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Uveitis in JIA calls for early screening, regular follow-ups
A European group of experts has released a series of 22 recommendations for the diagnosis, measurement, treatment and future clinical trials of uveitis associated with juvenile idiopathic arthritis.
Published in the Annals of the Rheumatic Diseases by the Single Hub and Access point for pediatric Rheumatology in Europe (SHARE) initiative, the recommendations include early referral by pediatric rheumatologists of children with juvenile idiopathic arthritis (JIA) to and ophthalmologist. The group also said that systemic immunosuppression, with drugs such as methotrexate and adalimumab (Humira, AbbVie), for children with moderate-to-severe uveitis could help better control the disease and avoid visual impairment.
“This paper provides evidence-based recommendations for the management of children with uveitis associated with juvenile idiopathic arthritis,” Athimalaipet V. Ramanan, FRCPCH, FRCP, of the University Hospitals Bristol NHS Foundation Trust and Bristol Medical School, England, a senior author of the recommendations, told Healio Rheumatology. “Uveitis is an important cause of visual impairment in children. Early diagnosis and appropriate management can reduce the visual morbidity from this disease.”
SHARE was established in 2012 with the goal of determining and disseminating best practices for diagnosing and treating children and adolescents with rheumatic diseases. Noting there had been no consensus statements specifically related to the diagnosis and treatment of JIA and related uveitis in Europe, the group sought to devise and recommend strategies that would minimize its damage to patients and prevent its development.”
SHARE formed a committee of 12 experts in pediatric rheumatology and ophthalmology to develop the recommendations. They conducted a systematic literature review, identifying 1,323 papers, which they later narrowed to a selection of 117 articles. The literature review was discussed by the committee during two consensus meetings. Final recommendations were accepted if more than 80% of the committee agreed on their inclusion.
The committee approved three recommendations related to diagnosis and screening, five on disease activity measurements, 12 on treatment and two on future plans.
On diagnosis and screening, the committee recommends that all patients with JIA be screened for uveitis according to a contemporary and audited protocol, and that a formal screening protocol should be administered in all centers where patients with JIA are seen. In addition, follow-ups appointments with an ophthalmologist should be scheduled based on disease severity and needs, and patients with JIA who stop systemic immunosuppression should be screened by an ophthalmologist at least every 3months for at least 1year.
For disease activity measurements, the committee suggests better communication between the ophthalmologist and the pediatric rheumatologist concerning changes in disease activity treatment and responsibility for treatment monitoring. They also said shared outcome measures should be developed to help guide decisions on systemic treatment.
According to the committee, the goal of treating JIA-associated uveitis should be no cells in the anterior chamber; the presence of macular and/or disk edema, ocular hypotony and rubeosis iridis may require anti-inflammatory treatment, even in the absence of AC cells. They added that patients should be treated with 2years of inactive disease off topical steroids before reducing systemic immunosuppression.
Concerning treatment, the committee said active uveitis in JIA usually requires immediate treatment, and that topical corticosteroids — preferably prednisolone acetate or dexamethasone — should be the first-line treatment of anterior uveitis. The committee added that topical and systemic NSAIDs have no demonstrable effect as monotherapy, but may be used as additional therapy.
The group also recommended systemic immunosuppression in active uveitis, if poor prognostic factors are present at the first visit, while systemic immunosuppression is recommended if inactivity could not be reached within 3months, or if inflammation is reactivating during steroid dose reduction.
Other treatment recommendations include:
- Methotrexate is the first choice for systemic immunosuppression;
- Add or switch to biological treatment in cases of methotrexate inefficacy or intolerance;
- Use anti-TNF treatment in uveitis that is refractory or resistant to DMARD therapy;
- Etanercept should not be considered for JIA-associated uveitis;
- Despite limited evidence, switching between different anti-TNF treatments might be valuable if uveitis is refractory to the first anti-TNF;
- In cases of low efficacy, physicians should consider testing for antidrug antibodies and drug trough level; and
- Tocilizumab, rituximab and abatacept might be potential options for cases resistant to previous anti-TNF therapy.
Lastly, the committee noted that there is a need for validated outcome measures for JIA-associated uveitis. The researchers also stressed the need for controlled clinical trials for JIA-associated uveitis.
“Initiating systemic immunosuppression with medicines such as methotrexate and adalimumab for children with moderate-to-severe uveitis will help in better control of disease and avoid visual impairment,” Ramanan told Healio Rheumatology. “These guidelines will provide an evidence-based approach to diagnosis and management of children with uveitis across Europe and worldwide.” – by Jason Laday
Disclosure: Ramanan reports honoraria and speaking fees from Abbvie, Roche, Lily, UCB and SOBI. Please see the study for all other authors’ relevant financial disclosures.