, J. García Ruiz de Morales: None declared, J. Herreras Grant/research support from: Allergan and Abbvie, M. Cordero-Coma Grant/research support from: Abbvie, Merck Sharp & Dohme, and Allergan