Failure of primary immunosuppressive agents in uveitis.

PURPOSE: This retrospective study aimed to evaluate the effectiveness of various immunomodulatory therapy (IMT) regimens in managing non-infectious uveitis (NIU) and to identify optimal treatment strategies for refractory cases. The study focused on patients who failed primary IMT and required revisions due to uncontrolled inflammation or frequent relapses.

METHODS

The study was conducted over 1 year (December 2023 to November 2024) and included patients diagnosed with NIU, scleritis, or episcleritis who failed primary IMT. The primary IMT and subsequent revisions were analyzed to identify patterns in the use of different IMT regimens and their effectiveness.

RESULTS

The study cohort consisted of 54 patients. Panuveitis was found to be the most common anatomical diagnosis (44.4%). The primary IMT used was predominantly methotrexate (MTx) (83.3%). The first revision of IMT often involved combination therapy, with MTx + mycophenolate mofetil (MMF) being the most common combination (24.1%). Subsequent revisions also favored combination therapy, with increasing use of biologics like Adalimumab (ADA) and tofacitinib (Tofa). Subgroup analysis revealed Vogt-Koyanagi-Harada (VKH), being the most common etiologically diagnosed uveitic entity with primary IMT failure and increased use of Tofa in subsequent revisions of IMT.

CONCLUSIONS

The study highlights the challenges in managing refractory uveitis. Combination therapy, particularly with MMF and MTx, is commonly advocated. The use of biologics like Tofa, especially in VKH, can be a valuable treatment option. Future prospective studies with larger cohorts are needed to validate these findings and explore the disease-specific effectiveness of IMT regimens.