TNF Inhibitor Therapy Effective for Behcet's Disease Uveitis

By Reuters Staff

July 21, 2014

NEW YORK (Reuters Health) - When uveitis due to Behcet's disease fails to respond to conventional therapy, anti-TNF-alpha therapy may help, according to a Spanish study.

Anti-TNF-alpha therapy was "effective and relatively safe" in patients with Bechet's disease uveitis refractory to conventional treatment, including high-dose corticosteroids and at least one immunosuppressant, the researchers said online July 4 in Rheumatology.

"Bechet's disease is an idiopathic, polysymptomatic, chronic, recurrent systemic vasculitis characterized mainly by the presence of recurrent oral aphthous ulcers, genital ulcers, skin lesions and ocular involvement," Dr. Miguel A. Gonzalez-Gay from Hospital Universitario Marques de Valdecilla in Santander, Spain and colleagues note in their paper.

It's estimated that 50% to 70% of patients with BD have ocular involvement, typically recurrent uveitis. BD is a leading cause of blindness. Several studies have found high levels of TNF-apha in serum and aqueous humour of patients with uveitis.

Dr. Gonzalez-Gay and colleagues assessed the clinical response to anti-TNF-alpha therapy in 68 men and 56 women (221 affected eyes) with refractory BD uveitis.

The patients, who were 38 years old on average, were treated for at least 12 months with infliximab (3-5 mg/kg at baseline, two and six weeks and then every four to eight weeks, 77 patients) or adalimumab (typically 40 mg every two weeks, 47 patients), in combination with conventional immunosuppressive drugs in most cases.

"Intraocular inflammation, macular thickness, visual acuity, the sparing effect of corticosteroids and immunosuppression load were the outcome variables. All of these showed a rapid and maintained improvement," the authors report.

The number of anterior chamber cells, vitritis, macular thickness and best-corrected visual acuity "showed a statistically significant improvement that was clinically evident since the first week," they note.

At the start of anti-TNF-apha therapy, 57% of patients had anterior chamber inflammation and 64% had vitreous inflammation. In both conditions the damage decreased significantly after one year of anti-TNF-alpha therapy.

After one year of follow-up, complete ocular clinical control of inflammation was achieved in 84 patients (67.7%).

In line with other reports, anti-TNF-alpha therapy "yielded a corticosteroid-sparing effect, achieving a significant decrease in the median prednisone dose from 37.5 mg/day at the initiation of biologic therapy to 6.2 mg/day after 12 months of biologic therapy," the authors say.

Biologic therapy was generally well tolerated in most patients. Minor side effects such as mild infusion reactions to infliximab and local reactions at the site of adalimumab injection were the most common side effects. None required discontinuation.

The researchers say two patients treated with infliximab suffered severe infusion reactions and were changed to adalimumab in one case and rituximab in the other. Two patients had pneumonia at four and 10 months after starting adalimumab. One patient treated with adalimumab suffered thoracic herpes zoster and responded well to antiviral therapy.

Three patients developed severe complications prompting discontinuation of biologic therapy: a patient who had been on infliximab for one month had miliary TB, another was diagnosed as having non-Hodgkin's lymphoma after six months on adalimumab and one patient, who died, was diagnosed as having melanoma three months after starting adalimumab. The authors say they can't confirm that the development of cancer in these two patients was the result of biologic therapy.

Summing up, the researchers say the percentage of patients with vision impairment as a result of uveitis due to BD "remains unacceptably high despite conventional systemic immunosuppressive therapy." The results of this study "support the claim that anti-TNF-alpha therapy is effective and relatively safe in refractory BD uveitis."

The authors did not respond to request for comment by press time.

The study was partially supported by the Instituto de Salud Carlos III (ISCIII), Madrid, Spain. Dr. Gonzalez-Gay and two co-authors have disclosed relationships with several drug companies including Abbott, Merck, Roche, Pfizer, Bristol-Myers Squibb and Janssen.


Rheumatology 2014.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as: