Apremilast in Refractory Behçet's Syndrome: A Multicenter Observational Study

Behçet's syndrome

Behçet's syndrome is a rare, chronic multisystemic inflammatory disorder also known as the Silk Route disease due to its geographical distribution. Behçet's syndrome is a multifactorial disease and infectious, genetic, epigenetic, and immunological factors contribute to its pathogenesis. Its heterogeneous spectrum of clinical features include mucocutaneous, articular, ocular, vascular, neurological, and gastrointestinal manifestations that can present with a relapsing and remitting course. Differential diagnosis is often hampered by the non-specific clinical presentation and the absence of laboratory biomarkers or pathognomonic histological features. The therapeutic approach is tailored on the basis of patient-specific manifestations and relies on glucocorticoids, colchicine, and traditional and biological immunosuppressants. Despite progress in the knowledge and management of the disease, unmet needs in diagnostics, monitoring, prediction, and treatment personalisation challenge clinical practice, making Behçet's syndrome a complex disorder associated with an increased risk of morbidity.

Behçet's disease uveitis

Uveitis in Behçet's disease (BD) is frequent (40% of cases) and is a major cause of morbidity. The age of onset of uveitis is between 20 and 30 years. Ocular involvement includes anterior, posterior or panuveitis. It is non-granulomatous. Uveitis may be the first sign of the disease in 20% of cases or it may appear 2 or 3 years after the first symptoms. Panuveitis is the most common presentation and is more commonly found in men. Bilateralisation usually occurs on average 2 years after the first symptoms. The estimated risk of blindness at 5 years is 10-15%. BD uveitis has several ophthalmological features that distinguish it from other uveitis. The main goals in the management of patients are the rapid resolution of intraocular inflammation, prevention of recurrent attacks, achievement of complete remission, and preservation of vision. Biologic therapies have changed the management of intraocular inflammation. The aim of this review is to provide an update previous article by our team on pathogenesis, diagnostic approaches, identification of factors associated with relapse and the therapeutic strategy of BD uveitis.

Behçet's Disease Uveitis

Uveitis in Behçet's disease (BD) is frequent (40% of cases) and is a major cause of morbidity. The age of onset of uveitis is between 20 and 30 years. Ocular involvement includes anterior, posterior, or panuveitis. Uveitis may be the first sign of the disease in 20% of cases or it may appear 2 or 3 years after the first symptoms. Panuveitis is the most common presentation and is more commonly found in men. Bilateralization usually occurs on average 2 years after the first symptoms. The estimated risk of blindness at 5 years is 10-15%. BD uveitis has several ophthalmological features that distinguish it from other uveitis. The main goals in the management of patients are the rapid resolution of intraocular inflammation, the prevention of recurrent attacks, the achievement of complete remission, and the preservation of vision. Biologic therapies have changed the management of intraocular inflammation. The aim of this review is to provide an update to a previous article by our team on pathogenesis, diagnostic approaches, and the therapeutic strategy of BD uveitis.

Current pharmacological solutions for Behçet's syndrome

INTRODUCTION

Behçet's syndrome (BS) has a heterogeneous clinical phenotype, and its clinical manifestations may respond differently to drugs commonly used to treat BS. The type, dose, and duration of immunomodulatory, immunosuppressive, and biologic agents should be tailored individually.

AREAS COVERED

We reviewed the literature for articles on BS management that were published until June 2022 and summarized the management options in BS for each type of organ involvement. We aimed to cover all currently available pharmacological agents used in BS, as well as surgical and interventional options, focusing on recent evidence.

EXPERT OPINION

The management aims in BS are to preserve function and quality of life and to avoid damage. The choice of treatment modalities depends on the organs that are actively involved, the severity of that involvement, and prognostic factors. A treat-to-attack strategy would help improve long-term outcomes in BS.

Recent Insights into the Management of Behçet Syndrome

Behçet syndrome (BS) is a multisystem vasculitis with variable vessel involvement that shows significant heterogeneity among patients in terms of clinical manifestations and disease course. Treatment choice and response are both influenced by this heterogeneity. BS treatments’ main goals are to quickly suppress inflammatory exacerbations and prevent relapses in order to protect organ functions and provide good quality of life. Besides the long-term experience with steroids and traditional immunosuppressives, biologic drugs, especially TNF inhibitors, have gained increasing importance in the treatment of BS over the years. In this review, we aimed to give an overview of the studies with conventional and biological drugs with proven efficacy in the treatment of BS, as well as promising drugs and current management strategies according to clinical phenotypes.

An evaluation of apremilast for the treatment of adult patients with oral ulcers associated with Behçet's syndrome

INTRODUCTION

Behçet's syndrome is a chronic, multi-system, variable vasculitis of unknown etiology that can result in significant morbidity and mortality. Mucocutaneous lesions such as oral ulcers and genital ulcers are common manifestations that can affect the quality of life of patients significantly. Treatment for mucocutaneous lesions in Behçet's syndrome continues to be critical, and an unmet need remains a significant issue.

AREAS COVERED

This review evaluates the mechanism of action of apremilast, its effect on the number and pain of oral ulcers, other manifestations, such as genital ulcers, disease activity, quality of life and safety profile in Behçet's syndrome patients. Data from clinical trials as well as observational studies were included.

EXPERT OPINION

Two randomized placebo-controlled trials and real-world observational data suggest that apremilast is an effective and well-tolerated treatment modality for oral and genital ulcers in Behçet's syndrome. Observational studies additionally showed beneficial results for skin lesions, arthritis, and intestinal involvement.

Old and New Challenges in Uveitis Associated with Behçet's Disease

Behçet’s disease (BD) is a systemic vasculitis disease of unknown origin occurring in young people, which can be venous, arterial or both, classically occlusive. Ocular involvement is particularly frequent and severe; vascular occlusion secondary to retinal vasculitis may lead to rapid and severe loss of vision. Biologics have transformed the management of intraocular inflammation. However, the diagnosis of BD is still a major challenge. In the absence of a reliable biological marker, diagnosis is based on clinical diagnostic criteria and may be delayed after the appearance of the onset sign. However, therapeutic management of BD needs to be introduced early in order to control inflammation, to preserve visual function and to limit irreversible structural damage. The aim of this review is to provide current data on how innovations in clinical evaluation, investigations and treatments were able to improve the prognosis of uveitis associated with BD.