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 Table of Contents  
EDITORIAL
Year : 2018  |  Volume : 8  |  Issue : 3  |  Page : 115-116

Biologics for the treatment of noninfectious uveitis


Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan

Date of Web Publication20-Sep-2018

Correspondence Address:
Dr. Chang-Ping Lin
Department of Ophthalmology, National Taiwan University Hospital, Taipei
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjo.tjo_99_18

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How to cite this article:
Lin CP. Biologics for the treatment of noninfectious uveitis. Taiwan J Ophthalmol 2018;8:115-6

How to cite this URL:
Lin CP. Biologics for the treatment of noninfectious uveitis. Taiwan J Ophthalmol [serial online] 2018 [cited 2018 Dec 12];8:115-6. Available from: http://www.e-tjo.org/text.asp?2018/8/3/115/240736





In this issue, we have two case-reports and a special report about the use of biologics in the treatment of noninfectious uveitis. Uveitis is one of the leading causes of blindness in the world. The pathogenesis of uveitis is classified into two groups: infectious and noninfectious. Treatment for infectious uveitis should be pathogen specific. Noninfectious uveitis should be treated with anti-inflammatory agents, in which corticosteroid is the mainstay. However, long-term use of moderate-to-large dose of corticosteroid is associated with various adverse effects. Immunomodulatory treatment (IMT) and biologics are used for corticosteroid sparing.

In Taiwan, the most difficult noninfectious is panuveitis associated with Behcet's disease and idiopathic retinal vasculitis, followed by juvenile idiopathic iridocyclitis. For uveitis with Behcet's disease, a significant portion of patients has guarded prognosis when treated only with corticosteroid or along with IMT. Infliximab, one of the tumor necrosis factor alpha inhibitors, is off-label used in Japan for Behcet's uveitis with good results.[1],[2] However, infliximab was not approved in Taiwan due to the concern of tuberculosis. The VISUAL I[3] and VISUAL II[4] studies showed that the efficacy of Adalimumab in treating nonanterior noninfectious uveitis (NANIU). Adalimumab got the approval of the indication of NANIU in the USA, EU, and Japan in 2016, and in Taiwan, in 2017. A special report on the recommendation of the use of biologics is proposed by a group of uveitis subspecialists in Taiwan. This report is based on thorough review[5],[6] of the previous guidelines in treating uveitis, especially those with strong evidence basis, and take special consideration of regional, ethnical, and socioeconomic variations. However, several points in addition should be mentioned as the followings:

Anti-TNF alpha and other biologics are associated with some adverse effects, especially the increased susceptibility to tuberculosis[7] and increased risk of reactivation of hepatitis virus B,[8] which should be monitored with the Risk-Management Plan, suggested by rheumatologists in Taiwan.

Since steroid is still the mainstay of the treatment of uveitis. Steroid responder is another reason for using steroid-sparing agents, and hence IMT and/or biologics, in earlier stage of the disease.

Most of the anterior uveitis could be controlled with topical or periocular treatment, mainly corticosteroid, as mentioned in the Special Report. Adalimumab got the indication of NANIU. However, chronic “anterior” uveitis associated with Juvenile idiopathic arthritis[9] and psoriatic arthritis are exceptional. They are chronic uveitis. Long-term use of systemic immunomodulatory is frequently indicated. Some of them could not be adequately controlled even with the use of IMT. In this condition, biologics may also play a role. In uveitis associated with psoriatic arthritis, biologics could be used under the indication of psoriasis or arthritis.[10] Since iridocyclitis in children could occur with absent or minimal activity of arthritis, we are looking forward to the approval of the indication of biologics for juvenile idiopathic iridocyclitis.[11]

There are a lot of variations in many aspects of uveitis such as disease entities, ethnical groups, and environmental factors. In Visual I and II studies, NANIU is regarded as a group.[12] When subgroups are examined, only the groups of idiopathic uveitis and birdshot chorioretinitis are of enough number of subjects for statistical analysis.[3],[4] We believe that the response in other disease entities may not be all the same. Further studies are required for each noninfectious uveitis. However, the approval of the indication for NANIU may well give us one powerful weapon to combat the difficult battle against noninfectious uveitis with poor prognosis.[13]



 
  References Top

1.
Okada AA, Goto H, Ohno S, Mochizuki M; Ocular Behçet's Disease Research Group of Japan. Multicenter study of infliximab for refractory uveoretinitis in Behçet disease. Arch Ophthalmol 2012;130:592-8.  Back to cited text no. 1
    
2.
Takeuchi M, Kezuka T, Sugita S, Keino H, Namba K, Kaburaki T, et al. Evaluation of the long-term efficacy and safety of infliximab treatment for uveitis in Behçet's disease: A multicenter study. Ophthalmology 2014;121:1877-84.  Back to cited text no. 2
    
3.
Jaffe GJ, Dick AD, Brézin AP, Nguyen QD, Thorne JE, Kestelyn P, et al. Adalimumab in patients with active noninfectious uveitis. N Engl J Med 2016;375:932-43.  Back to cited text no. 3
    
4.
Nguyen QD, Merrill PT, Jaffe GJ, Dick AD, Kurup SK, Sheppard J, et al. Adalimumab for prevention of uveitic flare in patients with inactive non-infectious uveitis controlled by corticosteroids (VISUAL II): A multicentre, double-masked, randomised, placebo-controlled phase 3 trial. Lancet 2016;388:1183-92.  Back to cited text no. 4
    
5.
Levy-Clarke G, Jabs DA, Read RW, Rosenbaum JT, Vitale A, Van Gelder RN, et al. Expert panel recommendations for the use of anti-tumor necrosis factor biologic agents in patients with ocular inflammatory disorders. Ophthalmology 2014;121:785-96.  Back to cited text no. 5
    
6.
Cordero-Coma M, Yilmaz T, Onal S. Systematic review of anti-tumor necrosis factor-alpha therapy for treatment of immune-mediated uveitis. Ocul Immunol Inflamm 2013;21:19-27.  Back to cited text no. 6
    
7.
Lim CH, Chen HH, Chen YH, Chen DY, Huang WN, Tsai JJ, et al. The risk of tuberculosis disease in rheumatoid arthritis patients on biologics and targeted therapy: A 15-year real world experience in Taiwan. PLoS One 2017;12:e0178035.  Back to cited text no. 7
    
8.
Chen MH, Chen MH, Liu CY, Tsai CY, Huang DF, Lin HY, et al. Hepatitis B virus reactivation in rheumatoid arthritis patients undergoing biologics treatment. J Infect Dis 2017;215:566-73.  Back to cited text no. 8
    
9.
Yu HH, Chen PC, Wang LC, Lee JH, Lin YT, Yang YH, et al. Juvenile idiopathic arthritis-associated uveitis: A nationwide population-based study in Taiwan. PLoS One 2013;8:e70625.  Back to cited text no. 9
    
10.
Salek SS, Pradeep A, Guly C, Ramanan AV, Rosenbaum JT. Uveitis and juvenile psoriatic arthritis or psoriasis. Am J Ophthalmol 2018;185:68-74.  Back to cited text no. 10
    
11.
Ramanan AV, Dick AD, Jones AP, McKay A, Williamson PR, Compeyrot-Lacassagne S, et al. Adalimumab plus methotrexate for uveitis in juvenile idiopathic arthritis. N Engl J Med 2017;376:1637-46.  Back to cited text no. 11
    
12.
Goto H, Zako M, Namba K, Hashida N, Kaburaki T, Miyazaki M, et al. Adalimumab in active and inactive, non-infectious uveitis: Global results from the VISUAL I and VISUAL II trials. Ocul Immunol Inflamm 2018 Jul 17, p. 1-11.  Back to cited text no. 12
    
13.
Suhler EB, Adán A, Brézin AP, Fortin E, Goto H, Jaffe GJ, et al. Safety and efficacy of adalimumab in patients with noninfectious uveitis in an ongoing open-label study: VISUAL III. Ophthalmology 2018;125:1075-87.  Back to cited text no. 13
    




 

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