Uveitis, Juvenile Idiopathic Arthritis Medication

  • Author: Manolette R Roque, MD, MBA; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Sep 28, 2010
 

Medication Summary

The treatment of JIA-associated uveitis is a step-wise progression beginning with topical steroids and mydriatics, progressing to regional steroids, systemic NSAIDs, systemic steroids, immunosuppressive agents, and biologics.

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Corticosteroids

Class Summary

These agents decrease inflammation. When considered, corticosteroid treatment often is initiated only after consultation with an ophthalmologist. However, long-term systemic therapy results in an unfavorable visual prognosis.

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Prednisolone acetate (Pred Mild, Pred Forte, Econopred)

 

Strongest steroid of its group and best choice for uveitis. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.

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Triamcinolone (Kenalog)

 

Periocular injections of corticosteroids reserved for patients with more severe disease, or those with posterior segment (eg, vitreous) inflammation. Also used in patients at high risk for CME.

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Prednisone (Deltasone)

 

May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity.

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Cycloplegics

Class Summary

These agents block nerve impulses to the pupillary sphincter and ciliary muscles, easing pain and photophobia.

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Cyclopentolate 0.5-2% (Cyclogyl)

 

Induces cycloplegia in 25-75 min and mydriasis in 30-60 min. These effects last up to 1 d; however, the duration may be less in the setting of a severe anterior chamber reaction. For this reason, cyclopentolate is less attractive for treating uveitis than homatropine.

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Homatropine (Isopto)

 

Induces cycloplegia in 30-90 min and mydriasis in 10-30 min. Useful in treating pain from ciliary spasm and decreasing formation of synechiae. These effects last 10-48 h for cycloplegia and 6 h to 4 d for mydriasis, but the duration may be less in the setting of a severe anterior chamber reaction. Homatropine is the preferred agent of choice for uveitis.

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Nonsteroidal anti-inflammatory drugs

Class Summary

NSAIDs reduce pain and inflammation and allow for improvements in mobility and function. Used to reduce effect of diffusing prostaglandins on retinal microvasculature and, hence, used in patients at high risk for the development of CME. There are several NSAIDs; however, no single agent exists that is superior to another. Naproxen is used commonly in children.

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Indomethacin (Indocin)

 

For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which is responsible for prostaglandin synthesis.

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Naproxen (Anaprox, Naprelan, Naprosyn)

 

For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which is responsible for prostaglandin synthesis.

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Ibuprofen (Ibuprin, Advil, Motrin)

 

For relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

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Ketorolac ophthalmic (Acular)

 

Inhibits prostaglandin synthesis by decreasing the activity of the enzyme, cyclooxygenase, which results in decreased formation of prostaglandin precursors.

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Diclofenac ophthalmic (Voltaren)

 

Inhibits prostaglandin synthesis by decreasing activity of enzyme cyclooxygenase, which, in turn, decreases formation of prostaglandin precursors. May facilitate outflow of aqueous humor and decreases vascular permeability.

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Immunosuppressives (systemic)

Class Summary

These are second-line agents that ameliorate the disease process. Most frequently they are used in combination with first-line agents. They include methotrexate, cyclosporin A, cyclophosphamide, and chlorambucil.

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Etanercept (Enbrel)

 

Binds specifically to tumor necrosis factor (TNF) and blocks its interaction with cell-surface TNF receptor. TNF is a naturally occurring cytokine that is involved in normal inflammatory and immune responses.

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Methotrexate (Folex PFS)

 

Folic acid analog, decreases inflammation, and has steroid-sparing effect. Useful in JIA-associated uveitis, where may reduce inflammation in patients who do not respond adequately to steroid treatment.

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Cyclosporine (Sandimmune)

 

Potent immunosuppressive agent with narrow therapeutic range. Cyclic polypeptide that suppresses some humoral immunity and, to a greater extent, cell-mediated immune reactions (eg, delayed hypersensitivity, allograft rejection, experimental allergic encephalomyelitis, and graft-vs-host disease) for a variety of organs.

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Cyclophosphamide (Cytoxan, Neosar)

 

Chemically related to nitrogen mustards. As alkylating agent, mechanism of action of the active metabolites may involve cross-linking of DNA, which may interfere with growth of normal and neoplastic cells.

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Chlorambucil (Leukeran)

 

Aromatic nitrogen mustard derivative that acts as bifunctional alkylating agent. Alkylation takes place through formation of highly reactive ethylenimonium radical. Probable mode of action involves cross-linkage of the ethylenimonium derivative between 2 strands of helical DNA and subsequent interference with replication.

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Tumor necrosis factor (TNF) inhibitors

Class Summary

TNF is a cytokine of which 2 forms have been identified with similar biological properties. TNF-alpha or cachectin is produced predominantly by macrophages, and TNF-beta or lymphotoxin is produced by lymphocytes. TNF is but one of many cytokines involved in the inflammatory cascade that may contribute to symptoms.

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Adalimumab (Humira)

 

Recombinant human IgG1 monoclonal antibody specific for human tumor necrosis factor (TNF). Indicated to reduce inflammation and inhibit progression of structural damage in moderate-to-severe rheumatoid arthritis. Reserved for those who experience inadequate response to one or more disease-modifying antirheumatic drugs (DMARDs). Can be used alone or in combination with methotrexate (MTX) or other DMARDs. Binds specifically to TNF-alpha and blocks interaction with p55 and p75 cell-surface TNF receptors. In 2008, adalimumab was approved by the FDA for juvenile idiopathic arthritis.

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Infliximab (Remicade)

 

Chimeric IgG1k monoclonal antibody that neutralizes cytokine TNF-alpha and inhibits its binding to TNF-alpha receptor. Reduces infiltration of inflammatory cells and TNF-alpha production in inflamed areas. Used with methotrexate in patients who have had inadequate response to methotrexate monotherapy.

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Immunomodulator

Class Summary

Abatacept decreases inflammation by blocking T-cell activation.

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Abatacept (Orencia)

 

Selective co-stimulation modulator that inhibits T-cell activation by binding to CD80 and CED86, thereby blocking CD28 interaction. CD28 interaction provides a signal needed for full T-cell activation that is implicated in RA pathogenesis. Indicated for reducing signs and symptoms of RA, slowing progression of structural damage and improving physical function in adults with moderate-to-severe RA who have inadequate response to DMARDs, methotrexate, or TNF antagonists. May be used as monotherapy or with DMARDs (other than TNF antagonists, because of increased risk of serious infections [4.4% vs 0.8%]). Not recommended for concomitant use with anakinra (insufficient experience).

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Contributor Information and Disclosures
Author

Manolette R Roque, MD, MBA  President and CEO, Service Chief of Ocular Immunology and Uveitis, Refractive Surgery, EYE REPUBLIC Ophthalmology Clinic; General Manager, Ophthalmic Consultants Philippines; Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, Asian Hospital and Medical Center; Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, St Luke's Medical Center Global City; Senior Eye Surgeon, The LASIK Surgery Clinic; Senior Eye Surgeon, Precise Eye Laser Center

Manolette R Roque, MD, MBA is a member of the following medical societies: American Academy of Ophthalmic Executives, American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, American Society of Ophthalmic Administrators, American Uveitis Society, International Ocular Inflammation Society, Philippine Medical Association, Philippine Ocular Inflammation Society, and Philippine Society of Cataract and Refractive Surgery

Disclosure: Nothing to disclose.

Coauthor(s)

Barbara L Roque, MD  Full Partner, Ophthalmic Consultants Philippines Co; Ophthalmology Consultant, Eye Republic Ophthalmology Clinic; Visiting Ophthalmologist, QC Eye Center and Asian Hospital and Medical Center

Barbara L Roque, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Philippine Academy of Ophthalmology, and Philippine Society of Cataract and Refractive Surgery

Disclosure: Nothing to disclose.

Elisabetta Miserocchi, MD  Fellow in Immunology and Uveitis Service, Department of Ophthalmology, Harvard Medical School

Disclosure: Nothing to disclose.

C Stephen Foster, MD, FACS, FACR, FAAO  Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Founder and President, Ocular Immunology and Uveitis Foundation, Massachusetts Eye Research and Surgery Institution

C Stephen Foster, MD, FACS, FACR, FAAO is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Association of Immunologists, American College of Rheumatology, American College of Surgeons, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, American Uveitis Society, Association for Research in Vision and Ophthalmology, Massachusetts Medical Society, Royal Society of Medicine, and Sigma Xi

Disclosure: Nothing to disclose.

Specialty Editor Board

Andrew A Dahl, MD  Director of Ophthalmology Teaching, Mid-Hudson Family Practice Institute, The Institute for Family Health; Assistant Professor of Surgery (Ophthalmology), New York College of Medicine

Andrew A Dahl, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD  Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

R Christopher Walton, MD  Professor, Director of Uveitis and Ocular Inflammatory Disease Service, Department of Ophthalmology, Assistant Dean for Graduate Medical Education, University of Tennessee College of Medicine; Consulting Staff, Regional Medical Center, Memphis Veterans Affairs Medical Center, St Jude Children's Research Hospital

R Christopher Walton, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Healthcare Executives, American Uveitis Society, Association for Research in Vision and Ophthalmology, and Retina Society

Disclosure: Nothing to disclose.

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

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Acute anterior uveitis with hypopyon in a child. Courtesy of Manolette Roque, MD, Ophthalmic Consultants Philippines Co, EYE REPUBLIC Ophthalmology Clinic.
Juvenile idiopathic arthritis uveitis. Band keratopathy. Courtesy of Manolette Roque, MD, Ophthalmic Consultants Philippines Co, EYE REPUBLIC Ophthalmology Clinic.
Juvenile idiopathic arthritis uveitis. Pseudophakia with posterior chamber intraocular lens with anterior membrane and posterior capsular opacification with cyclitic membrane formation. Courtesy of Manolette Roque, MD, Ophthalmic Consultants Philippines Co, EYE REPUBLIC Ophthalmology Clinic.
Juvenile idiopathic arthritis uveitis. Use of Grieshaber iris hooks to create and maintain a large enough pupil for adequate visualization during membranectomy and pars plana vitrectomy in a pseudophakic child. The intraocular lens was clear after the anterior lenticular membrane was peeled off. Courtesy of Manolette Roque, MD, Ophthalmic Consultants Philippines Co, EYE REPUBLIC Ophthalmology Clinic.
 
 
 
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