Recidivant Polychondritis Unresponsive to Treatment

Arthur Kavanaugh, MD

Disclosures

April 21, 2008

Question

I have a patient with recidivant polychondritis whose eye involvement is very unresponsive after 1 year of treatment with mycophenolate (beginning with 1 mg/kg and increasing to 20 mg/kg) and etanercept. What would you suggest as an alternative treatment?

Response from Arthur Kavanaugh, MD

 

Arthur Kavanaugh, MD
Professor, Department of Rheumatology, University of California, San Diego

Relapsing polychondritis can be quite severe, depending on the extent of involvement. Unfortunately, due to its heterogeneity and relatively low prevalence, there are no rigorous large clinical trials that provide more definitive answers in regard to optimal treatment strategies, compared with the large volume of clinical trials and data for diseases such as rheumatoid arthritis. Much of the reported experience is anecdotal, and of course those reports are subject to reporting bias, with negative experiences being less likely to be reported. Although polychondritis classically involves inflammation of cartilage, such as that of the ear (in about 85% of patients), nose (about 50% of patients), and laryngotracheal area (about 50% of patients), eye involvement is not uncommon and occurs in about 50% of patients. Eye involvement may present as iridocyclitis, but also as retinal vasculitis, extraocular muscle paresis, scleritis, and episcleritis. In this particular case, the type of eye involvement is not reported; if it is iridocyclitis, by extension from the seronegative spondyloarthropathies, consideration of TNF inhibitors would be reasonable, although the monoclonal antibody TNF inhibitors may be more effective. Other aspects of the case that might also affect choice of therapy would be the cartilaginous involvement. Finally, other past therapies are not reported for this patient. If the patient has not tried cyclosporine or cyclophosphamide, these would also be options, depending on potential comorbidities.

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