Collaboration between ophthalmologists, rheumatologists needed for immunosuppression
CHICAGO — Rheumatologists should make greater efforts to collaborate with ophthalmologists to better care for patients with inflammatory and systemic eye diseases such as uveitis and scleritis, according to Jim T. Rosenbaum, MD, chief of the division of arthritis and rheumatic diseases at Oregon Health & Science University.
However, the other side of that equation is that rheumatologists must gain a better understanding of these diseases, he said.
“Ophthalmologists are not comfortable with immunosuppression, with very few exceptions,” Rosenbaum told attendees at the 2019 Interdisciplinary Autoimmune Summit. “Ophthalmologists need us, with ‘us’ meaning rheumatology interns who are comfortable with immunosuppression. However, this requires time, communication and some understanding of uveitis, and it is not a simple task. I wish it could be done more successfully.”
According to Rosenbaum, there are a host of suspected immune-mediated causes of uveitis, which accounts for 10% of blindness and is comparable to diabetes and macular degeneration in terms of years of visual morbidity. These potential causes include ankylosing spondylitis, Behçet’s disease, inflammatory bowel disease, juvenile idiopathic arthritis, psoriatic arthritis, reactive arthritis, rheumatic fever, lupus, vasculitis and more, he said.
Typical treatments an ophthalmologist would prescribe for uveitis include regional corticosteroids and, if those prove ineffective, or in the case of posterior uveitis, oral corticosteroids. Regarding immunosuppressive therapies for the disease, the only noncorticosteroid approved by the FDA for adults with noninfectious intermediate uveitis, posterior uveitis and panuveitis is the TNF inhibitor adalimumab (Humira, Abbvie). The approval did not include anterior uveitis.
However, according to Rosenbaum, off-label immunosuppressive treatments have included anti-metabolites such as methotrexate, if the patient is corticosteroid-dependent, as well as calcineurin antagonists like tacrolimus and alkylators such as cyclophosphamide.
In addition, case reports have shown that infliximab (Remicade, Janssen) can be effective in treating Behçet’s disease in uveitis, he said. However, there have been no randomized controlled trials.
“I don’t think there has ever been a randomized controlled trial showing that infliximab works for Behcet’s uveitis, but I don’t think there needs to be because it is so dramatic,” Rosenbaum said. “I have been taking care of uveitis patients now for almost 35 years, and the response rate to infliximab is about 80% to 90%.”
Although infliximab is approved for Behçet’s-associated uveitis in Japan, where the condition is far more common than it is in North America, according to Rosenbaum, it is not an approved for that use in the United States.
In scleritis, a rare vasculitis of the scleral vessels that is about one-tenth as prevalent as uveitis, systemic disease associations include rheumatoid arthritis, granulomatosis with polyangiitis, lupus, ankylosing spondylitis, Behçet’s disease and infections.
According to Rosembaum, patients with scleritis typically fail to respond to topical therapy. Approximately 20% respond to oral NSAIDs, and most patients with the disease will require oral corticosteroids, he said. However, as the average duration of scleritis is 7 years, most patients will require steroid-sparing immunosuppression. These can include methotrexate, mycophenolate or azathioprine, Rosenbaum said.
In addition, a study, published by Rosenbaum and colleagues in 2014 in Ophthalmology, examined rituximab (Rituxan, Genentech) in patients with refractory scleritis, and found that nine of 12 patients responded to the drug. This, according to Rosenbaum, was based on the extrapolation that many of the included patients may have a limited form of granulomatosis with polyangiitis.
“Here is the bottom line: If you know the eye, you will be a better rheumatologist, because most rheumatic diseases involve the eye,” Rosenbaum said. “Ophthalmologists need you, because they are not really prepared to deal with these systemic diseases, and these systemic medications.” – by Jason Laday
Rosenbaum JT. Inflammatory eye disease management. Presented at: Interdisciplinary Autoimmune Summit; April 5-7, 2019; Chicago.
Disclosure: Rosenbaum reports consulting fees from Abbvie, Gilead, Horizon, Janssen, Novartis, Regeneron, Roche and UCB, as well as grant support from Pfizer.