Session Information
Date: Sunday, November 13, 2016
Session Title: Pediatric Rheumatology – Clinical and Therapeutic Aspects - Poster I: Juvenile Idiopathic Arthritis, Uveitis
Session Type: ACR Poster Session A
Session Time: 9:00AM-11:00AM
Background/Purpose: Pediatric HLA-B27-associated uveitis is a common form of non-infectious uveitis (NIU) that can lead to ocular complications and vision loss. Methotrexate (MTX) is the usual first-line systemic treatment in NIU. Tumor necrosis factor-α inhibitors (TNFi) are primary therapy in other HLA-B27-associated diseases such as ankylosing spondylitis and inflammatory bowel disease. There is no standard treatment protocol for pediatric HLA-B27-associated uveitis. Given the success of TNFi in other HLA-B27-associated diseases, our aim is to describe MTX and TNFi use in pediatric HLA-B27-associated uveitis.
Methods: We reviewed medical records of 21 children with HLA-B27-associated uveitis. We compared demographics and clinical characteristics based on treatment with TNFi.
Results: There were 12 (57%) children with HLA-B27-associated uveitis alone (U), and 9 (43%) with JIA-associated uveitis (JIAU) that was all enthesitis related arthritis (Table 1). Most were non-Hispanic (86%) White (95%) males (52%), diagnosed at a median of 10.5 (8.1-11.8) years, with anterior (90%), unilateral (67%) disease and several complications. Of these, 14 (67%) did not require TNFi (8 topical steroids alone, 6 MTX alone,) and 7 (33%) required TNFi. There was a clinical trend of earlier treatment with TNFi in JIAU (0.5 vs. 2.6 years of MTX) despite similar uveitis duration before MTX start (0.2 vs. 0.3 years). Comparing by TNFi use, more females were treated with TNFi (60% vs. 9%, p = 0.02) (Table 2). There was no difference in race, age at uveitis diagnosis, uveitis type, laterality, or complications. Comparing by gender, more females 8/10 (80%) then males 5/11 (45%) also needed MTX. Although they had similar uveitis type (40% associated with ERA), complications (80%), and age at diagnosis (10.8 vs. 9.7 years), more females needed TNFi and MTX.
Conclusion: Usual treatment for pediatric NIU includes MTX and then TNFi if MTX fails, ocular complications arise/worsen or uveitis persists. Based on our results, it appears reasonable to treat pediatric HLA-B27-associated uveitis with MTX prior to TNFi. However, we demonstrate the increased use of TNFi in females despite a similar uveitis course. We were unable to determine clinical factors that explained this difference due to our sample size, but this requires further study. There may be an inherent gender difference in immune pathway response which may mitigate uveitis course and improve visual outcomes.
| Table 1. Demographics and Clinical Characteristics of Children with HLA-B27-associated Uveitis | ||||
| All (N=21) | HLA-B27 associated uveitis alone (U) (N=12) | JIA-associated uveitis (JIAU) (N=9) | P-value** | |
| Gender, female | 10 (48%) | 6 (50%) | 4 (44%) | 1.00 |
| Hispanic | 3 (14%) | 1 (8%) | 2 (22%) | 0.55 |
| Race* | ||||
| Caucasian | 20 (95%) | 11 (92%) | 9 (100%) | 1.00 |
| African American | 2 (10%) | 2 (17%) | 0 | 0.49 |
| Age at Uveitis Diagnosis, years, median (25th – 75th) | 10.5 (8.1-11.8) | 9.1 (5.9-10.9) | 11.6 (10.1-14.1) | 0.11 |
| Duration of Uveitis To Date, years, median (25th – 75th) | 4.4 (2.0-5.9) | 4.4 (2.8-5.9) | 4.4 (1.6-5.9) | 0.92 |
| Bilateral Disease | 7 (33%) | 5 (42%) | 2 (22%) | 0.16 |
| Location* | ||||
| Anterior | 19 (90%) | 10 (83%) | 9 (100%) | 0.49 |
| Intermediate | 5 (24%) | 3 (25%) | 2 (22%) | 1.0 |
| Other (Panuveitis) | 2 (10%) | 2 (17%) | 0 (0%) | 0.49 |
| Complications* | ||||
| Any | 17 (81%) | 11 (92%) | 6 (67%) | 0.27 |
| Synechiae | 12 (57%) | 9 (75%) | 3 (33%) | 0.09 |
| Cataracts | 6 (29%) | 3 (25%) | 3 (33%) | 1.00 |
| Cystoid Macular Edema | 6 (29%) | 3 (25%) | 3 (33%) | 1.00 |
| Glaucoma/ Increased intraocular pressure | 5 (24%) | 4 (33%) | 1 (11%) | 0.34 |
| Band Keratopathy | 4 (19%) | 2 (17%) | 2 (22%) | 1.00 |
| Amblyopia | 1 (5%) | 0 (0%) | 1 (11%) | 0.43 |
| Methotrexate Use, Ever | 13 (62%) | 6 (50%) | 7 (78%) | 0.37 |
| Maximum dose >0.5 mg/kg/week | 12 (92%) | 6 (100%) | 6 (86%) | 0.52 |
| Mode of administration, oral | 7 (54%) | 4 (67%) | 3 (43%) | 0.59 |
| Duration of Uveitis Before MTX, years, median (25th – 75t h) |
0.2 (0.0-0.6) | 0.3 (0.2-0.6) | 0.2 (0-1.7) | 0.87 |
| Duration of MTX Before TNFi use, years, median (25th – 75th) | 1.7 (0.4 – 3.6) | 2.6 (1.0 – 5.6) | 0.5 (0.0 – 1.9) | 0.40 |
| Adalimumab Use, Ever*** | 2 (29%) | 2 (50%) | – | – |
| % on weekly | 2 (100%) | 2 (100%) | – | |
| Duration of Uveitis Before adalimumab, years, median (25th – 75th) | 3.0 (2.1-3.8) | 3.0 (2.1-3.8) | – | |
| Infliximab Use, Ever*** | 5 (71%) | 2 (50%) | 3 (100%) | 0.43 |
| Duration of Uveitis Before infliximab, years, median (25th – 75th) | 1.9 (0.5-2.2) | 4.0 (0.5-7.5) | 1.9 (0.3-2.2) | 0.80 |
| Max Dose mg/kg, median (25th – 75th) | 8 (7 – 10) | 7.3 (7 – 7.5) | 10 (8 – 10) | 0.20 |
| Frequency every XX weeks, median (25th – 75th) | 4.0 (4.0-4.0) | 4.0 (4.0-4.0) | 4.0 (2.0-4.0) | 1.0 |
|
*Not mutually exclusive (‘select all that apply’): Race=one person identified as both races; Location= some patients have multiple locations of disease; Complications=some patients have multiple complications. **Fisher’s exact tests for categorical data or non-parametric Wilcoxon rank-sum tests between U and JIAU , alpha=0.05, two-sided p-value. *** Out of 7 total who were taking a TNFi. |
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| Table 2. Comparison of Children with HLA-B27-associated Uveitis Treated with a Tumor Necrosis Factor α Inhibitor (TNFi) | ||||
| All (N=21) | NO TNFi use (N=14) | TNF use (N=7) | P-value** | |
| Gender, female | 10 (48%) | 4 (29%) | 6 (86%) | 0.02** |
| Hispanic | 3 (14%) | 2 (14%) | 1 (14%) | 1.00 |
| Race* | ||||
| Caucasian | 20 (95%) | 14 (100%) | 6 (86%) | 0.33 |
| African American | 2 (10%) | 1 (7%) | 1 (14%) | 1.00 |
| Age at Uveitis Diagnosis, median | 10.5 (8.1-11.8) | 10.4 (6.5-11.8) | 10.5 (8.1-13.5) | 0.97 |
| Duration of uveitis To Date, years, median (25th – 75th) | 4.4 (2.0-5.9) | 4.4 (0.9-5.9) | 4.4 (2.0-7.2) | 0.58 |
| Bilateral Disease | 7 (33%) | 3 (21%) | 4 (57%) | 0.26 |
| Location* | ||||
| Anterior | 19 (90%) | 13 (93%) | 6 (86%) | 1.00 |
| Intermediate | 5 (24%) | 2 (14%) | 3 (43%) | 0.28 |
| Other (Panuveitis) | 2 (10%) | 14 (67%) | 7 (33%) | 1.00 |
| Complications* | ||||
| Any | 17 (81%) | 11 (79%) | 6 (86%) | 1.00 |
| Synechiae | 12 (57%) | 8 (57%) | 4 (57%) | 1.00 |
| Cataracts | 6 (29%) | 4 (29%) | 2 (29%) | 1.00 |
| Cystoid Macular Edema | 6 (29%) | 3 (21%) | 3 (43%) | 0.35 |
| Glaucoma/ increased IOP | 5 (24%) | 3 (21%) | 2 (29%) | 1.00 |
| Band Keratopathy | 4 (19%) | 3 (21%) | 1 (14%) | 1.00 |
| Amblyopia | 1 (5%) | 1 (5%) | 0 (0%) | 1.00 |
| *Not mutually exclusive (‘select all that apply’): Race=one person identified as both races; Location= some patients have multiple locations of disease; Complications=some patients have multiple diseases. **Fisher’s exact tests for categorical data or non-parametric Wilcoxon rank-sum tests between IU and JIA diseases, alpha=0.05, two-sided p-value. | ||||
To cite this abstract in AMA style:
Frias B, McCracken C, Jenkins K, Figueroa J, Tramposch A, Yeh S, Patel P, Drews-Botsch C, Prahalad S, Angeles-Han S. Use of Tumor Necrosis Factor-α Inhibitors in Pediatric HLA-B27-Associated Uveitis [abstract]. Arthritis Rheumatol. 2016; 68 (suppl 10). https://acrabstracts.org/abstract/use-of-tumor-necrosis-factor-%ce%b1-inhibitors-in-pediatric-hla-b27-associated-uveitis/. Accessed November 13, 2019.« Back to 2016 ACR/ARHP Annual Meeting
ACR Meeting Abstracts - https://acrabstracts.org/abstract/use-of-tumor-necrosis-factor-%ce%b1-inhibitors-in-pediatric-hla-b27-associated-uveitis/