What is the recommended treatment for Tubulointerstitial Nephritis and Uveitis (TINU) syndrome?

Treatment Recommendations for Tubulointerstitial Nephritis and Uveitis (TINU) Syndrome

The recommended treatment for Tubulointerstitial Nephritis and Uveitis (TINU) syndrome consists of topical glucocorticoids for uveitis and systemic corticosteroids for nephritis, with immunomodulatory agents reserved for refractory cases. 1

Initial Treatment Approach

Ocular Management

• Begin with prednisolone acetate 1% topical drops for anterior uveitis component, as this is conditionally recommended over other topical steroid formulations 2
• For short-term control of active uveitis, adding or increasing topical glucocorticoids is conditionally recommended over immediately adding systemic glucocorticoids 2
• Limit topical glucocorticoid therapy to ≤3 months when possible to minimize risk of complications such as elevated intraocular pressure and cataract formation 3

Renal Management

• For patients with significant renal insufficiency, initiate systemic corticosteroids (typically prednisone 1 mg/kg/day) 4, 5
• Continue systemic therapy for approximately 2-3 weeks at full dose, then taper gradually over 8-10 weeks based on clinical response 4
• Monitor renal function parameters regularly during treatment and tapering 6

Treatment of Refractory Cases

For Persistent Uveitis Despite Topical Therapy

• If topical glucocorticoids are required for >3 months at 1-2 drops/day, adding systemic therapy is conditionally recommended to allow tapering of topical steroids 2
• For patients with severe active uveitis and sight-threatening complications, consider starting both methotrexate and a monoclonal antibody TNF inhibitor immediately 2

Immunomodulatory Options for Refractory Cases

• Methotrexate (preferably subcutaneous route) is the first-line systemic immunomodulator 2
• For cases refractory to methotrexate, consider:
  • Mycophenolate mofetil 2, 1
  • Azathioprine 1
  • Monoclonal antibody TNF inhibitors (adalimumab or infliximab) 2

Monitoring and Follow-up

Ophthalmologic Monitoring

• For patients with controlled uveitis on therapy, ophthalmologic monitoring should occur no less frequently than every 3 months 2
• When tapering topical glucocorticoids, ophthalmologic monitoring within 1 month after each change in topical therapy is strongly recommended 2
• Monitor regularly for elevated intraocular pressure and cataract formation, especially when treatment extends beyond a few weeks 3

Renal Monitoring

• Monitor renal function, urinalysis, and markers of tubular dysfunction (β2-microglobulin, N-acetylglucosaminidase) regularly during treatment 7, 6
• When tapering or discontinuing systemic therapy, ophthalmologic monitoring within 2 months of changing systemic therapy is strongly recommended 2

Treatment Duration and Tapering

• For patients with well-controlled uveitis on systemic therapy, maintain treatment for at least 2 years before attempting to taper 2
• When tapering therapy in patients on both topical and systemic treatments, taper topical glucocorticoids first before tapering systemic therapy 2
• Consider low-dose steroid maintenance therapy for up to 1 year to decrease the risk of recurrence 5

Special Considerations

• Uveitis tends to have a higher recurrence rate than nephritis and recurrences are often more severe than the initial episode 4, 7
• Inflammation is typically more severe in recurrent uveitis (≥3+ cells in anterior chamber), often requiring more aggressive treatment 7
• For recurrent or severe uveitis that is refractory to local therapy, oral corticosteroids should be initiated promptly 7
• The renal component tends to be self-limiting with appropriate treatment, while the uveitis component may require longer-term management 4, 1