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Immunosuppressant moderately viable alternative to steroids for ocular inflammation
Am J Ophthalmol. 2009;148(4):500-509.
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Azathioprine, a noncorticosteroidal immunosuppressant, proved moderately effective in controlling ocular inflammation but was slow-acting and had side effects, a study showed.
"Treatment-limiting side effects occurred in approximately one-fourth of patients within 1 year, but typically were reversible," the study authors said.
The retrospective cohort study included 255 eyes of 145 patients starting azathioprine as a sole noncorticosteroidal immunosuppressant. Primary outcome measures were control of inflammation, sustained control after tapering prednisone to 10 mg or less daily, and cessation of treatment due to side effects.
Of all patients treated with azathioprine, 63% had uveitis, 23% had mucous membrane pemphigoid, 11% had scleritis and 3% had other inflammatory conditions. Data analysis showed that 62% of patients with active inflammation achieved and sustained complete inactivity of inflammation for a minimum 28 days within 1 year of starting therapy, the authors said.
Forty-seven percent of patients reduced systemic corticosteroid dosage to 10 mg or less daily while controlling inflammation within 1 year of starting therapy.
Treatment effectiveness was highest in patients with intermediate uveitis, with 90% sustaining control of inflammation within 1 year of starting treatment. During the mean follow-up interval of 230 days, azathioprine was discontinued most commonly because of side effects, followed by ineffectiveness, disease remission and unspecified causes, the authors said
Finding alternatives to steroids for control of severe ocular inflammation is of paramount importance. The SITE study looked at those patients in whom ocular inflammation is most difficult to control. This study demonstrates the effectiveness of azathioprine in reducing or completely eliminating the need for oral steroids in about half of patients at 1 year after initiation of treatment. Future head to head studies with other immunosuppressive agents will help us determine which, if any, of these drugs are optimal.
–Edwin S. Chen, MD
Cornea Service, Wills
Eye Institute, Philadelphia