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S. M. Sharma, A. V. Ramanan, P. Riley, A. D. Dick; Use of Infliximab in Juvenile Onset Rheumatological Disease Associated Refractory Uveitis: Efficacy in Joint and Ocular Disease. Invest. Ophthalmol. Vis. Sci. 2007;48(13):3911. doi: https://doi.org/.
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To report the efficacy of infliximab therapy in ocualr and joint disease in a cohort of patients treated for severe uveitis associated with paediatric rheumatic onset including those who had previoulsy been treated with other anti-TNF agents
We retrospectively reviewed the case notes of 6 patients with refractory joint and ocular paediatric-onset disease ( 1 multisystem sarcoidosis, 1 multisystem granulomatous disease, 3 psoriatic arthropathy, 1 multisystem JIA ) treated with infliximab in a multi-disciplinary clinic. Our report utilizes the Standardised Uveitis Nomenclature (SUN) grading system for uveitis and steroid dose as an outcome measure. All patients received infliximab infusions at weeks 0, 2, 6 and 8 weekly. 5 out of 6 had prior treatment with another anti-TNF biologic agent (3 Adalumimab, 2 etancercept) for 6 months (1), 18months (3) and 42 months(1). Treatment change to inflixmab was directed by a single physician ( ADD) on the basis of ongoing uveitis in excess of 1+ cells or where vision was deteriorating ( 2 patients) or if there additional systemic disease(3)Patient age range was 8-18. patients were treated with inflximab for 6 months (2), 9 months(2) , 12 months(1) and 15 months (1). Starting dose was 3mg/kg with 4 out of 6 requiring dose increase to 6mg/kg .
Drug induced remission on infliximab occurred in 50% (3 patients) with improvement of ocular inflammation in 2 patients. Remission of joint disease occurred in 5/6 patients. We saw a reduction oral prednisone dose to 5mg/day in 3. Halving of the visual angle in the worst eye occurred in 4/6 patients. Infliximab use also suppressed inflammatory activity to permit intraocular surgery in 3 patients without high dose steroids.There was no serious adverse event.
Our data confirms, in part, other reports of successful anti-TNF therapy suppressing joint disease more effectively than uveitis We observe that infliximab is well tolerated and successfully suppresses ocular inflammation. Of note is that we could not show evidence that failure of a previous biologic agent predicts failure with infliximab. The clinical setting can make outcomes difficult to interpret. SUN guidelines suggest a threshold daily steroid dose e.g 5mg . This has limitations in clinical practice for children if oral steroid is relatively contraindicated. This can limit the interpretation of steroid dose as a clinical marker of treatment success.
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