Immunomodulatory Therapy in Noninfectious Uveitis During the COVID-19 Pandemic
abstract
This abstract is available on the publisher's site.
Access this abstract nowBACKGROUND
Immunomodulatory therapy (IMT) is often considered for systemic treatment of non-infectious uveitis (NIU). During the evolving coronavirus disease-2019 (COVID-19) pandemic, given the concerns related to IMT and the increased risk of infections, an urgent need for guidance on the management of IMT in patients with uveitis has emerged.
METHODS
A cross-sectional survey of international uveitis experts was conducted. An expert steering committee identified clinical questions on the use of IMT in patients with NIU during the COVID-19 pandemic. Using an interactive online questionnaire, guided by background experience and knowledge, 139 global uveitis experts generated consensus statements for IMT. In total, 216 statements were developed around when to initiate, continue, decrease and stop systemic and local corticosteroids, conventional immunosuppressive agents and biologics in patients with NIU. Thirty-one additional questions were added, related to general recommendations, including the use of non-steroidal anti-inflammatory drugs (NSAIDs) and hydroxychloroquine.
RESULTS
Highest consensus was achieved for not initiating IMT in patients who have suspected or confirmed COVID-19, and for using local over systemic corticosteroid therapy in patients who are at high-risk and very high-risk for severe or fatal COVID-19. While there was a consensus in starting or initiating NSAIDs for the treatment of scleritis in healthy patients, there was no consensus in starting hydroxychloroquine in any risk groups.
CONCLUSION
Consensus guidelines were proposed based on global expert opinion and practical experience to bridge the gap between clinical needs and the absence of medical evidence, to guide the treatment of patients with NIU during the COVID-19 pandemic.
Click on any of these tags to subscribe to Topic Alerts. Once subscribed, you can get a single, daily email any time PracticeUpdate publishes content on the topics that interest you.
Visit your Preferences and Settings section to Manage All Topic Alerts
Additional Info
Disclosure statements are available on the authors' profiles:
Evolving Consensus for Immunomodulatory Therapy in Non-Infectious Uveitis During the COVID-19 Pandemic
Br J Ophthalmol 2020 Jun 25;[EPub Ahead of Print], R Agrawal, I Testi, CS Lee, E Tsui, M Blazes, JE Thorne, AA Okada, JR Smith, PJ McCluskey, JH Kempen, C Tappeiner, M Agarwal, B Bodaghi, QD Nguyen, V Gupta, MD De Smet, M Zierhut, C PavesioFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Despite the use of systemic immunomodulatory therapy (IMT) for the treatment of noninfectious uveitis (NIU) and the associated increased risk for infection, especially viral, there are limited data on how this treatment will affect those with COVID-19. Because of this, an important take-home message of this article with respect to NIU treatment is the consensus statement that “management decisions were influenced by the patient’s COVID-19 infection status and systemic risk factors, including severity of uveitis and number of IMT agents required for the NIU.” Notably, for those with suspected or confirmed COVID-19, systemic corticosteroid or immunosuppression for NIU, treatment should not be started, while for those who are receiving corticosteroids, doses should be tapered and eventually stopped. The authors point out that these guidelines may change as knowledge about the virus and the effects of immunosuppression are updated.
This article is a nice contribution to the literature, and timely as well, as the first published worldwide survey of uveitis specialists on the advisability of immunomodulatory therapy (IMT) in noninfectious uveitis (NIU). The article provides a useful flow chart (Figure 3) of treatment recommendations for very high–risk patients, differentiating four categories: patients on oral steroids; not on oral steroids; on or considering immunosuppressive drugs; and on or considering biologics. The determination of IMT to prevent sight-threatening flare-ups must be weighed carefully for patients at very high risk of COVID-19, and it requires collaboration with other practitioners involved in the patient's care.
The authors performed a cross-sectional survey of international uveitis experts regarding the potential risks involving the use of immunomodulatory therapy (IMT) for systemic treatment of noninfectious uveitis (NIU) during the COVID-19 pandemic. The findings were used to generate consensus guidelines that were proposed based on the results of the survey. The tables and figures should prove particularly helpful to clinicians seeking the safest means to address the risks and benefits of various treatment modalities in patients with NIU during the present pandemic.