TNFα-blocking Agents or Conventional Immunosuppressive Drugs in the Therapy of Children with Uveitis? – An Evidence Based Approach

Abstract

Treatment of childhood uveitis associated with juvenile idiopathic arthritis (JIA) is a challenge for both, ophthalmologists and pediatricians. In this study, we use the tools of evidence based medicine (EBM) to analyse studies concerning disease-modifying antirheumatic drugs (DMARD)/ immunosuppressive drugs and tumor necrosis factor alpha (TNFα) blocking agents. Most experience among DMARD's/ immunosuppressive drugs has been obtained with methotrexate (MTX) in juvenile idiopathic arthritis. However, controlled studies in uveitis are still missing, so that treatment with MTX and all other immunosuppressive drugs (ciclosporine A, azathioprine, mycophenolate mofetil) only reaches an evidence level III (expert opinion, clinical experience or descriptive study). Studies on TNFα-blocking agents reach an evidence level II–III, depending on the substance. In future, MTX will have to be examined in comparison to the new biological substance classes (e.g., tumor necrosis factor-α-blockers) for the treatment of uveitis in juvenile idiopathic arthritis. Controlled studies which have led to the approval of drugs for JIA are needed for uveitis in order to have the most effective and safe therapy for children with uveitis, who do not respond to conventional therapy with local and systemic steroids.

Zusammenfassung

Die Behandlung der JIA-assoziierten Uveitis im Kindes-und Jugendalter (JIA - Juvenile Idiopathische Arthritis) stellt eine Herausforderung sowohl für Augenärzte als auch für Kinderärzte dar. Anhand der Methoden der evidenzbasierten Medizin (EBM) haben wir in dieser Analyse Studien über DMARDs, Immunsuppressiva und Tumor-Nekrose-Faktor-α-blockierenden Substanzen untersucht. Bei der Behandlung der JIA besteht die meiste Erfahrung unter den DMARDs und Immunsuppressiva mit dem Medikament Methotrexat (MTX). Bei der Behandlung der Uveitis fehlen kontrollierte Studien, so dass der Evidenzgrad für die Behandlung mit Methotrexat und anderen Immunsuppressiva (CSA, Azathioprin und MMF) nur den Evidenzgrad III (Expertenmeinung) erreicht. Die Studien bei der Uveitis über TNF-blockierende Substanzen erreichen einen Evidenzgrad II – III, abhängig von der Substanz. In Zukunft wird zur Beurteilung der Effektivität unbedingt notwendig sein, MTX gegen die neuen Biologica zu testen. Kontrollierte Studien, die bei der JIA zur Zulassung der Medikamente geführt haben, sind auch für die Uveitis zu fordern, damit Kindern und Jugendlichen mit einer Uveitis eine effektive und sichere Therapie angeboten werden kann, wenn die konventionelle Therapie und lokal wie systemisch applizierte Steroide versagen.

Key words

uveitis - juvenile idiopathic arthritis - immunosuppression - methotrexate - TNFα-blocking agents - etanercept - infliximab - adalimumab - evidence based medicine

Schlüsselwörter

Uveitis - juvenile idiopathische Arthritis - Immunsuppression - Methotrexat - TNFα-Inhibitoren - Etanercept - Infliximab - Adalimumab - evidence based medicine

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