Results: Forty-six patients with spondylarthropathy treated with anti-TNF drugs had at least one uveitis flare (33 treated with anti-TNF antibodies—infliximab or adalimumab—and 13 with soluble TNF receptor—etanercept). The mean age at first symptoms was 26 years, 71% were men. Patients were followed for 15.2 years (mean) prior to anti-TNF versus 1.2 years during anti-TNF treatment. The number of uveitis flares per 100 patient-years before and during anti-TNF were, respectively: for all anti-TNF treatments: 51.8 versus 21.4 (p=0.03), RR=2.4, NNT=3 (95% confidence interval [CI] 2 to 5); for soluble TNF receptor: 54.6 versus 58.5 (p=0.92), RR=0.9; and for anti-TNF antibodies: 50.6 v 6.8 (p=0.001), RR=7.4, NNT=2 (95% CI 2 to 5).
Conclusion: Anti-TNF treatments were efficacious in decreasing the number of uveitis flares in patients with spondylarthropathy. Anti-TNF antibodies decreased the rate of uveitis flares, whereas soluble TNF receptor did not seem to decrease this rate. These results could have consequences for the choice of anti-TNF treatment in certain patients.
Commentary
Acute anterior uveitis occurs in up to 40% of patients with spondyloarthritis. Recurrent episodes are common and uveitis may be the disease’s most distressing feature for some patients. Although most flares can be treated effectively with local therapy, for patients with frequent flares, it is important to determine if systemic therapy can prevent recurrences or reduce flare frequency. Sulfasalazine and methotrexate have been used with some success to prevent recurrences of uveitis. The growing use of anti–TNF-alpha medications to treat spondyloarthritis has generated interest in determining if these medications can prevent uveitis flares, and whether effectiveness differs among anti-TNF medications.
This observational study compared rates of uveitis episodes (calculated per 100 patient-years) before and after the start of treatment with etanercept or anti-TNF antibodies (infliximab or adalimumab). The study was limited to patients with spondyloarthritis who had at least one uveitis episode (although the episode may have occurred after the start of treatment), who were starting their first course of anti-TNF medication, and who had observation on treatment for at least one week. The mean length of observation on treatment was 1.2 years. The study was retrospective; all episodes of uveitis occurred and treatment was started before the study began. The number of uveitis episodes per patient, extending back to illness onset, was determined from clinical records and patient report.
The 13 patients treated with etanercept had similar rates of uveitis episodes before treatment and after the start of treatment. (See Table 1) For the 25 patients treated with infliximab and eight patients treated with adalimumab, the rate was substantially lower after the start of treatment. The number of uveitis flares per patient before treatment was higher among those treated with anti-TNF antibodies than those treated with etanercept, but the length of observation before treatment was also longer in the anti-TNF antibody group.
