What is the treatment for uveitis in Ankylosing Spondylitis (AS)?

Treatment of Uveitis in Ankylosing Spondylitis

For patients with ankylosing spondylitis and recurrent uveitis, TNF inhibitor monoclonal antibodies (adalimumab or infliximab) are strongly recommended as the preferred treatment option. 1

First-Line Treatment Options

TNF Inhibitor Monoclonal Antibodies

• Adalimumab: First-choice TNFi for AS-associated uveitis

  • Demonstrated superior efficacy with rates of uveitis of 13.6 per 100 patient-years compared to pre-treatment rates of 36.8 1
  • FDA-approved for non-infectious intermediate, posterior, and panuveitis 2
  • Dosing: Initial dose of 80 mg followed by 40 mg every other week 2

• Infliximab: Alternative first-line TNFi

  • Effective with rates of uveitis of 27.5 per 100 patient-years compared to pre-treatment rates of 45.5 1

Other TNFi Monoclonal Antibodies

• Certolizumab or Golimumab: May be considered, though supporting data are less substantial 1
  • Golimumab has shown significant reduction in AAU occurrence rate from 11.1 to 2.2 per 100 patient-years in AS patients 3

Treatment to Avoid

• Etanercept: Not recommended for AS patients with uveitis
  • Higher rates of uveitis (60.3 per 100 patient-years) compared to pre-treatment rates of 41.6 1
  • May trigger paradoxical uveitis in some patients 4

Treatment Algorithm

1. For mild-moderate anterior uveitis in AS:

   • Begin with topical corticosteroids
   • If inadequate response, add TNFi monoclonal antibody (preferably adalimumab)

2. For moderate-severe or recurrent uveitis in AS:

   • Initiate TNFi monoclonal antibody (adalimumab or infliximab)
   • Consider combination with methotrexate for enhanced efficacy 4

3. For refractory cases:

   • Switch between TNFi monoclonal antibodies
   • Consider adding methotrexate if not already included in regimen
   • Evaluate for treatment adherence, infections, or masquerade syndromes before changing therapy 1

Monitoring and Follow-up

• Monitor disease activity at least every three months
• Continue treatment for at least 2 years after achieving inactive disease
• Regular ophthalmologic examinations to assess disease activity
• Screen for tuberculosis before initiating TNFi therapy

Special Considerations

• If patient also has inflammatory bowel disease, TNFi monoclonal antibodies are strongly preferred over other biologics 1
• IL-17 inhibitors (secukinumab, ixekizumab) should be avoided in patients with AS and uveitis as they have not shown efficacy for uveitis control and may exacerbate inflammatory bowel disease 1
• Treatment decisions should involve collaboration between rheumatologist and ophthalmologist 1

Treatment Pitfalls to Avoid

1. Delaying initiation of TNFi therapy in recurrent or severe uveitis cases
2. Using etanercept for AS patients with history of uveitis
3. Failing to screen for tuberculosis before starting TNFi therapy
4. Discontinuing TNFi therapy too early after achieving remission
5. Not considering combination therapy with methotrexate for enhanced efficacy

The evidence strongly supports the use of TNFi monoclonal antibodies, particularly adalimumab and infliximab, as the most effective treatment options for uveitis in AS patients, with significant reduction in uveitis flares and improved visual outcomes.