The following therapies are used with low dose steroids or when the patient has been taken off steroids altogether. High dose steroid is nearly always used initially when there is a need to quell inflammation rapidly. It also provides time for other, additional agents to become effective. Once other drugs are controlling inflammation, it becomes possible to lower the dose of steroid and often to stop it altogether.
Patients who take any of the following drugs are monitored closely for side effects through regular checks of blood pressure, weight, blood and urine. These checks may occur as frequently as once a week when therapy begins and doses are being increased, but once results are stable at the therapeutic dose, checks may be extended to every three months.
Children tend to be monitored more closely, and might need blood and urine checks every two to six weeks throughout their treatment.
Below we discuss:
- Antimetabolite Drugs (Immunosuppressants)
- T-cell Inhibitors/ Calcineurin Inhibitors
- Alkylating Agents
This is an immunosuppressant with an anti-inflammatory effect. It is taken as tablets or by injection once a week. It is common for the Methotrexate dose to be built up during the initial months of therapy and it can take about three months before the treatment has an effect on uveitic activity. Folic acid is also prescribed to reduce the side effects. Some clinics instruct patients to take their folic acid every day except Methotrexate day; others prescribe the folic acid to be taken less frequently. Side effects can include nausea, but this should lessen over time. Anti emetics such as Ondansetron (Zofran) can be prescribed to adults and children suffering with nausea.
Information about Methotrexate can be found here:
This is an immunosuppressant and is taken daily as tablets. An effect on uveitic activity may take six to twelve weeks. This immunosuppressant is not suitable for all uveitis patients and a blood test before beginning treatment identifies those patients for whom this is so.
Information about Azathioprine can be found here:
Mycophenolate Mofetil (Cellcept)
This is an immunosuppressant and is taken as tablets twice daily. It may take three to four months to have an effect on uveitis. It is not usually prescribed as a first antimetabolite drug, but it is used as a treatment of choice for certain types of uveitis, such as Birdshot, where its efficacy has been demonstrated well. If a patient’s uveitis does not respond adequately to Methotrexate, then Mycophenolate mofetil is an alternative treatment that may be considered.
Information about Mycophenolate mofetil can be found here:
These may be effective as single drug therapy, but most patients will stubborn uveitis require combination therapy with an antimetabolite from the group above and low dose steroid.
Ciclosporin is an immunosuppressant which is taken as tablets twice a day. Patients are advised to avoid grapefruit and grapefruit juice since these increase the effect of ciclosporin in the body. Like the preceding drugs, when a dose is being built up, an effect may not be seen for three months, although it’s not uncommon for adults and children to gain a reaction much faster.
Ciclosporin is often used in combination with Methotrexate or with Mycophenolate mofetil. Ciclosporin may affect blood pressure and cholesterol, so these are closely monitored. Many patients experience a tingling sensation in their hands and feet, but this side effect tends to abate within the first month or so. Women may be troubled by excess hair growth.
Information about Ciclosporin can be found here:
This drug is similar in action to Ciclosporin and is sometimes prescribed when a patient is unable to tolerate the side effects of Ciclosporin, or Ciclosporin therapy has failed. It is taken as tablets twice a day. Again blood pressure and blood test results are closely monitored.
Information about Tacrolimus can be found here:
UK patients took part in worldwide trials of this new drug, which is similar to Ciclosporin in its action and has reportedly fewer side effects. It may be available for use in the UK in late 2011. Currently, the US Federal government has not approved it and has requested further clinical trials.
Information about the drug and its history can be found here:
This drug is used in very severe cases, which are resistant to other treatments. It is given through intravenous infusion or taken as tablets. Intravenous infusion is considered safer than tablets and supplementary medicine is given to reduce the risk of bladder cancer in the years to follow. When this treatment is used, it is used for as short a time as possible. It affects fertility and its use with younger patients is avoided as much as possible. In some types of uveitis, the systemic disease needs to be treated with this agent as much as the eyes do.
Information about cyclophosphamide is found here:
See the next section on Biological Agents >>