Treatment for Anterior Uveitis, an Extraspinal Manifestation of Ankylosing Spondylitis
David Borenstein, MD Executive Editor theSpineCommunity
One of my patients described the pain associated with anterior uveitis as being stabbed in the eye with a knife. It is what he experienced when he looked at a light when his eye was inflamed. The iris is part of the uveal tract which is the part of the eye that opens and shuts in response to light. When the uveal tract is inflamed (uveitis) any light will make it try to close. Inflammation makes movement difficult resulting in pain. HLA-B27 is a genetic factor that predisposes to uveitis and is also a finding in patients with ankylosing spondylitis (AS). Approximately a third of patients with AS have anterior uveitis.
Biologic therapies, such as Enbrel (etanercept), Humira (adalimumab), and Remicade (infliximab), are drugs known as tumor necrosis factor inhibitors (TNF) and are effective in the treatment of AS. A recent Swedish biologic registry study has reported on the effect of these drugs on the occurrence of anterior uveitis in AS patients. Enbrel is a receptor analogue that adsorbs unattached TNF. Humira, and Remicade are monoclonal antibodies that will attach to free and membrane attached TNF molecules.
In a 7 year study following 1365 AS patients, a reduction in overall anterior uveitis rate was identified for AS patients treated with Humira and Remicade. The occurrence of uveitis for both of these biologics was similar. The rates of uveitis were higher for Enbrel patients compared with those of the other two biologic therapies. These findings suggest that antibody-related anti-TNF therapy is more effective than receptor therapy in the treatment of anterior uveitis in AS.
Cosentyx (secukinumab) is an anti-Il-17 antibody approved in the therapy of AS. Initial studies have been conducted for treatment of noninfectious uveitis, not exclusively in AS. In these studies of a wide spectrum of disorders, Cosenytx is associated with a decreased need for concomitant immunosuppressive therapy (corticosteroids) for the control of uveitis.
Bottomline – In the portion of patients with AS and anterior uveitis, antibody-based biologic therapy, Humira and Remicade, is a better choice than Enbrel for control of uveitis. For those individuals where anti-TNF therapy may not be effective, Cosentyx is an appropriate alternative to decrease the need for additional therapy
- Lie E et al. Tumor necrosis factor inhibitor treatment and occurrence of anterior uveitis in ankylosing spondylitis: results from the Swedish biologics register. Ann Rheum Dis 2017 Mar 2 pii: annrheum dis-2016-210931.doi:10.1136/annrheumdis-2016-210931 (e pub ahead of print)
- Dick AD etal. Secukinumab in the treatment of noninfectious uveitis: Results of three randomized, controlled clinical trials; Ophthalmology 2013;120:777-787