Do patients with recurrent uveitis and Crohn's (Crohn's disease) receive suppression therapy outside of exacerbation periods?

From the Guidelines

For patients with recurrent uveitis and Crohn's disease, suppression therapy with biologic agents such as adalimumab or infliximab is recommended, even outside of exacerbation periods, to manage both ocular and intestinal inflammation and prevent long-term complications. This approach is supported by the 2019 update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network recommendations for the treatment of ankylosing spondylitis and nonradiographic axial spondyloarthritis 1. The use of TNFi monoclonal antibodies, such as adalimumab or infliximab, is conditionally recommended for adults with AS and recurrent uveitis, as well as for those with AS and inflammatory bowel disease.

Key considerations for suppression therapy include:

• The use of biologic agents, such as adalimumab (40 mg subcutaneously every 1-2 weeks) or infliximab (3-5 mg/kg IV at weeks 0,2,6, then every 8 weeks), to manage both ocular and intestinal inflammation
• Regular monitoring for medication side effects, including liver function tests, complete blood counts, and kidney function
• The importance of preventing long-term complications, such as cataract, glaucoma, and macular edema, which can result from untreated recurrent uveitis

The Canadian Association of Gastroenterology clinical practice guideline for the management of luminal Crohn's disease also supports the use of anti-TNF therapy, such as infliximab or adalimumab, as first-line therapy to induce complete remission in patients with moderate to severe luminal Crohn's disease 1. Additionally, the Guidance on Noncorticosteroid Systemic Immunomodulatory Therapy in Noninfectious Uveitis: Fundamentals of Care for Uveitis (FOCUS) initiative provides recommendations for the use of systemic immunosuppressants in the treatment of noninfectious uveitis, including the use of biologic agents such as adalimumab or infliximab 1.

From the Research

Uveitis Treatment

• Patients with recurrent uveitis, including those with Crohn's disease, may receive immunosuppressive therapy to control inflammation and prevent exacerbations 2, 3.
• The choice of immunosuppressive agent depends on the cause and severity of the patient's underlying inflammation, the presence or absence of associated systemic inflammation, and the patient's prior response to immunosuppressive treatments 2.
• Corticosteroids are the primary initial treatment for patients with uveitis, but noncorticosteroid immunosuppressive agents may be used in selected patients to improve control and decrease the risk of corticosteroid-induced side effects 2.

Suppression Therapy

• Suppression therapy may be continued for a period of 2 years while the patient is in remission before considering tapering medication 4.
• The use of anti-tumour necrosis factor (TNF) antibodies, such as infliximab, has been successful in controlling uveitis in some patients, particularly those with posterior uveitis or panuveitis 3.
• Other immunosuppressive agents, such as methotrexate and mycophenolate mofetil, may also be used as corticosteroid-sparing treatments for uveitis, although their effectiveness may vary depending on the anatomical subtype of uveitis 5.

Recurrent Uveitis Management

• Patients with recurrent acute anterior uveitis may benefit from oral nonsteroidal anti-inflammatory drug (NSAID) therapy to prevent recurrences 6.
• The use of NSAID therapy has been shown to reduce the number of relapses and prevent morbid attacks in patients with recurrent AAU 6.
• Combination immunomodulatory therapy (IMT) agents may be necessary for refractory and recurrent uveitis 4.