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Clarke D, Sartor L, Do V, Manolios N, Swaminathan S, Samarawickrama C. Biologics in peripheral ulcerative keratitis. Semin Arthritis Rheum 2023; 63:152269. [PMID: 37776666 DOI: 10.1016/j.semarthrit.2023.152269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 08/23/2023] [Accepted: 09/04/2023] [Indexed: 10/02/2023]
Abstract
Over the past two decades biologic therapies have seen a rapid uptake in the management of ocular inflammation. Peripheral ulcerative keratitis (PUK), once a harbinger of blindness and mortality in refractory rheumatological disease, is now increasingly being treated with these agents. We conducted a review to evaluate the evidence base for this application and to provide a road map for their clinical usage in PUK, including dosage and adverse effects. A literature search across Medline, Embase and Cochrane Database of Systematic Reviews was undertaken to identify all patients with PUK that were treated with a biologic in a peer viewed article. Overall, whilst the evidence base for biologic use in PUK was poor, reported cases demonstrate an increasingly powerful and effective role for biologics in refractory PUK. This was particularly the case for rituximab in PUK secondary to granulomatous with polyangiitis.
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Affiliation(s)
- Daniel Clarke
- Department of Ophthalmology, Royal Hobart Hospital, Tasmania, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Lauren Sartor
- Department of Ophthalmology, Westmead Hospital, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Vu Do
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Nicholas Manolios
- Department of Ophthalmology, Westmead Hospital, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Sanjay Swaminathan
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Department of Rheumatology, Westmead Hospital, Westmead, Sydney, New South Wales, Australia; Department of Clinical Immunology and Immunopathology, Westmead Hospital, Sydney, New South Wales, Australia; Centre for Immunology and Allergy Research, The Westmead Institute for Medical Research, Sydney, New South Wales, Australia
| | - Chameen Samarawickrama
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Translational Ocular Research and Immunology Consortium, Sydney University, New South Wales, Australia.
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Calvo-Río V, Sánchez-Bilbao L, Álvarez-Reguera C, Castañeda S, González-Mazón I, Demetrio-Pablo R, González-Gay MA, Blanco R. Baricitinib in severe and refractory peripheral ulcerative keratitis: a case report and literature review. Ther Adv Musculoskelet Dis 2022; 14:1759720X221137126. [PMID: 36419482 PMCID: PMC9677317 DOI: 10.1177/1759720x221137126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 10/12/2022] [Indexed: 10/02/2023] Open
Abstract
Ocular disease, such as scleritis and peripheral ulcerative keratitis (PUK), may be a serious ocular complication. We present a patient with severe and refractory PUK treated with baricitinib. A review of the literature on Janus kinase inhibitors (JAKINIB) in refractory ocular surface pathology was also performed. For the literature review, the search in PubMed, Embase, and the Cochrane library was carried out from inception until 31 May 2021, including conference proceedings from four major rheumatology congresses. All original research articles studying JAKINIB treatment in patients with inflammatory eye disease were included. We present an 85-year-old woman with rheumatoid arthritis (RA) and secondary Sjögren's syndrome refractory to methotrexate, leflunomide, certolizumab pegol, adalimumab, and tocilizumab (TCZ). However, 10 months after starting TCZ, the patient suffered a perforation secondary to PUK, requiring urgent surgical intervention. In the absence of infection, she was treated with boluses of intravenous methylprednisolone followed by oral prednisone at high doses in a decreasing pattern together with baricitinib at a dose of 2 mg/day with a very rapid and persistent favorable response to eye and joint symptoms. After 18 months of treatment, the patient had not presented serious side effects or signs of reactivation of her disease. In addition to this report, three other studies including one PUK associated with RA and two non-infectious scleritis treated with tofacitinib were included in this literature review. All three patients had experienced an insufficient response to conventional treatment, including biologic agents, before being switched to JAKINIB, leading to a complete or partial recovery in all of them without significant adverse effects so far. JAKINIBs (baricitinib and tofacitinib) may be an effective and safe therapy in patients with severe autoimmune and refractory ocular surface pathology, such as scleritis and PUK.
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Affiliation(s)
- Vanesa Calvo-Río
- Rheumatology and Ophthalmology, Hospital
Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Lara Sánchez-Bilbao
- Rheumatology and Ophthalmology, Hospital
Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Carmen Álvarez-Reguera
- Rheumatology and Ophthalmology, Hospital
Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Santos Castañeda
- Rheumatology, Hospital Universitario La
Princesa and IIS-IP, Madrid, Spain
| | - Iñigo González-Mazón
- Rheumatology and Ophthalmology, Hospital
Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Rosalía Demetrio-Pablo
- Rheumatology and Ophthalmology, Hospital
Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Miguel A. González-Gay
- Rheumatology Division, Hospital Universitario
Marqués de Valdecilla, Avda. Valdecilla s/n., Santander 39008, Spain
| | - Ricardo Blanco
- Rheumatology Division, Hospital Universitario
Marqués de Valdecilla, Avda. Valdecilla s/n., Santander 39008, Spain
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Hӧllhumer R. Peripheral ulcerative keratitis: A review of aetiology and management. AFRICAN VISION AND EYE HEALTH 2022. [DOI: 10.4102/aveh.v81i1.697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Background: Peripheral ulcerative keratitis (PUK) is a severe inflammatory disease of the peripheral cornea that can be caused by local factors or systemic inflammatory disease.Aim: The purpose of this review is to give an overview of the pathophysiology, aetiology, clinical features, diagnosis, and management of PUK.Method: A PubMed search was conducted using the keywords, ‘peripheral ulcerative keratitis’ and ‘Mooren’s ulcer’.Results: The peripheral cornea has unique characteristics the predispose to the development of PUK. These include fine capillary arcades that allow for deposition of immune complexes and subsequent activation of an inflammatory cascade with corneal melt. Several conditions have been implicated in the aetiology of PUK. The most commonly cited causes are rheumatoid arthritis (RA), granulomatosis with polyangiitis (GPA) and various dermatoses. In patients with RA, PUK usually presents in established disease, whereas in GPA, PUK may be the presenting feature in up to 60% of cases. In RA it heralds the onset of a systemic vasculitis with significant associated morbidity and mortality. The management of PUK follows an individualised stepwise approach. All patients require supportive measures to encourage healing and halt the process of keratolysis. Systemic autoimmune conditions need a systemic corticosteroid as a fast-acting agent to halt the inflammatory process while cytotoxic therapy maintains long term disease control. Failure to achieve disease control with CTT, necessitates the use of a biologic agent.Conclusion: Peripheral ulcerative keratitis is a severe inflammatory disease of the peripheral cornea that needs a thorough diagnostic workup and stepwise management approach.
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Bonnet I, Rousseau A, Duraffour P, Pouchot J, Nguyen CD, Gabison E, Seror R, Marotte H, Mariette X, Nocturne G. Efficacy and safety of rituximab in peripheral ulcerative keratitis associated with rheumatoid arthritis. RMD Open 2021; 7:rmdopen-2020-001472. [PMID: 33510042 PMCID: PMC7845725 DOI: 10.1136/rmdopen-2020-001472] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/20/2020] [Accepted: 12/28/2020] [Indexed: 12/23/2022] Open
Abstract
Objective Peripheral ulcerative keratitis (PUK) is a rare but severe ocular complication of rheumatoid arthritis (RA). It can be considered as an ocular manifestation of rheumatoid vasculitis (RV). Our case series aimed to evaluate the efficacy of rituximab (RTX) for PUK occurring in patients with RA. Methods Study population were patients with RA-associated PUK treated with RTX 1000 mg on days 1 and 15 at least once after the diagnosis. We identified patients referred to the rheumatology and ophthalmology departments of our hospital between February 2014 and June 2020. We also included patients referred by their specialist after being contacted through the Club Rhumatismes et Inflammation. Demographic data and clinical and biological features were retrospectively collected. Results We included seven patients (three men and four women, median age 58 years). All but one had a long-standing RA with a median disease duration of 13.9 years (IQR 0–30.2). RA was erosive in six out of seven patients. All patients had rheumatoid factors and anticitrullinated peptides antibodies were positive in six of them. PUK was complicated by corneal perforation in three patients and required surgery. After a median follow-up of 29.8 months (IQR 5–75), corneal inflammation was controlled in all patients. PUK recurred in one patient, 8 months after a single infusion of RTX. 71% of the patients presented a good articular response. No patient developed other manifestations of RV. No serious adverse event related to RTX was observed. Conclusion RTX appears to be an efficient and safe therapeutic option in the treatment of RA-associated PUK.
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Affiliation(s)
- Isabelle Bonnet
- Department of Rheumatology, AP-HP, Paris-Sud University Hospitals, Le Kremlin Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Antoine Rousseau
- Ophtalmology, Hospital Bicetre, Le Kremlin-Bicetre, Île-de-France, France.,Immunology of Viral Infections and Autoimmune, Hematological and Bacterial Diseases, Inserm U1184, Le Kremlin-Bicetre, Île-de-France, France
| | | | - Jacques Pouchot
- Internat Medicine, Hopital Europeen Georges Pompidou, Paris, Île-de-France, France
| | - Chi Duc Nguyen
- Rheumatology, Hospital Centre Bethune, Bethune, Nord-Pas de Calais, France
| | - Eric Gabison
- Ophtalmology, Hôpital Bichat Claude-Bernard, Paris, Île-de-France, France.,Centre de Référence pour les Maladies Ren Ophtalmologie (OPHTARA), Fondation Rothschild, Paris, Île-de-France, France
| | - Raphaele Seror
- Department of Rheumatology, AP-HP, Paris-Sud University Hospitals, Le Kremlin Bicêtre Hospital, Le Kremlin-Bicêtre, France.,Immunology of Viral Infections and Autoimmune, Hematological and Bacterial Diseases, Inserm U1184, Le Kremlin-Bicetre, Île-de-France, France
| | - Hubert Marotte
- Rhumatologie, CHU Saint-Etienne, Saint-Etienne, France.,SAINBIOSE, INSERM U1059, University of Lyon, Saint-Etienne, France, University of Lyon, Saint-Etienne, France
| | - Xavier Mariette
- Department of Rheumatology, AP-HP, Paris-Sud University Hospitals, Le Kremlin Bicêtre Hospital, Le Kremlin-Bicêtre, France.,Immunology of Viral Infections and Autoimmune, Hematological and Bacterial Diseases, Inserm U1184, Le Kremlin-Bicetre, Île-de-France, France
| | - Gaetane Nocturne
- Department of Rheumatology, AP-HP, Paris-Sud University Hospitals, Le Kremlin Bicêtre Hospital, Le Kremlin-Bicêtre, France.,Immunology of Viral Infections and Autoimmune, Hematological and Bacterial Diseases, Inserm U1184, Le Kremlin-Bicetre, Île-de-France, France
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Romano C, Esposito S, Ferrara R, Cuomo G. Tailoring biologic therapy for real-world rheumatoid arthritis patients. Expert Opin Biol Ther 2020; 21:661-674. [PMID: 33147106 DOI: 10.1080/14712598.2021.1847268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Introduction: The cornerstone of rheumatoid arthritis (RA) therapy relies on the treat-to-target strategy, which aims at dampening inflammation as soon as possible in order to achieve persistent low disease activity or, ideally, remission, according to validated disease activity measures. Traditional disease-modifying antirheumatic drugs (DMARDs) may be chosen in monotherapy or in combination as first-line therapy; in case of an unsatisfactory response after a 3-6-month trial, biologic therapy may be commenced.Areas covered: Real-life RA patients may present with concomitant comorbidities/complications or be in peculiar physiological states which raise more than one question as to which biotherapy may be more well suited considering the whole clinical picture. Therefore, a thorough literature search was performed to identify the most appropriate biologic therapy in each setting considered in this review.Expert opinion: Here we provide suggestions for the use of biologic drugs having a predictable better outcome in specific real-world conditions, so as to ideally profile the patient to the best of the current knowledge.
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Affiliation(s)
- Ciro Romano
- Department of Medicine, Clinical Immunology Outpatient Clinic, "Luigi Vanvitelli" University of Campania, Naples, Italy
| | - Sergio Esposito
- Department of Medicine, Clinical Immunology Outpatient Clinic, "Luigi Vanvitelli" University of Campania, Naples, Italy
| | - Roberta Ferrara
- Department of Medicine, Clinical Immunology Outpatient Clinic, "Luigi Vanvitelli" University of Campania, Naples, Italy
| | - Giovanna Cuomo
- Department of Medicine, Clinical Immunology Outpatient Clinic, "Luigi Vanvitelli" University of Campania, Naples, Italy
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Dominguez-Casas LC, Sánchez-Bilbao L, Calvo-Río V, Maíz O, Blanco A, Beltrán E, Martínez-Costa L, Demetrío-Pablo R, del Buergo MÁ, Rubio-Romero E, Díaz-Valle D, Lopez-Gonzalez R, García-Aparicio ÁM, Mas AJ, Vegas-Revenga N, Castañeda S, Hernández JL, González-Gay MA, Blanco R. Biologic therapy in severe and refractory peripheral ulcerative keratitis (PUK). Multicenter study of 34 patients. Semin Arthritis Rheum 2020; 50:608-615. [DOI: 10.1016/j.semarthrit.2020.03.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 03/26/2020] [Accepted: 03/30/2020] [Indexed: 12/17/2022]
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Systemic Treatment for Noninfectious Intraocular Inflammation. CURRENT OPHTHALMOLOGY REPORTS 2017. [DOI: 10.1007/s40135-017-0127-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Horiy D, Oliverira L, Guimaraes M, Dultra B, Giorgi R, Pernambuco R. RITUXIMABE NA CERATITE DIFUSA AGUDA EM UMA PACIENTE COM SÍNDROME DE SJOGREN PRIMÁRIA (SSP): RELATO DE CASO. REVISTA BRASILEIRA DE REUMATOLOGIA 2017. [DOI: 10.1016/j.rbr.2017.07.283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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9
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Gillan WD. Corneal manifestations of selected systemic diseases: A review. AFRICAN VISION AND EYE HEALTH 2015. [DOI: 10.4102/aveh.v74i1.287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
The corneal manifestations of several selected systemic diseases are reviewed. Metabolic, immunologic and inflammatory and infectious diseases are included. A brief overview of each disease and how it manifests in the cornea is discussed. The importance of conducting a slit-lamp examination on every patient is emphasised.
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Zandavalli FM, de Castro GRW, Mazzucco M, Stöfler MECW, Pereira IA. [Infliximab is effective in difficult-to-control peripheral ulcerative keratitis. A report of three cases]. REVISTA BRASILEIRA DE REUMATOLOGIA 2014; 55:310-2. [PMID: 25440698 DOI: 10.1016/j.rbr.2014.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Revised: 04/28/2014] [Accepted: 05/09/2014] [Indexed: 11/16/2022] Open
Abstract
Peripheral ulcerative keratitis is caused by an inflammatory and destructive process of the perilimbal peripheral cornea. This inflammation is due to immune complex deposition in this region of the cornea and in adjacent vessels. It can be idiopathic, or a manifestation of systemic disease such as rheumatoid arthritis, vasculitis of small vessels associated with ANCA, relapsing polychondritis, systemic lupus erythematosus and Crohn's disease. Its treatment includes the use of high-dose corticosteroids and, in some cases, the concomitant use of immunosuppressants such as methotrexate, azathioprine, mycophenolate mofetil, cyclophosphamide or cyclosporine. The use of immunobiological agents can be a strategy in cases of difficult control. The authors describe the treatment of three patients who, after failure with the use of corticosteroids or immunosuppressants, showed good response after the use of infliximab.
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Affiliation(s)
| | | | - Maiara Mazzucco
- Universidade do Sul de Santa Catarina, Florianópolis, SC, Brasil
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Tomkins-Netzer O, Taylor SRJ, Lightman S. Can rituximab induce long-term disease remission in patients with intra-ocular non-infectious inflammation? ACTA ACUST UNITED AC 2013; 230:109-15. [PMID: 23948944 DOI: 10.1159/000351426] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Treatment of non-infectious uveitis is based primarily on the use of systemic corticosteroids and second-line immunosuppressive drugs. However, their extensive side effect profile, particularly for steroids, has led to the increased use of other immunosuppressive drugs, as sparing capacity agents. Rituximab is an anti-CD20 chimeric antibody, often given as a single course of 2 infusions, resulting in complete depletion of peripheral mature B cells. While it is licensed to treat refractory systemic lymphoma patients, it has also shown promising results in systemic auto-immune diseases, where a single course of treatment is able to achieve long-term clinical remission. Treatment with rituximab has been reported for various ocular conditions, suggesting it may be effective in inducing long-term disease control and other systemic immunosuppressive agents can be reduced or discontinued. When disease relapse occurs, a further course or courses can be given with good results. This review summarizes the current evidence regarding the role of rituximab in treating non-infectious uveitis.
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Kraus CL, Culican SM. Use of biologic agents in ocular manifestations of rheumatic disease. Int J Rheumatol 2011; 2012:203819. [PMID: 22229035 PMCID: PMC3246731 DOI: 10.1155/2012/203819] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2011] [Accepted: 10/31/2011] [Indexed: 01/14/2023] Open
Abstract
Biologic agents have dramatically shifted the treatment paradigm for rheumatic disease. Use of these agents can decrease disease burden, allow the patient to be weaned from corticosteroids, and reduce the likelihood of relapse. Eye disease associated with rheumatic conditions may present with a wide range of signs and symptoms. This coexisting pathology should not be overlooked and should be considered a reason for initiation or continuation of biologic therapy. Additionally, many of the ocular manifestations of rheumatic disease respond preferentially to specific targeting molecules. This paper summarizes the available studies on the use, efficacy, and safety of biologic agents in the treatment of ocular manifestations of rheumatic disease.
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Affiliation(s)
- Courtney L. Kraus
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Susan M. Culican
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, MO 63110, USA
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