An Update on Treatment of Pediatric Chronic Non-infectious Uveitis

Abstract

Opinion Statement There are no standardized treatment protocols for pediatric non-infectious uveitis. Topical corticosteroids are the typical first-line agent, although systemic corticosteroids are used in intermediate, posterior and panuveitic uveitis. Corticosteroids are not considered to be long-term therapy due to potential ocular and systemic side effects. In children with severe and/or refractory uveitis, timely management with higher dose disease-modifying antirheumatic drugs (DMARDs) and biologic agents is important. Increased doses earlier in the disease course may lead to improved disease control and better visual outcomes. In general, methotrexate is the usual first-line steroid-sparing agent and given as a subcutaneous weekly injection at >0.5 mg/kg/dose or 10–15 mg/m2 due to better bioavailability. Other DMARDs, for instance mycophenolate, azathioprine, and cyclosporine are less common treatments for pediatric uveitis. Anti-tumor necrosis factor-alpha agents, primarily infliximab and adalimumab are used as second line agents in children refractory to methotrexate, or as first-line treatment in those with severe complicated disease at presentation. Infliximab may be given at a minimum of 7.5 mg/kg/dose every 4 weeks after loading doses, up to 20 mg/kg/dose. Adalimumab may be given up to 20 or 40 mg weekly. In children who fail anti-tumor necrosis factor-alpha agents, develop anti-tumor necrosis factor-alpha antibodies, experience adverse effects, or have difficulty with tolerance, there is less data available regarding subsequent treatment. Promising results have been noted with tocilizumab infusions every 2–4 weeks, abatacept monthly infusions and rituximab.

A review of ocular adverse events of biological anti-TNF drugs

“…Although the remaining anti-TNF therapies are considered off-label for uveitis, they are still used to control ocular inflammation associated with systemic diseases [21,22] and are specially effective in Behçet's disease [23,24] and juvenile idiopathic arthritis [25]. Experience with golimumab [26] and certolizumab [27] to treat ocular inflammatory disease is limited but encouraging.…”

Epidemiological and advanced therapeutic approaches to treatment of uveitis in pediatric rheumatic diseases: a systematic review and meta-analysis

“…Despite its low prevalence, potential complications of uveitis as well as high disease burden present the disease management as a considerable challenge. Although uveitis, due to rheumatic diseases, may be easily diagnosed, the effective treatments of this event remain limited owing to serious systemic side effects [3]. More importantly, delay of diagnosis and treatment may lead to irreversible consequences like severe vision loss [4].…”

Etiologic Spectrum and Follow-Up Results of Noninfectious Uveitis in Children: A Single Referral Center Experience

“…DMARDs, methotrexate being the most commonly employed, should be initiated in patients unresponsive to corticosteroids and it is recommended that early initiation of immunosuppressive treatment should be considered in children with active uveitis with already established complications at the time of diagnosis. 4,[24][25][26] Complications of pediatric uveitis are band keratopathy, cataracts, synechia, glaucoma, cystoid macular edema, retinal detachment, neovascularization of retina, optic disc and iris, decreased visual acuity, and loss of vision. These complications have been reported to be seen in more than half of the patients.…”