Immunosuppressive therapy has been shown to reduce the risk of blindness in the better eye by 60% (Am. J. Ophthalmol. 2007;143:840-6). The most widely used immunomodulatory agent for children is methotrexate. Anti–TNF-alpha agents may be used in patients who fail to respond to conventional immunosuppressive therapy. A recent study in Italy that compared infliximab and adalimumab for refractory uveitis in 91 patients with JIA found higher remission rates after 1 year with adalimumab (67% vs. 43%, P = .025) (J. Rheumatol. 2013;40:74-9). Adalimumab has the convenience of subcutaneous administration, stable serum concentrations, and a more favorable safety profile, whereas infliximab offers fast onset and potent anti-inflammatory effects (J. Ophthalmic Vis. Res. 2011;6:259-69).
The anti–TNF-alpha agent golimumab was found to be helpful in three cases of refractory JIA uveitis. Golimumab offers the advantage of subcutaneous once-a-month dosing and avoids the expense and time commitment of outpatient infliximab infusions, Dr. Kedhar noted (J. Ophthalmic. Inflamm. Infect. 2012;2:231-3).
"Uveitis may require higher doses of immunomodulatory agents than those used for rheumatologic manifestations," Dr. Kedhar said. "The activity of uveitis associated with JIA may be independent from the rheumatologic disease. Although we used to recommend treating uveitis for 1 year once quiescence is established, many uveitis specialists now recommend treating until 2 years of quiescence to minimize the risk of recurrence."