|Year : 2015 | Volume
| Issue : 4 | Page : 156-163
Immunosuppressive therapy for eye diseases: Effectiveness, safety, side effects and their prevention
Dana M Hornbeak, Jennifer E Thorne
Division of Ocular Immunology, The Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
|Date of Web Publication||8-Dec-2015|
Jennifer E Thorne
Division of Ocular Immunology, The Wilmer Eye Institute, Johns Hopkins School of Medicine, 600 North Wolfe Street, Woods Building, Room 476, Baltimore, MD 21287-9217
Source of Support: None, Conflict of Interest: None
Ocular inflammation is a significant cause of ocular morbidity and visual impairment. Topical, periocular, intraocular, and systemic corticosteroids are highly effective for treating appropriate forms of ocular inflammation. However, their use may be constrained by local and/or systemic side effects, especially if long-term therapy is required. As a result, immunosuppressive agents increasingly have been used to manage ocular inflammation alongside or in place of corticosteroids. The four categories of agents used today are antimetabolites [primarily methotrexate, mycophenolate mofetil (MMF), and azathioprine]; T-cell inhibitors (usually cyclosporine, less often tacrolimus or sirolimus); alkylating agents (cyclophos-phamide and chlorambucil); and biologic agents [tumor necrosis factor (TNF) inhibitors, lymphocyte inhibitors, and interleukin inhibitors]. The primary goals of immunosuppressive therapy are (1) to control inflammation when corticosteroids fail to do so; (2) to prevent corticosteroid-induced toxicity when the necessary corticosteroid dosage exceeds the desired or safe level (corticosteroid sparing); and (3) to treat specific high-risk uveitis syndromes known to respond poorly to corticosteroids alone. Growing evidence shows the effectiveness of immunosuppressive drugs in achieving these goals, as well as improved visual function, prevention of ocular complications, and in some cases even disease remission. However, these agents also have side effects, which must be considered in each patient's management. In this report, we summarize the effectiveness and safety of immunosuppressive drug therapy utilized in the treatment of ocular inflammatory diseases.
Keywords: drug safety, inflammation, immunosuppressive agents, treatment outcome, uveitis
|How to cite this article:|
Hornbeak DM, Thorne JE. Immunosuppressive therapy for eye diseases: Effectiveness, safety, side effects and their prevention. Taiwan J Ophthalmol 2015;5:156-63
|How to cite this URL:|
Hornbeak DM, Thorne JE. Immunosuppressive therapy for eye diseases: Effectiveness, safety, side effects and their prevention. Taiwan J Ophthalmol [serial online] 2015 [cited 2021 Oct 23];5:156-63. Available from: https://www.e-tjo.org/text.asp?2015/5/4/156/204393
| 1. Effectiveness of immunosuppressive agents|| |
Ocular inflammation can produce considerable ocular morbidity and visual impairment. Although topical, periocular, intraocular, and systemic corticosteroids may be highly effective, their use may be limited in some patients due to ocular and/or systemic side effects. Thus, immunosuppressive agents are increasingly used to manage ocular inflammation alongside or in place of corticoste-roids. The categories of immunosuppressive agents are antime-tabolites (e.g., methotrexate, MMF, and azathioprine); T-cell inhibitors (e.g., cyclosporine and tacrolimus); alkylating agents (e.g., cyclophosphamide and chlorambucil); and biologic agents (e.g., TNF inhibitors, lymphocyte inhibitors, and interleukin in hibitors; [Table 1]).
|Table 1: Classes of immunosuppressive drugs used in ocular inflammation.|
Click here to view
Immunosuppressive therapy is primarily used in the following cases: (1) to control inflammation when corticosteroids fail to do so; (2) to prevent corticosteroid-induced toxicity (corticosteroid sparing); and (3) to treat high-risk uveitis syndromes unresponsive to corticosteroids alone. Growing evidence shows the effectiveness of immunosuppressive drugs in achieving these goals, as well as producing desirable clinical outcomes such as improved visual function, prevention of ocular complications, and in some cases even disease remission.
1.1. Effectiveness: Disease control, corticosteroid reduction, and treatment of specific diseases
Although the number of randomized clinical trials for uveitis treatments is increasing, the majority of data regarding the effectiveness of immunosuppressive drug therapy in treating ocular inflammatory diseases are derived from retrospective studies. These include uncontrolled case series and cohort studies in which more robust statistical techniques such as longitudinal data analysis and time-to-event data (cumulative incidence data) may be used. For example, the Systemic Immunosuppressive Therapy for Eye Diseases Cohort Study (SITE) is a large retrospective cohort study of 7957 patients with noninfectious ocular inflammatory diseases treated at five tertiary-care centers from 1979 to 2005. This study provided data on the demographic characteristics, clinical course, treatment outcomes, side effects, discontinuation rates, and overall and cancer-associated mortality due to immunosuppressive therapy in these patients.
Reported outcomes typically used for measuring treatment efficacy and effectiveness are disease control and reduction of corti-costeroid dosage to desirable levels (“corticosteroid-sparing” effect). Disease control in uveitis (inactive anterior uveitis) may be defined as rare cells or less in the anterior chamber; grade 0 vitreous cells (not including inactive cells seen in the formed vitreous) and grade 0 vitreous haze; and absence of active chorioretinal lesions, depending on the anatomic categorization of the uveitis. Although there are some published studies describing specific parameters for disease control in other ocular inflammatory diseases,, many retrospective studies use the medical judgment of the physician to define disease control. Occasionally, reproduc-ibility of disease control is required as part of the treatment-related outcome, as is the case in published SITE data in which disease control requires inactivity of inflammation spanning at least two visits spaced 28 days apart. The end point of corticosteroid-sparing success includes the control of the ocular inflammation disease coupled with the ability to taper the systemic corticosteroid to a level acceptable for long-term use. In the past, that level had been thought to be ≤ 10 mg of oral prednisone daily, although more recently a cutoff of ≤ 7.5 mg of prednisone daily is typically used in most cases. [Table 2] summarizes the control of ocular inflammation and corticosteroid-sparing success for specific immunosuppressive drug therapies as reported by the SITE Cohort Study. These studies are summarized comparatively because the same end point was utilized in each report focusing on specific immunosuppressive drugs.
|Table 2: Effectiveness: Percentage of patients achieving disease control, corticosteroid-sparing success, both, or remission.|
Click here to view
Regarding antimetabolites, azathioprine successfully controlled inflammatory disease in 62% of patients; methotrexate in 66% of patients; and MMF in 73% of patients. The T-cell inhibitors cyclosporine and tacrolimus achieved disease control in 52% and 62% of patients, respectively; and the alkylating agent cyclophosphamide controlled disease in 76% of patients. Corticosteroid-sparing success was reported as 47%, 58%, and 55–82% for azathioprine, methotrexate, and MMF, respectively.,,, Corticosteroid-sparing success for mycophenolate was different in the Daniel et al and Thorne et al papers because in the case of the Thorne et al article, success measured over two visits was not required. Although this article and another from the Johns Hopkins cohort suggest that corticosteroid-sparing success may occur more frequently and more rapidly with MMF than with the other antimetabolites, a multicenter, randomized, observer-masked clinical trial of 80 patients comparing methotrexate with mycophenolate therapy for uveitis failed to demonstrate a statistically significant difference between the two therapies.
The corticosteroid-sparing success of cyclosporine was lower (36%) and that of cyclophosphamide was similar (61%) to the results observed with the antimetabolites in the SITE studies., The bi-ologics (specifically TNF inhibitors) achieved corticosteroid reduction in 75% of patients at 1 year, although this study only described treatment outcomes in children [Table 2].
Immunosuppression also may be used in specific diseases in which high doses of corticosteroids are not adequate to control the disease (e.g., mucous membrane pemphigoid, Behçet retinal vasculitis) or in which clinical outcomes have been reported to improve with the use of these drugs (e.g., birdshot chorioretinop-athy). For example, immunosuppression achieved disease control in 50–89% of patients with Behcet’s disease,,,, and disease remission in 75% of patients with serpiginous choroidopathy. For mucous membrane pemphigoid, immunosuppressive medications achieved disease control in 83% of patients by 6 months, and disease remission in 91% of patients by 2 years [Table 3].
|Table 3: Effectiveness: Outcomes of immunosuppressive therapy for specific diseases.|
Click here to view
1.2. Effectiveness: Improved clinical outcomes
In addition to disease control and corticosteroid-sparing effects, immunosuppressive medications may improve a variety of clinical outcomes. For example, immunosuppression significantly reduced new-onset cystoid macular edema [relative risk (RR) = 0.17; 95% confidence interval (CI) 0.05–0.64; p = 0.009], and reversed visual field loss in patients with Birdshot chorioretinitis. For patients with multifocal choroiditis and panuveitis (MFCPU), use of immunosuppressive agents reduced the risk of posterior segment complications by 83%, prevented risk of visual loss to the 20/200 or worse threshold by 90%; and prevented new cases of optic neuropathy and choroidal neovascularization (CNV) in contralateral eyes of patients with unilateral optic neuropathy or CNV due to MFCPU., In the case of chronic Vogt–Koyanagi–Harada syndrome (VKH), use of immunosuppressive drug therapy was associated with a 67% reduction of vision loss to the 20/50 threshold or worse, and a 92% reduction of vision loss to the 20/200 threshold or worse. For patients with acute VKH uveitis, addition of immu-nosuppressive medication (specifically MMF) to corticosteroids as first-line therapy led to a 15% reduction in disease recurrence, a 35% reduction in overall complications, a 36% increase in achievement of 20/20 visual acuity, and 100% prevention of late-stage retinal findings (sunset glow fundus).
In comparison to corticosteroids, immunosuppressant agents are capable of inducing medication-free remission (as opposed to suppression). For the antimetabolites, remission rates typically were 0.09/person-year (PY; 95% CI 0.07–0.12/PY) for methotrexate and 0.09/PY (95% CI 0.06–0.14/PY) for azathioprine. For the alky-lating agent cyclophosphamide, remission rates have been reported to be between 0.32/PY and 0.50/PY annually,; 63% of patients achieved remission within 2 years, and 75% of patients achieved remission within 3 years. Similarly, chlorambucil has a reported remission rate of 43% in patients with Behcet’s disease uveitis over 1.5 years, and 77% in patients with all types of ocular inflammation within 4 years. Among patients with mucous membrane pemphigoid, the rate of remission appeared even higher for cyclophosphamide with a cumulative incidence of remission of 91% at 2 years after initiation of therapy [Table 3].
| 2. Short-term toxicities of immunosuppressive agents|| |
Despite a growing literature supporting the effectiveness of immunosuppressive drug therapy in the treatment of ocular inflammatory disease, side effects of such therapy remain a concern. Fortunately, recent data from both prospective and retrospective studies of ocular inflammation patients support the relative safety of immunosuppressive medications, particularly in terms of short-term safety and tolerability. In the Multicenter Uveitis Steroid Treatment (MUST) trial, for example, systemic adverse events typically associated with immunosuppression were no more common in the group randomized to systemic therapy (in which 86% received immunosuppression) than in the group randomized to fluocinolone acetonide implant therapy, with the exception that an increased risk of infections required antibiotics; however, this risk was low in both groups. The immunosuppressant-specific risks requiring surveillance are summarized in [Table 4].
2.1. Short-term toxicities: Antimetabolites
The majority of data on the use of antimetabolites suggest a favorable safety profile, including decades of experience in non-ocular fields (such as for methotrexate and azathioprine). Most side effects are detectable by following established monitoring guidelines, are reversible with dose reduction or cessation, and only infrequently require discontinuation of drug [Table 4]. One significant irreversible effect of the antimetabolites is teratogenicity; therefore, withdrawal of therapy before planned pregnancy and use of contraception during therapy is mandatory.
Adverse effects of methotrexate monotherapy include gastrointestinal intolerance, oral ulcers, hepatotoxicity, cytopenias, and interstitial pneumonia. The SITE study reported discontinuation due to these side effects at a rate of 0.13/PY (95% CI 0.10–0.17/PY). For MMF monotherapy, the SITE study reported cessation due to side effects at a rate of 0.10/PY (95% CI 0.06–0.14/PY), similar to two retrospective case series reporting discontinuation due to side effects at rates of 0.08/PY (95% CI 0.03–0.16/PY) and 0.09/PY over 6 years of follow-up, respectively. Enteric-coated mycophenolate sodium is available to help minimize gastrointestinal side effects (the most common treatment-limiting toxicity of antime-tabolites) while maintaining similar immunosuppressive benefits.
For azathioprine monotherapy, gastrointestinal symptoms caused discontinuation at a rate of 0.06/PY (95% CI 0.03–0.10/PY) during 2 years of follow-up. This was followed in frequency by bone marrow suppression (0.03/PY; 95% CI 0.01–0.07/PY), elevated liver enzymes (0.03/PY; 95% CI 0.01–0.06/PY), and allergic reaction (0.01/PY; 95% CI 0.001–0.03/PY), with an overall toxicity-related discontinuation rate of 0.16/PY (95% CI 0.11–0.22/PY). Rarely, a homozygous deficiency of thiopurine methyltransferase (TPMT) can result in severe decreases in leukocytes, red blood cells, and platelets; thus, many clinicians recommend testing for TPMT activity prior to initiating azathioprine therapy, as dose-adjustment guidelines are available.
2.2. Short-term toxicities: T-cell inhibitors
Of the T-cell inhibitors, cyclosporine has been the most widely used and studied for ocular inflammatory diseases, although tacrolimus and sirolimus also may be used. In the SITE study, cyclosporine side effects resulted in a discontinuation rate of 0.07/ PY (95% CI 0.05–0.09/PY). Renal toxicity and hypertension were the most frequent side effects, occurring at rates of 0.02/PY (95% CI 0.01–0.04/PY) and 0.02/PY (95% CI 0.009–0.03/PY), respectively. Discontinuation of cyclosporine was statistically significantly associated with increasing age; compared with patients aged 18–39 years, discontinuation for toxicity was 3.25 times more common in patients aged 55–64 years, and was 5.66 times more common in patients aged > 65 years (overall p = 0.0005). Although no data on treatment with cyclosporine for ocular inflammatory diseases during pregnancy are available, in a transplant pregnancy cohort, no excess malformations were observed in women receiving cyclosporine during pregnancy.
A previous retrospective case series evaluating tacrolimus for ocular inflammation also found a low discontinuation rate due to toxicity (0.13/PY), predominantly due to noncardiovascular and nonrenal effects such as neurologic symptoms (e.g., tremor, par-esthesias), gastrointestinal symptoms, hyperglycemia, insomnia, and headache. Rarely, tacrolimus causes irreversible toxicity to pancreatic beta cells leading to type 1 diabetes mellitus. Sirolimus has been associated with cytopenias, hypercholesterolemia, ar-thralgias, extremity edema, and impaired wound healing.
2.3. Short-term toxicities: Alkylating agents
The alkylating agents cyclophosphamide and chlorambucil typically are used for very severe inflammatory disease due to the high-toxicity risk associated with these drugs. For example, the SITE study reported discontinuation of cyclophosphamide therapy at an overall rate of 0.39/PY (95% CI 0.31–0.49/PY), substantially higher than rates of antimetabolites or T-cell inhibitors observed in the same cohort. The most commonly reported side effects were leukopenia (0.20/PY; 95% CI 0.14–0.27/PY), thrombocytopenia (0.016/PY; 95% CI 0.003–0.046/PY), anemia (0.04/PY; 95% CI 0.015–0.075/PY), and cystitis/blood in the urine (0.07/PY; 95% CI 0.04–0.12/PY). Other studies have shown the bone marrow suppression of cyclophosphamide to be dose dependent and reversible, with older individuals being more susceptible.,
The adverse effects of chlorambucil therapy are similar to those of cyclophosphamide, with bone marrow suppression being the most common toxicity. Both cyclophosphamide and chlorambucil can cause alopecia, sterility, and embryotoxicity., Bladder toxicity is not associated with chlorambucil therapy.
2.4. Short-term toxicities: Biologics
Many of the side effects of TNF-alpha inhibitors are sufficiently mild to not require discontinuation. These include autoantibody formation,; limited treatment in volume-sensitive individuals (such as those with low cardiac output), due to intravenous administration of the medication; and infusion reactions such as local erythema at the injection site, atopic dermatitis, flushing, rash, hypertension, fever, and fatigue. Subcutaneously delivered bi-ologics may be associated with injection site pain as well. These effects generally do not lead to discontinuation of therapy. Some of these agents appear to be safe to use during pregnancy.
Rituximab has side effects, which are usually mild, transient, and do not result in discontinuation of therapy. Hypersensitivity reactions including hypotension, local erythema, cough, laryngeal edema, and infusion-related rigors occur occasionally. A meta-analysis of patients with lymphoma taking rituximab showed increased risk of severe leukopenia (RR = 1.24; 95% CI 1.12–1.37) and granulocytopenia (RR = 1.07; 95% CI 1.02–1.12), although this did not result in higher infection risk.
Dose-dependent flu-like symptoms from interferon-alpha treatment are expected, but usually do not require discontinuation. In a retrospective study of interferon-alpha treatment in patients with severe uveitis due to Behcet’s disease, discontinuation due to toxicity occurred in 9.4% of patients during nearly 5 years of follow-up. In addition to flu-like symptoms, mild leukopenia (> 2000/μL) was seen in all patients, but caused discontinuation in none. Uncommon findings during treatment included fibromy-algia, depression, hair loss, thrombocytopenia, headache, mild hepatotoxicity, thyroiditis, fever, and nausea.
The more concerning side effects reported with biologic therapy such as increased risk of infections (including tuberculosis) and the potential risk of cancer with use of these agents are discussed in the following sections.
| 3. Infection risk with immunosuppressive agents|| |
Increased infection risk is a frequent concern when using immunosuppressive medications for ocular inflammation, and data regarding this risk are summarized in [Table 5]. In the MUST trial, a higher risk of infections requiring a drug prescription was observed in the systemic therapy group (systemic corticosteroids plus immunosuppression in 86% of patients) than in the implant group (0.60/PY vs. 0.36/PY, p = 0.034). However, these typically were mild infections and as such, it is unclear to what extent the difference reflected an increased likelihood of prescribing drugs for mild infections in patients known to be taking immunosuppressive drugs (as both participants and clinicians were unmasked) rather than a true difference in infection incidence.
|Table 5: Infection and malignancy risk of immunosuppressive medications for ocular inflammatory disease.|
Click here to view
Existing data from the SITE Cohort Study reported no observed opportunistic infections in patients treated with MMF, metho-trexate, or azathioprine monotherapy (with or without systemic corticosteroids).,, This confirmed previous evidence showing no increase in infection risk associated with MMF monotherapy. The SITE study also showed no increased infection risk associated with T-cell inhibitors, consistent with previous studies reporting no association of cyclosporine or tacrolimus monotherapy with increased risk of serious infections.
These results for monotherapy are reassuring, but patients sometimes require multiagent therapy. The combination of an antimetabolite with a T-cell inhibitor such as cyclosporine is a common approach, because the drugs have different toxicity profiles and have been used together for other conditions such as transplantation. In some transplant cohorts, the combination of MMF with cyclosporine (with or without corticosteroids) has been associated with a nonsignificant increase in opportunistic infections compared with either agent alone [Table 5]; however, infection risk was substantially lower in an ocular inflammation cohort in which only two patients developed major infections while taking MMF–cyclosporine combination therapy.
In contrast to antimetabolites and T-cell inhibitors, cyclophos-phamide has been associated with opportunistic infections in ocular inflammation patients, leading to discontinuation in 3.0% (95% CI 1.2–7.1%) of patients in the 1st year, at a rate of 0.03/PY over 3 years of follow-up (95% CI 0.0084–0.061). Infections included Pneumocystis jirovecii pneumonia leading to death in one (0.5%) patient, who had been managed according to standard guidelines but had not taken the recommended Pneumocystis prophylaxis with trimethoprim/sulfamethoxazole. These findings are consistent with (but less extreme than) results of a previous randomized controlled clinical trial of 50 patients with Wegener’s granulomatosis, which reported infections in 70% of patients receiving cyclophosphamide, including 30% who developed P. jirovecii pneumonia. Substantial granulocytopenia (absolute neutrophil count < 1000 cells/μL) associated with cyclophosphamide can increase the risk of bacterial infections, particularly sepsis. To decrease the risk of infections and sepsis, many clinicians temporarily discontinue cyclophosphamide for white blood counts below 2500 cells/μL, followed by downward dose adjustment. This practice may explain the lower risk of infection observed in the ocular inflammation cohort.
The most common infection sites in patients taking biologics are the respiratory tract, skin and soft tissues, and urinary tract. Anti-TNF therapy is associated with increased risk of infection with intracellular pathogens, such as Mycobacterium tuberculosis, Listeria monocytogenes, and Legionella pneumophila. A meta-analysis of TNF inhibitors in 369 patients with Behçet’s disease reported tuberculosis reactivation in four patients, and opportunistic infections in 10 patients (including P. jirovecii pneumonia, L. pneumophila pneumonia, cryptococcal meningitis, varicella zoster infection, cytomegalovirus colitis, forearm cellulitis, and bacterial endocarditis). A meta-analysis of adults with rheumatoid arthritis taking infliximab or adalimumab reported a statistically significant higher risk [odds ratio (OR) = 2.0; 95% CI 1.3–3.1) of serious infections during 22–54 weeks of follow-up, but the absolute risk was low (0.036% with anti-TNF therapy vs. 0.017% with placebo). Such a low absolute risk probably does not represent a clinically important constraint on the use of these agents for ocular inflammation, but clinicians should bear in mind that significant infection does occur occasionally.
The risk of severe infection due to rituximab therapy also appears low.,, Although a randomized, double-blind, placebo-controlled, dose-ranging trial of rituximab reported serious infection that was 0.015/PY higher than in the placebo group, the absolute rates for both groups were low (0.052/PY vs. 0.037/PY, respectively) and no tuberculosis or opportunistic infections occurred in either group. Furthermore, two meta-analyses of patients with lymphoma treated with rituximab showed no statistically significant increases in the risk of severe infection (defined as life threatening, or requiring hospitalization or intravenous antibiotics).,
Infection risk with interferon treatment has also been reported to be low, with no increased risk of opportunistic infections for either interferon-alpha or interferon-gamma.
| 4. Cancer risk with immunosuppressive agents|| |
Immunosuppression has been thought to increase the risk of skin, mucosal, and lymphoproliferative cancers. Proposed mechanisms include susceptibility to infection with oncogenic infectious agents, interrupted immune surveillance of malignant cells, and damage to DNA (alkylating agents) or to DNA metabolism (anti-metabolites). However, most of these observations are from transplant studies, and may not apply to ocular inflammation patients. Incidences of cancer associated with immunosuppressive drugs used in ocular inflammatory disease are summarized in [Table 5].
Antimetabolites appear to have a relatively low risk of clinically important carcinogenicity. Azathioprine has been studied in patients with rheumatoid arthritis, inflammatory bowel disease, and multiple sclerosis, and consistently has shown no increased risk of malignancy except for sporadic reports of post-transplant lym-phoproliferative disorder (PTLD)-like cases, which do not occur more often in treated than in nontreated patients (RR = 1.27, 95% CI 0.03–8.20). Methotrexate also has shown no increased cancer risk in several cohorts with a variety of diseases. Although rare PTLD-like cases have been reported, a large observational study following 19,591 rheumatoid arthritis patients over 89,710 PY found no increased lymphoma risk with methotrexate therapy, suggesting that PTLD-like cases are rare in nontransplant patients. Observational studies of MMF in the post-transplant setting have found a significantly reduced risk of PTLD, improved survival of patients with PTLD, and a lower cancer risk when MMF is compared with alternative regimens, which has contributed to a preference for this drug over alternatives in transplant patients.
Studies of T-cell inhibitors, derived from transplant cohorts, show the increased malignancy risk typical of those cohorts. However, this risk is not necessarily applicable to nontransplant cohorts., For example, a cohort of rheumatoid arthritis patients showed no increased malignancy risk due to cyclosporine treatment. Thus, in the absence of these treatments or of an organ transplant, such as in uveitis patients, cyclosporine likely would not confer a higher cancer risk.
By contrast, alkylating agents are associated with higher malignancy risk. Several studies have shown that cyclophosphamide increases incidence of leukemia, lymphoma, and skin malignancies, as well as bladder cancer due to the accumulation of acrolein (a carcinogenic metabolite) in urine. Bladder cancer risk appears to be dose and/or duration dependent, is higher in smokers, and can be mitigated by intravenous or oral hydration to prevent acrolein buildup. Chlorambucil has been linked to development of cutaneous malignancies, lymphoma, and leukemia, but not with bladder cancer.
The majority of reports on cancer risk with TNF inhibitors are favorable. Seven large observational studies of TNF inhibitors for rheumatoid arthritis, with nearly 100,000 PYof follow-up, showed no increased malignancy risk,,,,,,,, except for nonmelanotic skin cancer in one analysis (OR = 1.5 vs. no anti-TNF therapy). Results in a Crohn’s disease cohort also found no increased cancer risk. Regarding lymphoma specifically, a large observational database of 19,591 patients (approximately 89,710 PY of follow-up) with rheumatoid arthritis showed no increased lymphoma risk with anti-TNF therapy; in addition, a meta-review of lymphoma risk in patients with rheumatoid arthritis found no clear association between lymphoma and anti-TNF therapy. By contrast, a meta-analysis of TNF inhibitors in 5014 patients with rheumatoid arthritis in clinical trials showed a 3.3-fold higher cancer risk over 22–54 weeks of follow-up, but this was theorized to be the result of accelerated diagnosis of pre-existing cancers given the short period during which the difference appeared.
Published results from clinical trials have shown no increased risk of malignancy due to rituximab therapy (RR = 1.05, 95% CI 0.76–1.42). These findings were similar to an observational cohort study of 186 rheumatoid arthritis patients reporting no increased cancer risk due to rituximab treatment. For this reason, rituximab is sometimes considered the first choice in patients with current or previous history of cancer in whom anti-TNF is contraindicated.
Regarding interferon-alpha therapy, a retrospective study of patients with Behet-associated uveitis found no increase in malignancy with interferon-alpha over nearly 8 years of follow-up, as did a systematic literature review of 338 patients with ocular and systemic manifestations of Behçet’s disease.
| 5. Mortality risk with immunosuppressive agents|| |
Data on mortality risk of immunosuppressive drugs for patients with ocular inflammatory disease were evaluated in the SITE Cohort Study.
Antimetabolites as a class were not associated with increased overall mortality [adjusted hazard ratio (aHR) = 1.08, 95% CI 0.86–1.37) or cancer-related mortality (aHR = 0.89, 95% CI 0.54–1.48). Azathioprine, methotrexate, and MMF individually were not associated with increased overall or cancer-related mortality. Similarly, T-cell inhibitors as a class–or cyclosporine individually–did not increase overall mortality (aHR = 0.81, 95% CI 0.59–1.11) or cancer-related mortality (aHR = 0.78, 95% CI 0.38–1.59). The latter observation was consistent with a retrospective cohort study showing no increased mortality risk in patients with rheumatoid arthritis treated with cyclosporine.
Alkylating agents as a class were not associated with significantly increased overall mortality (aHR = 1.17, 95% CI 0.85–1.61) or cancer-related mortality. However, statistical power for the latter outcome was limited and available data did show a trend toward increased risk (aHR = 1.74, 95% CI 0.91–3.32), which was similar to the increased cancer risk observed in other cohorts and also consistent with previous reports showing a dose-dependent increase in cancer-related mortality due to cyclophosphamide., These risks generally restrict the use of these agents to the most serious cases of ocular inflammatory disease.
Several well-powered rheumatologic cohort studies of TNF inhibitors have found no increased mortality risk.,,,, By contrast, the SITE Cohort Study showed significant increases in overall mortality (fully aHR = 1.99, 95% CI 1.00–3.98) and cancer mortality (HR = 3.83, 95% CI 1.13–13.01) in association with TNF inhibitors. Individual risk ratios for etanercept and infliximab were similar in magnitude, but nonsignificant due to sample size and follow-up time.
Long-term data are more limited on rituximab. A recent analysis of 500 patients with pemphigus vulgaris treated with rituximab therapy showed no increase in mortality risk. However, because B-cell depletion can last for ≥ 18 months after rituximab therapy, there is reasonable concern that future data will show an increase in infection-related mortality. Further research is needed to determine the risk of mortality with interferon therapy for eye disease.
| 6. Conclusion|| |
In summary, increasing evidence supports the effectiveness and safety of using immunosuppressive drug therapy as treatment for ocular inflammatory diseases. The antimetabolites and the biologics, in particular, appear to offer the best balance between effectiveness and safety and pose excellent alternatives to long-term high-dose corticosteroid therapy. Immunosuppressive drugs should be used to control inflammation when corticoste-roids fail to do so, to prevent corticosteroid-induced toxicity, and to treat high-risk uveitis syndromes unresponsive to corticoste-roids alone.
Conflicts of interest: All contributing authors declare no conflicts of interest
| References|| |
Kempen JH, Daniel E, Gangaputra S, et al. Methods for identifying long-term adverse effects of treatment in patients with eye diseases: the Systemic Immunosuppressive Therapy for Eye Diseases (SITE) Cohort Study. Ophthalmic Epidemiol
Jabs DA, Nussenblatt RB, Rosenbaum JT, Standardization of Uveitis Nomenclature (SUN) Working Group. Standardization of uveitis nomenclature for reporting clinical data. Results of the First International Workshop. Am JOph-thalmol
Thorne JE, Woreta FA, Jabs DA, Anhalt GJ. Treatment of ocular mucous membrane pemphigoid with immunosuppressive drug therapy. Ophthalmology
Sen HN, Sangave AA, Goldstein DA, et al. A standardized grading system for scleritis. Ophthalmology
Pasadhika S, Kempen JH, Newcomb CW, et al. Azathioprine for ocular inflammatory diseases. Am J Ophthalmol
Gangaputra S, Newcomb CW, Liesegang TL, et al. Methotrexate for ocular inflammatory diseases. Ophthalmology
Daniel E, Thorne JE, Newcomb CW, et al. Mycophenolate mofetil for ocular inflammation. Am J Ophthalmol
Kaçmaz RO, Kempen JH, Newcomb C, et al. Cyclosporine for ocular inflammatory diseases. Ophthalmology
Pujari SS, Kempen JH, Newcomb CW, et al. Cyclophosphamide for ocular inflammatory diseases. Ophthalmology
Thorne JE, Jabs DA, Qazi FA, Nguyen QD, Kempen JH, Dunn JP. Mycophenolate mofetil therapy for inflammatory eye disease. Ophthalmology
. 2005;112: 1472–1477.
Galor A, Jabs DA, Leder HA, et al. Comparison of antimetabolite drugs as corticosteroid-sparing therapy for noninfectious ocular inflammation. Ophthalmology
Rathinam SR, Babu M, Thundikandy R, et al. A randomized clinical trial comparing methotrexate and mycophenolate mofetil for noninfectious uveitis. Ophthalmology
Lerman MA, Burnham JM, Chang PY, et al. Response of pediatric uveitis to tumor necrosis factor-α inhibitors. J Rheumatol
Deuter CM, Zierhut M, Möhle A, Vonthein R, Stöbiger N, Kotter I. Long-term remission after cessation of interferon-a treatment in patients with severe uveitis due to Behcet’s disease. Arthritis Rheum
Masuda K, Nakajima A, Urayama A, Nakae K, Kogure M, Inaba G. Double-masked trial of cyclosporin versus colchicine and long-term open study of cyclosporin in Beliefs disease. Lancet
Arida A, Fragiadaki K, Giavri E, Sfikakis PP. Anti-TNF agents for Behcet’s disease: analysis of published data on 369 patients. Semin Arthritis Rheum
. 2011;41: 61–70.
Akpek EK, Jabs DA, Tessler HH, Joondeph BC, Foster CS. Successful treatment of serpiginous choroiditis with alkylating agents. Ophthalmology
. 2002;109: 1506–1513.
Thorne JE, Jabs DA, Peters GB, Hair D, Dunn JP, Kempen JH. Birdshot reti-nochoroidopathy: ocular complications and visual impairment. Am J Oph-thalmol
Thorne JE, Jabs DA, Kedhar SR, Peters GB, Dunn JP. Loss of visual field among patients with birdshot chorioretinopathy. Am JOphthalmol
Thorne JE, Wittenberg S, Jabs DA, et al. Multifocal choroiditis with panuveitis incidence of ocular complications and of loss of visual acuity. Ophthalmology
Thorne JE, Wittenberg S, Kedhar SR, Dunn JP, Jabs DA. Optic neuropathy complicating multifocal choroiditis and panuveitis. Am JOphthalmol
. 2007;143: 721–723.
Bykhovskaya I, Thorne JE, Kempen JH, Dunn JP, Jabs DA. Vogt-Koyanagi-Harada disease: clinical outcomes. Am JOphthalmol
Abu El-Asrar AM, Hemachandran S, Al-Mezaine HS, Kangave D, Al-Muammar AM. The outcomes of mycophenolate mofetil therapy combined with systemic corticosteroids in acute uveitis associated with Vogt-Koyanagi-Harada disease. Acta Ophthalmol
Baltus JA, Boersma JW, Hartman AP, Vandenbroucke JP. The occurrence of malignancies in patients with rheumatoid arthritis treated with cyclophos-phamide: a controlled retrospective follow-up. Ann Rheum Dis
. 1983;42: 368–373.
Zaghetto JM, Yamamoto MM, Souza MB, et al. Chlorambucil and cyclosporine A in Brazilian patients with Behcet’s disease uveitis: a retrospective study. Arq Bras Oftalmol
Goldstein DA, Fontanilla FA, Kaul S, Sahin O, Tessler HH. Long-term follow-up of patients treated with short-term high-dose chlorambucil for sight-threatening ocular inflammation. Ophthalmology
Multicenter Uveitis Steroid Treatment (MUST) Trial Research Group, Kempen JH, Altaweel MM, et al. Randomized comparison of systemic anti-inflammatory therapy versus fluocinolone acetonide implant for intermediate, posterior, and panuveitis: the multicenter uveitis steroid treatment trial. Ophthalmology
Teoh SC, Hogan AC, Dick AD, Lee RW. Mycophenolate mofetil for the treatment of uveitis. Am J Ophthalmol
Deuter CM, Doycheva D, Stuebiger N, Zierhut M. Mycophenolate sodium for immunosuppressive treatment in uveitis. Ocul Immunol Inflamm
. 2009;17: 415–419.
Relling MV, Gardner EE, Sandborn WJ, et al. Clinical Pharmacogenetics Implementation Consortium guidelines for thiopurine methyltransferase genotype and thiopurine dosing. Clin Pharmacol Ther
Armenti VT, Radomski JS, Moritz MJ, et al. Report from the national transplantation pregnancy registry (NTPR): outcomes of pregnancy after transplantation. Clin Transpl
Hogan AC, McAvoy CE, Dick AD, Lee RW. Long-term efficacy and tolerance of tacrolimus for the treatment of uveitis. Ophthalmology
Buhaescu I, Izzedine H, Covic A. Sirolimus–challenging current perspectives. Ther Drug Monit
Jabs DA, Rosenbaum JT, Foster CS, et al. Guidelines for the use of immuno-suppressive drugs in patients with ocular inflammatory disorders: recommendations of an expert panel. Am J Ophthalmol
Ali YM, Kuriya B, Orozco C, Cush JJ, Keystone EC. Can tumor necrosis factor inhibitors be safely used in pregnancy? J Rheumatol
Cohen SB, Emery P, Greenwald MW, et al. Rituximab for rheumatoid arthritis refractory to anti-tumor necrosis factor therapy: results of a multicenter, randomized, double-blind, placebo-controlled, phase III trial evaluating primary efficacy and safety at twenty-four weeks. Arthritis Rheum
. 2006;54: 2793–2806.
Lanini S, Molloy AC, Fine PE, Prentice AG, Ippolito G, Kibbler CC. Risk of infection in patients with lymphoma receiving rituximab: systematic review and meta-analysis. BMC Med
Kempen JH, Daniel E, Dunn JP, et al. Overall and cancer related mortality among patients with ocular inflammation treated with immunosuppressive drugs: retrospective cohort study. BMJ
European Mycophenolate Mofetil Cooperative Study Group. Placebo-controlled study of mycophenolate mofetil combined with cyclosporin and corticoste-roids for prevention of acute rejection. European Mycophenolate Mofetil Cooperative Study Group. Lancet
Lacki JK, Schochat T, Sobieska M, et al. Immunological studies in patients with rheumatoid arthritis treated with methotrexate or cyclophosphamide. Z Rheumatol
Furst DE. The risk of infections with biologic therapies for rheumatoid arthritis. Semin Arthritis Rheum
Salliot C, van der Heijde D. Long-term safety of methotrexate monotherapy in patients with rheumatoid arthritis: a systematic literature research. Ann Rheum
Bongartz T, Sutton AJ, Sweeting MJ, Buchan I, Matteson EL, Montori V. Anti-TNF antibody therapy in rheumatoid arthritis and the risk of serious infections and malignancies: systematic review and meta-analysis of rare harmful effects in randomized controlled trials. JAMA
Kelesidis T, Daikos G, Boumpas D, Tsiodras S. Does rituximab increase the incidence of infectious complications? A narrative review. Int J Infect Dis
Cannon GW, Pincus SH, Emkey RD, et al. Double-blind trial of recombinant gamma-interferon versus placebo in the treatment of rheumatoid arthritis. 1989. Arthritis Rheum
Kempen JH, Gangaputra S, Daniel E, et al. Long-term risk of malignancy among patients treated with immunosuppressive agents for ocular inflammation: a critical assessment of the evidence. Am J Ophthalmol
Lewis JD, Bilker WB, Brensinger C, Deren JJ, Vaughn DJ, Strom BL. Inflammatory bowel disease is not associated with an increased risk of lymphoma. Gastro-enterology
Wolfe F, Michaud K. Biologic treatment of rheumatoid arthritis and the risk of malignancy: analyses from a large US observational study. Arthritis Rheum
Birkeland SA, Hamilton-Dutoit S. Is posttransplant lymphoproliferative disorder (PTLD) caused by any specific immunosuppressive drug or by the transplantation per se? Transplantation
van den Borne BE, Landewé RB, Houkes I, et al. No increased risk of malignancies and mortality in cyclosporin A-treated patients with rheumatoid arthritis. Arthritis Rheum
Talar-Williams C, Hijazi YM, Walther MM, et al. Cyclophosphamide-induced cystitis and bladder cancer in patients with Wegener granulomatosis. Ann Intern Med
Carmona L, Descalzo MA, Perez-Pampin E, et al. All-cause and cause-specific mortality in rheumatoid arthritis are not greater than expected when treated with tumour necrosis factor antagonists. Ann Rheum Dis
. 2007;66: 880–885.
Fleischmann RM, Tesser J, Schiff MH, et al. Safety of extended treatment with anakinra in patients with rheumatoid arthritis. Ann Rheum Dis
. 2006;65: 1006–1012.
Jacobsson LT, Turesson C, Nilsson JA, et al. Treatment with TNF blockers and mortality risk in patients with rheumatoid arthritis. Ann Rheum Dis
. 2007;66: 670–675.
Lebwohl M, Blum R, Berkowitz E, et al. No evidence for increased risk of cutaneous squamous cell carcinoma in patients with rheumatoid arthritis receiving etanercept for up to 5 years. Arch Dermatol
. 2005;141: 861–864.
Setoguchi S, Solomon DH, Weinblatt ME, et al. Tumor necrosis factor alpha antagonist use and cancer in patients with rheumatoid arthritis. Arthritis Rheum
Askling J, Fored CM, Brandt L, et al. Risks of solid cancers in patients with rheumatoid arthritis and after treatment with tumour necrosis factor antagonists. Ann Rheum Dis
Askling J, Fored CM, Baecklund E, et al. Haematopoietic malignancies in rheumatoid arthritis: lymphoma risk and characteristics after exposure to tumour necrosis factor antagonists. Ann Rheum Dis
Chakravarty EF, Farmer ER. Risk of skin cancer in the drug treatment of rheumatoid arthritis. Expert Opin Drug Saf
Biancone L, Orlando A, Kohn A, et al. Infliximab and newly diagnosed neoplasia in Crohn’s disease: a multicentre matched pair study. Gut
Wolfe F, Michaud K. The effect of methotrexate and anti-tumor necrosis factor therapy on the risk of lymphoma in rheumatoid arthritis in 19,562 patients during 89,710 person-years of observation. Arthritis Rheum
. 2007;56: 1433–1439.
Dommasch E, Gelfand JM. Is there truly a risk of lymphoma from biologic therapies? Dermatol Ther
van Vollenhoven RF, Emery P, Bingham 3rd CO, et al. Longterm safety of patients receiving rituximab in rheumatoid arthritis clinical trials. J Rheumatol
Slimani S, Lukas C, Combe B, Morel J. Rituximab in rheumatoid arthritis and the risk of malignancies: report from a French cohort. Joint Bone Spine
. 2011;78: 484–487.
Gueudry J, Wechsler B, Terrada C, et al. Long-term efficacy and safety of low-dose interferon alpha2a therapy in severe uveitis associated with Behcet disease. Am J Ophthalmol
Kötter I, Gunaydin I, Zierhut M, Stubiger N. The use of interferon alpha in Behcet disease: review of the literature. Semin Arthritis Rheum
. 2004;33: 320–335.
Baker GL, Kahl LE, Zee BC, Stolzer BL, Agarwal AK, Medsger Jr TA. Malignancy following treatment of rheumatoid arthritis with cyclophosphamide. Long-term case-control follow-up study. Am J Med
Ahmed AR, Shetty S. A comprehensive analysis of treatment outcomes in patients with pemphigus vulgaris treated with rituximab. Autoimmun Rev
Shetty S, Ahmed AR. Preliminary analysis of mortality associated with ritux-imab use in autoimmune diseases. Autoimmunity
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
|This article has been cited by|
||Systemic Immunosuppression in Cornea and Ocular Surface Disorders: A Ready Reckoner for Ophthalmologists
| ||Anahita Kate,Sayan Basu |
| ||Seminars in Ophthalmology. 2021; : 1 |
|[Pubmed] | [DOI]|
||Tacrolimus for Treating Orbital and Cranial Form of Idiopathic Inflammatory Pseudotumors
| ||Hyun Jae Kim,Seonkyung Lee,Yu Jin Koo,Eunjin Kwon,Hyo-Jung Kim,Jeong-Yoon Choi,Ji-Soo Kim |
| ||Journal of Clinical Neurology. 2020; 16(4): 674 |
|[Pubmed] | [DOI]|
||Pharmacotherapeutic management of atopic keratoconjunctivitis
| ||Ibtesham T Hossain,Priyanka Sanghi,Bita Manzouri |
| ||Expert Opinion on Pharmacotherapy. 2020; : 1 |
|[Pubmed] | [DOI]|
||Hydrogel-based ocular drug delivery systems for hydrophobic drugs
| ||Cesar Torres-Luna,Roman Domszy,Naiping Hu,Nam Sun Wang,Arthur Yang |
| ||European Journal of Pharmaceutical Sciences. 2020; : 105503 |
|[Pubmed] | [DOI]|
||Optimization of the effectiveness and cytocompatibility of Nigella sativa as a co-treatment for reducing methotrexate-related adverse effects
| ||Esraa Ahmed,Rasha Abd-ellatief,Marwa Ali,Tarek Saleh,Ebtehal Ahmed |
| ||Comparative Clinical Pathology. 2019; |
|[Pubmed] | [DOI]|
||Act quickly when treating atopic keratoconjunctivitis to avoid adverse outcomes
| || |
| ||Drugs & Therapy Perspectives. 2019; |
|[Pubmed] | [DOI]|
||Atopic Keratoconjunctivitis: Pharmacotherapy for the Elderly
| ||Erminia Ridolo,P. Kihlgren,I. Pellicelli,M. C. Nizi,F. Pucciarini,C. Incorvaia |
| ||Drugs & Aging. 2019; |
|[Pubmed] | [DOI]|
||Capabilities of cytostatic agents usage in ophthalmology
| ||N Yu Belousova,T I Poltanova |
| ||Kazan medical journal. 2019; 100(4): 673 |
|[Pubmed] | [DOI]|
||Pharmacokinetics of topically applied tacrolimus dissolved in Marinosolv, a novel aqueous eye drop formulation
| ||Cornelia Siegl,Marielle König-Schuster,Sabine Nakowitsch,Christiane Koller,Philipp Graf,Nicole Unger-Manhart,Yvonne Schindlegger,Norman Kirchoff,Christian Knecht,Eva Prieschl-Grassauer,Wolfgang Sipos |
| ||European Journal of Pharmaceutics and Biopharmaceutics. 2019; 134: 88 |
|[Pubmed] | [DOI]|
||The Protective Effect of Polygonum cuspidatum (PCE) Aqueous Extract in a Dry Eye Model
| ||Bongkyun Park,Ik Lee,Soo-Wang Hyun,Kyuhyung Jo,Tae Lee,Jin Kim,Chan-Sik Kim |
| ||Nutrients. 2018; 10(10): 1550 |
|[Pubmed] | [DOI]|