Uveitis and tumour necrosis factor blockade in ankylosing spondylitis

Etanercept-associated episcleritis: a pediatric case report of a paradoxical adverse reaction and review of the literature

Scleritis is an inflammation of the episcleral and scleral tissues, characterized by injection in both superficial and deep episcleral vessels. When only episcleral tissue is involved, it is referred to as episcleritis. Episcleritis is mainly idiopathic but may be secondary to an underlying rheumatologic disease. Despite being rare, drug-associated episcleritis and scleritis should also be included in the differential diagnosis. Tumor necrosis factor-alpha (TNF-α) inhibitors are generally well-tolerated, but etanercept, in particular, has the potential to cause paradoxical adverse reactions including ocular inflammations, such as uveitis, scleritis, and ocular myositis. Etanercept differs in its mechanism of action from other TNF-α inhibitors as it acts as a decoy receptor, and this may partly explain the more frequently reported etanercept-associated ocular inflammation. Etanercept may also be ineffective in preventing ocular inflammation. However, the dechallenge and rechallenge phenomena have proven there is a causative link between etanercept and new-onset ocular inflammation. We report a case of a 15-year-old boy with enthesitis-related arthritis and familial Mediterranean fever who presented with episcleritis and blepharitis while receiving etanercept treatment and subsequently showed dechallenge and rechallenge reactions. Therefore, physicians should also be aware that episcleritis should be considered a paradoxical adverse reaction to etanercept and can occur in pediatric patients. We also reviewed the English literature to provide an overview and evaluate intervention options.

Pharmacologically induced uveitis

Treatments of numerous systemic and local diseases of different etiologies may be accompanied by an unwanted side effect in the form of uveitis. We inform readers about medications that have the potential to cause uveitis and analyze the strength of association of these medications with uveitis. Subsequently, cessation of medication or appropriate treatment can be individualized for each patient for the purpose of preventing further damage to tissue structure and function. Being aware of these associations, physicians may readily identify medications that may cause uveitis and avoid expensive and unnecessary clinical and laboratory testing.

Multi-modal Imaging in Etanercept-induced Uveitis: A Case Series

Introduction:

To report with multi-modal imaging the clinical course of 3 patients with new-onset uveitis following treatment with etanercept.

Methods:

Retrospective case-note reviews were conducted of 3 patients previously established on etanercept who developed new-onset acute uveitis.

Results and Discussion:

Three patients were assessed with a mean age of 44.3 (43-47). Etanercept was indicated for the treatment of ankylosing spondylitis in two patients and psoriatic arthritis in 1 patient. Duration of etanercept treatment ranged from 7 to 10 years; however, in two cases, treatment recently changed to an etanercept biosimilar agent. Two patients were diagnosed with bilateral panuveitis and one patient had chronic relapsing anterior uveitis. Infection screen was negative in all three patients. 2 patients developed cystoid macular oedema as viewed on Spectral Domain OCT. Fundus fluorescein angiography was performed in one patient who demonstrated bilateral retinal vasculitis. All three patients were started on systemic and topical treatment. One patient received sub-tenon triamcinolone injection. Etanercept was discontinued for all patients. 1 of 3 patients lost vision at 7 months. 2 patients demonstrated long-term remission and one patient required intravitreal steroid implantation to stabilize an ongoing intraocular inflammation. Two patients who had complete remission were commenced on Adalimumab while the third patient was commenced on Secukinumab.

Conclusion:

The clinical course of uveitis developing paradoxically following etanercept treatment is variable. Multi-modal imaging is useful for the clinician that helps in diagnosing and monitoring associated macular oedema and retinal ischaemia. Cessation of etanercept and systemic corticosteroid treatment are often required to prevent ocular morbidity.

A review of ocular adverse events of biological anti-TNF drugs

The recent introduction of biological agents has revolutionized the treatment of chronic immune-inflammatory diseases; however, this new therapy did not come without significant side effects.Through large controlled studies indicating decrease in the number of uveitis flares, the role of TNF inhibitors therapy for non-infectious uveitis gained more ground. Paradoxically to its therapeutic effect, there are reports associating these drugs with the onset or recurrence of inflammatory eye disease.A number of studies have suggested possible roles for anti-TNF-α agents in precipitating or worsening an underlying inflammatory process, including the hypothesis of a disequilibrium in cytokine balance, but to date the mechanisms responsible for these adverse events are not fully understood.A PubMed literature search was performed using the following terms: ophthalmic complication, uveitis, inflammatory eye disease, optic neuritis, neuropathy, adverse events, anti-TNF, TNF alpha inhibitor, infliximab, etanercept, adalimumab, golimumab, certolizumab, and biologics. The data presented in this study was mainly derived from the use of TNF inhibitors in rheumatology, essentially because these drugs have been used for a longer period in this medical field.Many of the ocular adverse events reported on this review may be considered a paradoxical effect of anti-TNF therapy. We found a variety of data associating new onset of uveitis with anti-TNF therapy for rheumatic conditions, predominantly under etanercept.In conclusion, although there is increasing data on ocular adverse events, it remains to be seen whether the suggested link between TNF inhibitors and the onset of ocular inflammation is substantiated by more quality data. Nevertheless, the awareness of potential treatment side effects with anti-TNF should be highlighted.

New onset or exacerbation of uveitis with infliximab: paradoxical effects?

Objective

To report four cases of new onset or exacerbation of uveitis following administration of infliximab.

Methods

This retrospective observational case series includes four patients who developed new onset or exacerbation of uveitis paradoxically during infliximab treatment.

Results

Four patients were assessed, including three women, with a mean age of 33 (14–84) years. Infliximab was introduced for the treatment of scleritis associated with rheumatoid arthritis (two cases), chronic anterior uveitis associated with juvenile idiopathic arthritis (JIA) (one case) and Crohn’s disease (one case). Anterior scleritis associated with rheumatoid arthritis successfully improved following infliximab administration; however, macular oedema or dense vitritis paradoxically developed in two cases. In one case, infliximab was switched to tocilizumab. In another case, infliximab was discontinued, and additional corticosteroids and immunosuppressive medications were added. In one patient with JIA, new-onset macular oedema and exacerbation of anterior uveitis were observed during infliximab treatment, so the patient was switched to adalimumab. In the patient with Crohn’s disease treated with infliximab, severe vasculitis and macular oedema occurred, requiring intravitreal triamcinolone injection. The patient was switched to adalimumab. Given that these reactions were paradoxical effects of infliximab, infliximab treatment was discontinued in all cases, and additional corticosteroids or immunosuppressive medications were added. All cases remained free of ocular inflammation at the last visit.

Conclusion

Uveitis rarely occurs de novo or is exacerbated during infliximab treatment. Cessation of infliximab led to resolution of this paradoxical adverse effect.

Scleritis: A Paradoxical Effect of Etanercept? Etanercept-associated Inflammatory Eye Disease

Objective.

To describe 3 cases of scleritis associated with etanercept use for rheumatoid arthritis (RA) and to review the literature related to inflammatory eye diseases associated with the use of etanercept.

Methods.

Three cases of severe scleritis during etanercept therapy were analyzed. A systematic review of the literature in PubMed, Embase, and the Cochrane Library was performed, from 1962 to July 2010.

Results.

Three patients with seropositive RA developed scleritis 7–28 months after initiation of etanercept, for the first time during their long-lasting disease. In all patients the underlying disease had responded well to anti-tumor necrosis factor therapy. Ocular inflammation went into remission after discontinuation of etanercept, and no other relapses were observed. One patient experienced a dechallenge-rechallenge phenomenon (improvement in symptoms following discontinuation of the agent, then reappearance or worsening of symptoms on reexposure to the agent). Forty-two cases of inflammatory eye diseases believed to be associated with the use of etanercept have been reported in the literature: 33 uveitis, 8 scleritis, 1 orbital myositis, concerning 16 patients with RA, 10 with juvenile idiopathic arthritis, 14 with ankylosing spondylitis, and 2 with psoriatic spondyloarthropathy. Dechallenge was performed in 28 patients, leading to resolution of symptoms. Rechallenge was done in 6 cases, with clear exacerbation.

Conclusion.

Ocular inflammation is paradoxically a potential adverse effect of etanercept, even in previously uninvolved eyes.

Biologics - beyond the joints

Biologics including tumor necrosis factor α (TNF-α), interleukin-6 receptor (IL-6R), T and B cell inhibitors are very effective therapeutic agents for the treatment of arthritides. These compounds effectively improve articular symptoms and inhibit joint damage. In this respect, there are no major differences in the efficacy of the available biologics. However, many arthritis patients also exert extra-articular features, systemic manifestations of the disease. These associated conditions include uveitis, inflammatory bowel disease, psoriasis, secondary bone loss and cardiovascular disease. There have been data suggesting that there may be differences in the effects of various TNF inhibitors, rituximab and tocilizumab on the systemic manifestations described above. At present, we do not always have sufficient evidence to confirm these differences, therefore, more information should be obtained from large trials and long-term observational studies.

Clinical review: Anti-TNFalpha therapies in uveitis: perspective on 5 years of clinical experience

Despite a lack of robust evidence, anti-TNF therapies are in wide use for the treatment of noninfectious ocular inflammatory diseases. There is a clear rationale, based on mechanistic and preclinical efficacy data, for their use in posterior segment intraocular inflammation. However, their increasing use for other indications has been largely extrapolated from the benefit observed in autoinflammatory and autoimmune systemic diseases. Given their cost and the potential for significant adverse events, this review highlights the evidence for their continued use, possibilities for switching anti-TNF agents, and ways of reducing the risk of therapy.

Adalimumab effectively reduces the rate of anterior uveitis flares in patients with active ankylosing spondylitis: results of a prospective open-label study

Objective:

To evaluate the effect of adalimumab on the frequency of anterior uveitis (AU) flares in patients with active ankylosing spondylitis (AS).

Methods:

We determined the history of ophthalmologist-diagnosed AU in 1250 patients with active AS who were enrolled in a multinational, open-label, uncontrolled clinical study of treatment with adalimumab, 40 mg every other week for up to 20 weeks. All AU flares were documented throughout the adalimumab treatment period plus 70 days. We compared the rates of AU flares per 100 patient years (PYs) reported during the year before adalimumab treatment with rates during adalimumab treatment, in total and by patient subgroups.

Results:

The AU flare rates before adalimumab treatment were 15/100 PYs in all patients (n = 1250), 68.4/100 PYs in 274 patients with a history of AU flares, 176.9/100 PYs in 106 patients with a recent history of AU flares, 192.9/100 PYs in 28 patients with symptomatic AU at baseline and 129.1/100 PYs in 43 patients with a history of chronic uveitis. During adalimumab treatment, the rate of AU flares was reduced by 51% in all patients, by 58% in 274 patients with a history of AU, by 68% in 106 patients with a recent history of AU, by 50% in 28 patients with symptomatic AU at baseline and by 45% in 43 patients with chronic uveitis. AU flares during adalimumab treatment were predominantly mild. Two patients with periods of high AS disease activity had new-onset AU during the treatment period.

Conclusions:

Results of this prospective open-label study suggest that adalimumab had a substantial preventive effect on AU flares in patients with active AS, including patients with a recent history of AU flares.

Clinical trials:

ClinicalTrials.gov Identifier: NCT00478660.