Background/Purpose:

Acute anterior uveitis (AAU) is the most common form of uveitis. One third of AAU patients may present recurrences, some requiring systemic disease-modifying antirheumatic drugs (DMARDs). The aim of this study was to perform a systematic and critical literature review on the use of synthetic and biologic DMARDs in AU.

Methods: A a systematic literature review was performed. Studies were identified by sensitive search strategies in the main bibliographic databases (Medline, Embase and Cochrane Library) up to July 2016. Mesh terms and text word were used. We selected articles that analyzed, in AU patients, the efficacy or safety of DMARDs and biologic therapies including: flares, time to flare, visual acity, corticoid sparing (CS) effect, etc. Any type of study except case series or case reports with less than 10 patients was eligible. Two reviewers (AG and EL) screened the titles and abstracts of the retrieved articles independently. Both reviewed the selected articles in detail and collected data from the studies by using ad hoc standard forms. A hand search was completed by reviewing the references of the included studies. Quality was graded using the Jadad sacale and the Oxford Centre for Evidence-based Medicine Levels of Evidence. Evidence and results tables were produced.

Results: A total of 14 articles included, 2 randomized controlled trials and 12 observational studies, with low or moderate quality. The mean duration/follow-up, number (n) and patients characteristics were highly variable. The definition of the anatomic classification of AUs was generally not clear. Systemic DMARDs were used, including Methotrexate (MTX), Azathioprine (AZA), Cyclosporine A (CsA) and anti-TNFα (Adalimumab (ADA), Golimumab (GLM)), at usual dosage prescription. Number of flares, disease activity and corticoid sparing (CS) effect were the most common outcomes, with big differences between studies in variables included and their definitions. MTX showed efficacy in disease remission, n of flares, time between flares, lower activity and CS effect. SSZ showed lower n of flares and improvement in visual acuity (VA) in AS-associated AAU patients. AZA (low quality RCT) showed no differences in VA, Tyndall, flares or IOP. A prospective OS showed lower activity and CS effect. CsA (moderate quality OS) showed efficacy improving activity and as CS agent (mid/long term). Anti-TNFα: ADA, (2 OSs) with SpA-associated AU patients lowered n of flares (mid/long term), can improve VA, Tyndall and be used as CS agent. GLM in AU patients refractory to DMARDs (some to other biologics), showed CS effect in 2 studies. One showed improvement in VA and Tyndall, but not in OCT or n of flares. Adverse events recorded were those usually registered for all these drugs.

Conclusion: MTX showed efficacy in idiopathic and systemic disease-associated (SDA) AU.(EL 2c; RG B), SSZ showed efficacy in idiopathic and SDA AU.(EL 3a; RG B-C), AZA seems to be effective in naïve and DMARDs-refractory AU (EL 3a; RG C), CsA showed efficacy in idiopathic and SDA AU (EL 2c; RG B-C), ADA showed efficacy in idiopathic and SDA AU, naïve or DMARDs-refractory AU (LE 2c; RG B), GLM showed efficacy in DMARD-refractory AU (2nd line and further) and other biologic therapies (EL 3a; RG B-C).

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/systemic-treatment-for-acute-anterior-uveitis-synthetic-and-biologic-disease-modifyingantirheumatic-drugs-a-systematic-literature-review/