Comparison of combination therapy of prednisolone and cyclosporine with corticosteroid pulse therapy in Vogt-Koyanagi-Harada disease

Cyclosporine Treatment in Patients with Kawasaki Disease and Coronary Artery Aneurysms or Treatment Resistance

OBJECTIVE

To describe the clinical course and outcome of 33 patients with Kawasaki disease (KD) treated with cyclosporine (CSA) for coronary artery abnormalities (CAA) or treatment resistance.

STUDY DESIGN

Single-center, retrospective study of patients with KD treated from 2013 through 2023 for CAA or treatment resistance. Demographics, laboratory studies, medications, adverse events, and echocardiographic data were analyzed.

RESULTS

Of the 33 KD patients treated with CSA, 25 patients received CSA for CAA and 8 for treatment resistance. Four patients received CSA intravenously initially, followed by oral therapy. Since 2014, all patients received CSA orally only. The target 2-hour postdose level (300-600 ng/ml) was best achieved by dividing 5 mg/kg/day every 12 hours. We developed a standardized treatment protocol based on our experiences with this patient population. The patients treated for CAA all showed improved coronary artery Z-scores at both the 2-week and 6-week follow-up. Two patients experienced significant adverse events. One patient had posterior reversible encephalopathy syndrome, while the other developed Epstein-Barr virus-associated lymphoproliferative disorder. Discontinuation of CSA led to complete recovery in both cases.

CONCLUSIONS

CSA was generally well tolerated in patients with KD and CAA or treatment resistance. Our study contributes to the limited literature on CSA use in KD, providing dosing guidance and advocating for cautious monitoring.

Clinical and Transcriptional Profiles Reveal the Treatment Effect of Adalimumab in Patients with Initial-Onset and Recurrent Vogt-Koyanagi-Harada Disease

PURPOSE

We aimed to evaluate adalimumab efficacy in patients with initial-onset or recurrent Vogt-Koyanagi-Harada (VKH) syndrome.

METHODS

A retrospective clinical study was performed to examine the therapeutic effect of adalimumab in 22 VKH patients,16 with initial-onset and six with recurrent VKH. Another 22 patients with initial-onset VKH who did not receive adalimumab were included as controls. The main observational parameters included the central macular thickness (CMT), subfoveal choroidal thickness (SCT), best-corrected visual acuity (BCVA), anterior chamber cell grade (ACC), glucocorticoid dose (GCD), and the development of sunset glow fundus. MRNA sequencing was used to profile the tumor necrosis factor (TNF)-α pathway in peripheral blood mononuclear cells obtained from nine patients with initial-onset VKH disease, six patients with recurrent VKH, and eight healthy controls.

RESULTS

In the initial-onset group, adalimumab therapy significantly improved the BCVA, CMT, SCT, and ACC. Furthermore, adalimumab significantly decreased GCD in patients with initial-onset. In patients with recurrent VKH, the SCT significantly improved after adalimumab treatment, but no significant changes in BCVA, CMT, and ACC were observed. All six patients experienced relapse during follow-up. The TNF-α pathway exhibited a significant increase in initial-onset VKH when compared with that in both healthy controls and recurrent patients. Conversely, it was suppressed in recurrent VKH when compared with that in the initial-onset or healthy control groups.

CONCLUSIONS

In patients with initial-onset VKH, adalimumab effectively reduces glucocorticoid dependence. However, adalimumab may not be effective for preventing relapse or providing long-term inflammation relief in patients with recurrent VKH.

Effect of prednisone plus either adalimumab or cyclosporine on dermatological symptoms in Vogt-Koyanagi-Harada disease: Systemic outcomes from a randomized trial

BACKGROUND

Vogt-Koyanagi-Harada (VKH) disease causes vitiligo, poliosis, and alopecia.

OBJECTIVE

To investigate the effect of prednisone plus either adalimumab or cyclosporine-based immunosuppression on VKH dermatologic disorders using ancillary data from a VKH eye disease trial.

METHODS

Patients with VKH disease treated with individualized prednisone tapering (maximum daily dose, 40 mg; maximum duration, 6 months) were randomized to adjunctive adalimumab (N = 54) or cyclosporine (N = 56). Outcomes included changes in vitiligo, poliosis, and alopecia at the sixth month.

RESULTS

Overall, there was a decrease in the percentage of alopecia but no change in the presence of vitiligo or poliosis at the sixth month. The adalimumab group showed no nominally significant differences in the percentage changes of each dermatologic manifestation but a greater reduction in the number of affected dermatologic categories compared with the cyclosporine group.

LIMITATIONS

This is a secondary analysis of a VKH eye disease trial. Six-month follow-up may not fully assess effects on vitiligo and poliosis.

CONCLUSIONS

In conjunction with prednisone tapering, both adalimumab and cyclosporine similarily improved alopecia but had no obvious effect on the presence of vitiligo or poliosis at 6 months. Adalimumab was associated with a greater decrease in the number of affected dermatologic conditions compared with cyclosporine.

Demographic Features, Diagnoses and Real-World Clinical Management of Uveitis in Japan

PURPOSE

This study aimed to investigate demographic features, diagnoses of uveitis (intraocular inflammation), and real-world clinical practice in the use of local and systemic therapies for patients with uveitis in Tokyo, Japan.

METHODS

Clinical records of 1,174 consecutive new patients (480 males, 694 females) referred to the Kyorin Eye Center, Kyorin University Hospital between January 2011 and December 2018 were retrospectively reviewed.

RESULTS

Mean age at presentation was 52.6 years (range 4-94 years). By anatomic location, 439 patients (37.4%) had anterior uveitis, 18 (1.5%) had intermediate uveitis, 214 (18.2%) had posterior uveitis and 503 (42.8%) had panuveitis. The 3 most common diagnoses were sarcoidosis (9.1%), Vogt-Koyanagi-Harada (VKH) disease (8.3%), and acute anterior uveitis (5.7%). Compared to our previous study, rates of herpetic anterior uveitis and cytomegalovirus (CMV) retinitis increased while tuberculosis-related uveitis decreased. Unclassified uveitis remained the most common diagnosis (44.9%). Systemic corticosteroids and/or immunomodulatory agents were used in only 18.3% of patients. Immunomodulatory drugs including biologic agents were utilized in 4.9% of patients.

CONCLUSIONS

The most common uveitis anatomic type was panuveitis due mainly to high rates of sarcoidosis and VKH disease. Diagnoses of herpetic anterior uveitis and CMV retinitis increased, while tuberculosis-related uveitis decreased. Less than one-fifth of uveitis patients required systemic treatment.

Cost-Effectiveness Analysis of Adalimumab Versus Cyclosporine for Vogt-Koyanagi-Harada Disease: A Randomized Controlled Study

PURPOSE

To compare the 26-week cost-effectiveness of adalimumab-corticosteroids (ADA-CS) and cyclosporine-corticosteroids (CSA-CS) for Vogt-Koyanagi-Harada (VKH).

METHODS

A preplanned cost-effectiveness analysis based on the per-protocol population of a randomized-controlled trial. VKH subjects were randomized to receive either cyclosporine (100-200 mg daily) combined with corticosteroids or adalimumab (40 mg twice monthly) combined with corticosteroids. The primary outcome of this cost-effectiveness study was the incremental cost-effectiveness ratio (ICER). Costs and quality-adjusted life-years (QALYs) data were calculated by the medical records and health utility, respectively. Subgroup (early and late-phase VKH) analysis and sensitivity analyses were performed.

RESULTS

The ICER at 26 weeks was $62,425/QALY for the total participants. Compared to the CSA-CS group, costs in the ADA-CS group were more expensive (mean difference [ΔA-C]: $2,497) with more gains in QALYs (mean difference [ΔA-C]: 0.04). The probability of ADA-CS being cost-effective was 0.17 and 0.41 at willingness to pay (WTP) thresholds of $12,000/QALY and $36,000/QALY, respectively. Subgroup analysis and sensitivity analyses showed consistent findings with the primary analysis.

CONCLUSIONS

Regardless of early or late-phase VKH, the CSA-CS strategy may be recommended as the preferred initial choice for the majority of VKH.

A Novel Risk Stratification-Based Immunomodulatory Treatment Strategy for Vogt-Koyanagi-Harada Disease

PURPOSE

To develop a more tailored immunomodulatory treatment (IMT) strategy based on a novel 2-arm risk stratification system in Vogt-Koyanagi-Harada (VKH) patients.

DESIGN

A retrospective clinical cohort study.

METHODS

Seventy-nine VKH patients in the acute stage were stratified into low- (n = 58) and high-risk (n = 21) groups based on their exposure to risk factors. They were treated with oral glucocorticoids (GCs) plus as-needed (PRN) or first-line IMT. Best corrected visual acuity (BCVA), sunset glow fundus (SGF) occurrence, relapse rate, and systemic adverse events were evaluated during follow-up.

RESULTS

Compared with the low-risk group, the high-risk group showed poorer BCVA at baseline (estimated difference 0.51, 95% CI 0.30-0.78; P < .001) and 6-month follow-up (estimated difference 0.08, 95% CI 0.00-0.08; P = .006), higher incidence of SGF at 12 months (52% vs 28%; RR 1.9, 95% CI 1.1-3.4; P = .040), and higher relapse rate at 6 months (24% vs 5%; RR 4.6, 95% CI 1.2-17.5; P = .028) and 12 months (52% vs 12%; RR 4.4, 95% CI 1.9-9.7; P < .001). In the low-risk cohort, no significant difference between the 2 IMT strategies was observed in primary outcomes. In the high-risk cohort, patients with the immediate IMT showed better BCVA (estimated difference -0.20, 95% CI -0.3 to -0.08; P = .007), lower incidence of SGF (27% vs 80%; RR 0.3, 95% CI 0.1-0.9; P = .030), and lower relapse rate (27% vs 80%; RR 0.3, 95% CI 0.1-0.9; P = .030) compared with the PRN regimen. Moreover, the immediate IMT regimen had a higher frequency of systemic adverse events than the PRN regimen (47% vs 7%; RR 7.1, 95% CI 2.5-20.4; P < .001).

CONCLUSIONS

High-risk stratification at baseline was associated with poor prognosis. The immediate IMT regimen was only beneficial for high-risk VKH patients regarding visual outcome, SGF, and relapse rate. This study suggests a potential need for a customized IMT strategy for VKH patients.

Regarding Kaya P et al. "Predictive Factors for the Prognosis of Vogt-Koyanagi-Harada Disease"

INTRODUCTION

VKH is a primary stromal choroiditis. Studies with indocyanine green angiography (ICGA) have shown that inflammation begins at the choroid and may persist without clinically apparent inflammation. Thus, systemic therapy must target choroidal inflammation and be maintained until the choroiditis resolves, as proven by ICG and/or EDI-OCT imaging studies.

DISCUSSION

Aggressive therapy with oral corticosteroids, with or without "pulsed" intravenous methylprednisolone, has been the mainstay of VKH therapy in the acute phase for many years. However, there is convincing evidence that corticosteroid monotherapy is insufficient to prevent progression onto the chronic recurrent form of the disease, which is associated with poor visual outcomes.

CONCLUSION

Numerous studies suggest that combined therapy with systemic corticosteroids and immunosuppressants is necessary to prevent the progression toward chronic recurrent disease, avoiding complications, get a better control of inflammation and visual outcomes in VKH patients seen at the uveitic phase of the disease.

Incidence and Risk Factors of Recurrent Anterior Uveitis in Initial Acute-Onset Vogt-Koyanagi-Harada Disease

PURPOSE

We report the estimated incidence of, and risk factors for, recurrent anterior uveitis in patients with initial acute-onset Vogt-Koyanagi-Harada (VKH) disease using survival analyses.

METHODS

Patients who were diagnosed with initial acute-onset VKH disease during 2003-2022 at two university hospitals were included. Recurrent anterior uveitis was defined as the first occurrence of the granulomatous anterior uveitis with anterior chamber cells and flare of 2+ or more by the Standardization of Uveitis Nomenclature (SUN) Working Group grading scheme, after the disappearance of conspicuous uveitis and serous retinal detachment for at least 3 months, regardless of systemic or local treatment. The univariate log-rank test and multivariate Cox regression analyses were performed, including patients' demographic characteristics, underlying diseases, presence of prodromal symptoms, duration of visual symptoms, visual acuity, slit-lamp and fundus findings, and height of serous retinal detachment. The treatment method and response to treatment were also included.

RESULTS

The estimated incidence was 39.3% at 10 years. Fifteen of 55 patients (27.3%) had recurrent anterior uveitis during the mean follow-up of 4.5 years. The presence of focal posterior synechiae at the diagnosis increased the risk of recurrent anterior uveitis 6.97-fold compared to the absence of synechiae (95% confidence interval [CI], 2.20-22.11; p < 0.001). Use of systemic high-dose steroid therapy more than 7 days after the development of visual symptoms resulted in a hazard ratio of 4.55 (95% CI, 1.27-16.40; p = 0.020).

CONCLUSIONS

This study reports the estimated incidence and risk factors of recurrent anterior uveitis in VKH disease from survival analyses. However, because of the retrospective nature of this study, it is hard to confirm the consistency of the medical records regarding risk factors, thus, the presence of focal posterior synechiae can be inconclusive as a risk factor. Further studies are warranted.

Mechanisms, Pathophysiology and Current Immunomodulatory/Immunosuppressive Therapy of Non-Infectious and/or Immune-Mediated Choroiditis

Non-infectious choroiditis comprises immune-mediated diseases resulting from diverse pathophysiological mechanisms. These conditions are sub-divided into two main groups, (1) diseases of the choriocapillaris and (2) diseases of the choroidal stroma. The purpose of this study is to expose the pathophysiology of the most common diseases of both these groups and recommend the optimal immunomodulatory/immunosuppressive therapy of each analyzed condition based on literature data and data from our own centers. Material and Methods: Narrative review. In the group of choriocapillaritis entities or primary inflammatory choriocapillaropathies (PICCPs) including multiple evanescent white dot syndrome (MEWDS), acute posterior multifocal placoid pigment epitheliopathy (APMPPE), idiopathic multifocal choroiditis (MFC) and serpiginous choroiditis (SC), as well as secondary choriocapillaritides including acute syphilitic posterior multifocal placoid chorioretinitis (ASPMPC) and tuberculosis-related SC (TB-SC), were analyzed. In the group of stromal choroidites, HLA-A29 birdshot retinochoroiditis (BRC) and Vogt-Koyanagi-Harada (VKH) disease were included. For each entity a literature search, in the PubMed database, on treatment was performed and analyzed and the therapeutic attitudes of our own centers were presented. Management of immune-mediated choroiditis implies vigorous immunosuppressive therapy given in a prompt and prolonged fashion in most of these entities.