Tocilizumab for anterior uveitis and juvenile idopathic arthritis – a case report

Abstract

Purpose We report a case of Juvenile Idiopathic Arthritis (JIA) and Anterior Uveitis (AU) responding well to Tocilizumab, a new humanized monoclonal antibody against the IL‐6 receptor, after having been refractory to classical immunosuppressive agents as well as to TNF‐α inhibitors. Methods The Patient was treated in our center from 2007‐2012. Collected data included: visual acuity (VA), anterior chamber cells and –flare, flaremeter measurements, intraocular pressure (IOP), presence of macular edema (ME) and cataract, topical and systemic medications, number and site of affected joints, laboratory inflammation parameters. Results Patient was born 1996, diagnosed with JIA 1998 and with AU 2005. Inflammation was initially controlled with methotrexate and corticosteroids, VA fluctuated between 20/40‐20/15(OD) and 20/20(OS). In 2007 VA decreased to 20/200(OD) as ME developed. Additional systemic therapy included between 2008 and 2009: Ciclosporin, Adalimumab, Mycophenolate, Leflunomide, and Infliximab. Control of ocular and/or joint inflammation was always insufficient or short lived. Between 2008 and 2010 ME required multiple periocular Triamcinolone injections. IOP first rose in 2008 to 34mmHg(OD), requiring combined topical and systemic therapy and finally trabeculectomy in 2010. Cataract developed on both eyes. Tocilizumab therapy was started in 02/2010. Since then AU and joints are free from inflammation. Cataract‐surgery and implantation of an artificial lens in OD was performed successfully in 2011. Systemic steroids could be reduced to 2 mg/d. IOP is <20mmHg; VA is stable at 20/32(OD) and 20/50(OS). Conclusion Tocilizumab may be another treatment option for JIA‐associated uveitis which is refractory to established immunosuppressants.

The Promise and Limitations of TNF-α Inhibition for Uveitis

“…Others have described similarly beneficial responses to tocilizumab in selected patients with refractory uveitis. [18][19][20][21][22][23] Taken together, these findings support the notion that the use or addition of an anti-TNF-a agent can help achieve control of uveitis in a high proportion of patient with uveitis, particularly those with Behçet's disease and JIA, two conditions for which TNF-a inhibitors are now strongly recommended as standard of care in the step-wise management of ocular inflammation. 24 The studies cited above also highlight, however, some of the limitations of TNF-a inhibitors, including the unpredictably varied response of each TNF-a inhibitor in an individual patient, both initially and over time, and the disappointingly low rate of successful discontinuation.…”

Tocilizumab for Severe Chronic Anterior Uveitis Associated with Juvenile Idiopathic Arthritis in a Pediatric Patient

“…6 To our knowledge, there is only one other reported case in which TCZ was used to treat JIA-associated uveitis in a pediatric patient. 7 TCZ was successful in controlling this patient's uveitis, which had been refractory to corticosteroids, MTX, adalimumab, and infliximab. 7 In our patient, TCZ therapy achieved remission of uveitis that was refractory to systemic corticosteroids, the maximum dose of MTX, and multiple biologics, including infliximab, adalimumab, abatacept, and rituximab.…”

“…7 TCZ was successful in controlling this patient's uveitis, which had been refractory to corticosteroids, MTX, adalimumab, and infliximab. 7 In our patient, TCZ therapy achieved remission of uveitis that was refractory to systemic corticosteroids, the maximum dose of MTX, and multiple biologics, including infliximab, adalimumab, abatacept, and rituximab. Abatacept, which induced an infusion reaction, is a CTLA-4-Ig that attenuates T-cell activation via the inhibition of the CD80/86;CD28 co-stimulatory pathway.…”