Early administration of adalimumab for paediatric uveitis due to Behçet’s disease
Behçet’s disease is a chronic inflammatory multisystem disorder that is characterised by oral and/or genital ulcerations as well as intraocular inflammation. Recurrent retinal vasoocclusive episodes and macular involvement may lead to severe loss of visual acuity. Patients may eventually become resistant to systemic corticosteroid and develop side effects; therefore, other immunosuppressive therapies are needed. Biologic agents are promising for the treatment of Behçet’s disease-associated uveitis. Here, we report two cases of paediatric uveitis due to Behçet’s disease that were successfully treated by early administration of adalimumab.
Patient 1 was an 11-year-old girl who presented with right conjunctival injection and photophobia. Patient 2 was a 14-year-old girl who presented with blurry vision in the left eye. Both patients were treated with topical treatment and prednisolone for uveitis; however, relapses occurred during the tapering of prednisolone. The patients were diagnosed with Behçet’s disease, and adalimumab therapy was initiated. In both cases, the inflammation was well-controlled by adalimumab administration without local or systemic corticosteroid.
Adalimumab is effective for treating children with Behçet’s disease-associated uveitis. Control of ocular inflammation was achieved without local and systemic corticosteroid, thus preventing further complications.
KeywordsAdalimumab Behçet’s disease Paediatrics Uveitis TNFα antagonist
- anti-TNF- α
Anti-tumour necrosis factor α
Best corrected visual acuity
Behçet’s disease is a chronic inflammatory multisystem disorder that is characterised by oral and/or genital ulcerations as well as recurrent intraocular inflammatory episodes, which can be vision-threatening . It may also involve the skin, joints, gastrointestinal tract, blood vessels, central nervous system, and other parts of the body . The onset of Behçet’s disease typically occurs among individuals aged 20–40 years. Behçet’s disease is rarely observed in children or patients above the age of 50; the disease starts in childhood in 4–26% of cases [2, 3]. Furthermore, the time to diagnosis may be lengthy in children due to a lack of symptoms at the time of presentation [4, 5, 6]. Ocular manifestation typically comprises a recurrent bilateral non-granulomatous uveitis, which occurs in 30–70% of Behçet’s patients [1, 7]. In the PEDBD cohort study, ocular symptoms were observed less frequently in children than in adults, with higher prevalence in males . Anterior uveitis of Behçet’s disease is typically managed by topical treatment, such as corticosteroid and mydriatic agents. Inflammation in the posterior segment can cause irreversible damage and may lead to severe loss of visual acuity; thus, systemic treatment is required . In the acute phase, Behçet’s disease responds well to systemic corticosteroid; however, patients may eventually become resistant to systemic corticosteroid treatment. Moreover, long-term administration of systemic corticosteroids may cause complications, such as cataract, glaucoma, and growth defects in children. Therefore, steroid-sparing immunosuppressive therapy is required. . With conventional treatment, the risk of blindness from posterior eye involvement and uveitis complications is approximately 25% at 10 years after the onset [1, 11, 12]. Biologic agents are now promising for treatment of Behçet’s disease. In Japan, infliximab was the only approved drug for Behçet’s disease; adalimumab is a newly available steroid-sparing drug. Currently, neither infliximab nor adalimumab is approved for paediatric use.
Here, we report successful treatment of two cases of paediatric uveitis due to Behçet’s disease; both were treated with early administration of adalimumab.
Discussion and conclusions
Here, we have reported successful treatment of paediatric uveitis due to Behçet’s disease via early administration of adalimumab. Extraocular symptoms, including oral ulcers, ileocecal ulcer, and arthralgia, were also improved by the therapy without systemic complications.
In Japan, anti-tumour necrosis factor- α (anti-TNF- α), infliximab was the only approved biologic agent for Behçet’s disease, despite the high prevalence of the disease. After adalimumab (anti-TNF- α) became available in 2016, the treatment strategy of non-infectious uveitis dramatically changed. Currently, neither infliximab nor adalimumab is approved for paediatric use; however, retrospective case series have shown the efficacies of both drugs in treatment of refractory non-infectious uveitis in children [18, 19, 20]. Importantly, the number of patients with Behçet’s disease is limited in many of the studies based on children. Deitch et al. reported the efficacy of adalimumab in 24 children with non-infectious uveitis, only four of which exhibited Behçet’s disease . Ljubetic et al. and Biester et al. reported the efficacy of adalimumab for refractory childhood uveitis; however, Behçet’s patients were not included [22, 23]. The current case report shows the detailed clinical course of paediatric Behçet’s uveitis treated by adalimumab, which comprises valuable information for paediatricians and uveitis specialists.
Previous reports have shown the earlier initiation of anti-TNF- α for Behçet’s disease-associated uveitis results in better visual outcome and reduced frequency of ocular attacks [24, 25]. Guzelant et al. compared two groups and reported that those who were on other immunosuppressive treatment for a median of 26.5 months (9–50.5 months) prior to infliximab had better outcomes than those who were on other immunosuppressive treatment for a median of 60 months (25–84 months) . Keino et al. also reported that the frequency of ocular attacks, severity of retinal vasculitis, and BCVA were significantly improved in a group of patients with a median duration of Behçet’s uveoretinitis of 15 months (11–18 months) prior to starting infliximab, compared with patients with a median duration of 89 months (40–112 months) . Vallet et al. showed equal effectiveness of infliximab and adalimumab; thus, we suspected that early administration of adalimumab could also be beneficial . In the present cases, the duration of uveoretinitis prior to starting adalimumab was approximately 11 months in case 1 and 13 months in case 2, which can be classified as “early.” Both patients achieved quiescence as a result of the early administration of adalimumab.
When treating uveitis in children, clinicians must consider the importance of preventing the complications of uveitis, as well as the side effects of treatment. The use of local corticosteroid is related to increased IOP, and the increased IOP is especially pronounced in children. Among patients with uveitis who were treated with topical difluprednate, there was reportedly an increase in IOP of more than 15 mmHg in 80% of children . In both of our cases, we successfully tapered corticosteroid eye drops and systemic prednisolone after the administration of adalimumab. BCVA remained ≥ 1.5 and IOPs in both eyes were within the normal range. The patients have not experienced growth disorder or any other symptoms caused by administration of systemic corticosteroid.
We regularly measured the laser flare photometry values of both patients. Aqueous flare and cells are two parameters used as indicators of anterior chamber inflammation . While the slit-lamp examination for assessment of intraocular inflammation remains subjective, laser flare photometry provides a noninvasive, objective, and quantitative measurement of aqueous humour protein levels in the anterior chamber . Inflammatory mediators, such as tumour necrosis factor-alpha (TNF- α), are factors underlying the breakdown of the blood-aqueous barrier, which leads to elevation of laser flare . The physiological laser flare value is approximately 3.0 ± 1.1 ph/ms in healthy individuals between 10 and 19 years of age . Previous reports have shown that blood-aqueous barrier disruption is pronounced in Behçet’s disease; moreover, patients with high flare (≥ 20 ph/ms) tend to develop new complications, such as cataract, glaucoma, and posterior synechiae [31, 32, 33]. In the present cases, laser flare values decreased to normal to low flare range (< 20 ph/ms) and laser flare-derived complications did not develop with adalimumab treatment. [31, 33] Furthermore, in both cases, laser flare began to decrease after improvement of the anterior chamber cell grade. According to Holland et al., patients with low flare have a lower risk of vision loss or vision-threatening complications, regardless of the presence of high anterior chamber cell levels during the course of the disease . The present cases emphasise the importance of laser flare monitoring, as treatment based on anterior cell grade alone may lead to loss of vision. FA taken after administration of adalimumab showed no sign of vascular leakage; furthermore, retinal structures remained intact in both cases. We managed to achieve complete control of inflammation due to adalimumab.
Adalimumab is not approved for treatment of paediatric ocular Behçet’s disease. However, we greatly desired to introduce adalimumab as treatment for these two patients, because we previously encountered a Behçet’s disease patient who had been treated with adalimumab after multiple severe recurrences. The patient showed no severe relapse after administration of adalimumab; however, BCVA improvement was limited due to irreversible retinal disruption, which largely involved the macula. The laser flare value of the patient remained high after quiescence, which may be due to irreversible disruption of the blood-ocular barrier. We learned from this patient that adalimumab should be introduced to uveitis patients before repeated inflammation causes irreversible structural and functional changes.
During adalimumab treatment, the patients in the present report did not experience any adverse effects. We chose to use adalimumab instead of infliximab, because we place great importance on stress-free, adequate, and continuous treatment, which results in minimal interference in the lifestyle of the affected children. Adalimumab can be self-administered and does not require hospitalisation or activity restriction; infliximab requires both of these accommodations. Moreover, adalimumab has a lower risk of anti-drug antibody formation .
Adalimumab may be effective in treating children with uveitis due to Behçet’s disease. Control of ocular inflammation and reduction of laser flare were achieved without local and systemic corticosteroid, thus preventing further complications. The visual outcome of Behçet’s disease has significantly improved since the introduction of biologic agents [35, 36]. We believe that it is essential to administer adalimumab before irreversible structural and functional changes occur. There are increased risks of serious infections, lymphoma, or other cancers as side effects of TNF- α antagonist administration. Long-term follow-up with a larger group of paediatric patients is necessary to clarify the efficacy and possible adverse effects of adalimumab.
We thank Ryan Chastain-Gross, Ph.D., from Edanz Group (www.edanzediting.com/ac) for editing a draft of this manuscript and helping to draft the abstract.
TH, YH, and TD cared for the patient. TH was a major contributor in writing the manuscript. All authors read and approved the final manuscript.
No funding or grant support was obtained for this study.
Ethics approval and consent to participate
Ethics approval and consent was approved by the Hiroshima University IRB.
Consent for publication
Both patients gave written consent to publish case details.
The authors declare that they have no competing interests.
- 1.Zeidan MJ, Saadoun D, Garrido M, Klatzmann D, Six A, Cacoub P. Behçet’s disease physiopathology: a contemporary review. Autoimmun Highlights. 2016. https://doi.org/10.1007/s13317-016-0074-1.
- 14.Kone-Paut I, Georgin-Laviallec S, Galeotti C, Rossi-Semerano L, Hentgen V, Savey L, et al. New data in causes of autoinflammatory diseases. Jt Bone Spine. 2018. https://doi.org/10.1016/j.jbspin.2018.11.003.
- 27.Difluprednate T. In summary, this study could represent an in vitro model that may allow for further investigation of dis- ease mechanisms and therapeutic interventions in TEN, vol. 40; 2013. p. 2011–3.Google Scholar
- 30.Fleisher LN, Ferrell JD, Mcgahan MC. Synergistic Uveitic effects of tumor necrosis, vol. 33; 1992. p. 2120–7.Google Scholar
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