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Published Online, 9 March 2004, www.theannals.com, DOI 10.1345/aph.1D361.
 The Annals of Pharmacotherapy: Vol. 38, No. 5, pp. 901-902. DOI 10.1345/aph.1D361
© 2004 Harvey Whitney Books Company.
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Effect of infliximab on refractory uveitis in Behçet's disease

Mehmet Sayarlioglu, MD

Assistant Professor Chief of Rheumatology Division of Rheumatology Department of Internal Medicine Medical Faculty Yüzüncü Y{iota}l University Arast{iota}rma Hastanesi Íc Hastaliklari A.D., Romatoloji B.D. 65200 Van, Turkey fax 90 432 2155051 sayarli{at}hotmail.com

Adnan Cinal, MD

Associate Professor Department of Ophthalmology Medical Faculty Yüzüncü Y{iota}l University

Nazan Topcu, MD

Resident Department of Internal Medicine Medical Faculty Yüzüncü Y{iota}l University

Ahmet Demirok, MD

Associate Professor Department of Ophthalmology Medical Faculty Yüzüncü Y{iota}l University

Published Online, March 9, 2004. www.theannals.com, DOI 10.1345/aph.1D361

TO THE EDITOR: Behçet's disease (BD) is a chronic, relapsing, and multisystemic inflammatory disorder. Ocular involvement is a common and serious component of BD.1 Blood levels of circulating tumor-necrosis factor (TNF) and soluble TNF receptors are increased in patients with active disease.2 We report successful treatment with anti–TNF-{alpha} chimeric monoclonal antibody (infliximab) in a patient with BD who had a severe ocular involvement refractory to other immunosuppressive agents.

Case Report. A 33-year-old Turkish man presenting with recurrent oral aphthous ulcers, erythema nodosum, superficial thrombophlebitis, and positive skin pathergy test had been diagnosed with BD 9 years previously. He had frequent attacks of panuveitis refractory to intensive immunosuppressive treatment for the last 8 years. Treatment with subconjunctival corticosteroid injections, systemic corticosteroids, cyclophosphamide, azathioprine, and cyclosporine had been tried several times for both relapses and maintenance of remission. However, clinical response had been incomplete and partial loss of vision had occurred.

A new relapse of bilateral posterior uveitis occurred in April 2002 while the patient was taking prednisolone 7.5 mg/day and azathioprine 2.5 mg/kg/day. He was treated with prednisolone 1.5 mg/kg/day, azathioprine 2.5 mg/kg/day, and cyclosporine 5 mg/kg/day. With clinical improvement, prednisolone was tapered to 10 mg/day within 2 months. Left posterior uveitis relapsed at the end of the third month of this treatment, and prednisolone was increased to 1 mg/kg/day. Cyclosporine was discontinued, and infliximab 5 mg/kg was started on the seventh day of relapse. Second and third doses were given at the second and sixth weeks. After the first infliximab infusion, obvious symptomatic improvement was noted within 24 hours. However, the improvement of the posterior uveitis and visual acuity could not be assessed properly due to bilateral cataract induced by long-term use of corticosteroids. A complete remission with all signs and symptoms resolving was achieved after the second infusion.

After the third infusion, maintenance treatment with infliximab infused at 8-week intervals was scheduled. However, because of the development of mild floaters (an early sign of acute uveitis attack) one week before the fourth and fifth infusions of infliximab, intervals were lowered to 6 weeks. Floaters and the other symptoms of BD completely resolved after the new schedule of infliximab infusion. After this treatment, he did not experience relapses during the next 8 months (5 infusions with 6-wk intervals). We were able to lower the dose of prednisolone to 5 mg/day and maintain the same azathioprine dose (2.5 mg/kg/day). Infliximab treatment was well tolerated and no adverse effects were observed. A cataract operation was planned at the end of the eighth month. We planned to increase the intervals of infliximab infusions gradually according to clinical course.

Discussion. Infliximab treatment was found to be effective for sight-threatening uveitis refractory to multiple high-dose immunosuppressive therapies, as reported in the literature.3-5 In the present case, infliximab, infused at 8-week intervals, could not maintain remission, which necessitated infusions at 6-week intervals. We experienced a longer duration of treatment compared with previous reports. Combined therapy with infliximab and azathioprine was found to be both feasible and effective.

References

  1. Kaklamani VG, Vaiopoulos G, Kaklamanis PG. Behcet's disease.Semin Arthritis Rheum 1998;27:197-217.[CrossRef][Medline]
  2. Turan B, Gallati H, Erdi H, Gurler A, Michel BA, Villiger PM. Systemic levels of the T cell regulatory cytokines IL-10 and IL-12 in Behcet's disease; soluble TNFR-75 as a biological marker of disease activity. J Rheumatol 1997;24:128-32.[Medline]
  3. Sfikakis PP, Theodossiadis PG, Katsiari CG, Kaklamanis P, Markomichelakis NN. Effect of infliximab on sight-threatening panuveitis in Behcet's disease. Lancet 2001;358:295-6.[CrossRef][Medline]
  4. Joseph A, Raj D, Dua HS, Powell PT, Lanyon PC, Powell RJ. Infliximab in the treatment of refractory posterior uveitis.Ophthalmology 2003;110:1449-53.[CrossRef][Medline]
  5. Muñoz-Fernandez S, Hidalgo V, Fernandez-Melon J, Schlincker A, Martin-Mola E. Effect of infliximab on threatening panuveitis in Behcet's disease (letter). Lancet 2001;358:1644.



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