An Update on Treatment of Pediatric Chronic Non-Infectious Uveitis

Abstract

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.

Keywords: Adalimumab; Infliximab; Juvenile Idiopathic Arthritis; Methotrexate; Pediatric uveitis; Uveitis.

Figure 1

Stepwise approach to the treatment of pediatric non-infectious uveitis. Topical corticosteroids are the typical first-line agent in anterior uveitis. Systemic corticosteroids may be used for rapid control of inflammation in intermediate, posterior or panuveitic uveitis. In children with severe and/or refractory uveitis, DMARDs are the next step in management with Methotrexate being the preferred agent. Anti TNF agents are used as second line agents in children refractory to methotrexate, or as a first-line treatment in children with severe and complicated disease at presentation. In patients who fail anti-TNF agents there is no agreement on subsequent therapy. Alternative biologics include abatacept, tocilizumab and rituximab. Many patients require a combination of medications or require short-term systemic corticosteroids for intermittent flares.