Background/Purpose: Methotrexate (MTX) is the most used immunomodulatory drug in Juvenile Idiopathic Arthritis-associated uveitis (JIA-U) although its efficacy has been shown only in retrospective studies with limited number of subjects, short follow up and sometimes questionable methodology. The timing of MTX start in JIA-U as well as of switch from first and second-line therapy are still controversial. Aim of the present study was to evaluate the efficacy of MTX as first-line therapy in a monocentric inception cohort of patients with JIA-U.

Methods: Patients with JIA-U refractory to local eye drops treatment were managed by a standard protocol including MTX, at a standard dose of 10-15 mg/m²/week, as first line systemic treatment. Data, recorded every 3 months, included ocular flares and complications, drug-related adverse events (AE) and treatment change. The diagnosis of JIA was based upon the ILAR criteria¹ and the diagnosis of uveitis was made according to the SUN Criteria². Uveitis flare was defined as an increase of cells in the anterior chamber of 2+ or more as compared to the baseline. Clinical remission was defined as the absence of flares for more than 6 months on treatment, without or with minimal topical treatment (corticosteroid and/or mydriatic-cycloplegic eye drops ≤ 1/day). Data of patients treated for at least 1 year were analyzed using descriptive statistics.

Results: 84 consecutive JIA patients (71 F, 13 M), 82 oligoarticular, 2 polyarticular, treated with MTX for JIA-U and at least one year f/u entered the study. Mean age at MTX start was 5.7 years (1.8–21.6); mean f/u since MTX start 8.9 y (1–20 y). 68 patients started MTX primarily to treat uveitis (group A) (JIA duration 1.8 y), 16 patients introduced MTX for arthritis (group B) (JIA duration 0.54 y). The mean interval time between arthritis and uveitis onset was 0.8 y in group A and 2.1 y in group B (p<0.01). After treatment start, 25% relapsed with uveitis flare by 5 months, 50% by 9.7 mo and 75% by 36 mo. At the last evaluation, 40 pts (47.6%), 28 in group A and 12 in group B, needed anti-TNF therapy to control uveitis flares; 35 (41.7%) were in remission on medication and only 9 (10.7%) (all in group A) reached a complete remission at a mean f/u of 39.4 mo.

Conclusion: MTX loses its efficacy quite rapidly overtime and ensures clinical remission only in a minority of patients. When started before uveitis, MTX delays the uveitis onset but does not prevent its severe course.

References

1. Petty RE, et al. J Rheumatol 2004;31:390-392.
2. Jabs DA, et al. Am J Ophthalmol 2005;140:509-516.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/methotrexate-as-first-line-therapy-in-juvenile-idiopathic-arthritis-associated-uveitis-myth-or-reality/