52
with underlying IBD [ 26 – 31 ]. Infliximab seems to be more effective than etaner-
cept, and adalimumab may be more effective than etanercept as well.
In a 2005 study, data from 4 placebo-controlled trials and 3 open-label studies of
patients with AS being treated with infliximab or etanercept were analyzed to assess
outcomes of patients with concomitant anterior uveitis. Follow-up data on 397
patients demonstrated that patients treated with ant-TNF agents had 6.8 uveitis
flares per 100 patient-years vs 15.6 in the placebo group. Flares were less frequent
in those treated with infliximab than etanercept, although this finding was not statis-
tically significant [ 27 ].
Similarly, a retrospective study of 17 children with chronic uveitis treated with
high dose infliximab (10–20 mg/kg at varying intervals) showed a favorable
response to the anti-TNF: 13 children had complete resolution of intra-ocular
inflammation within 1–2 weeks of their first for second infusion, and the other 4
had resolution of symptoms after up to 7 infusions [ 28 ]. Another retrospective
study of childhood uveitis (from conditions other than known IBD) in 21 patients
with active recalcitrant uveitis also showed favorable though more limited
responses to both etanercept and infliximab. Thirty-eight percent of those treated
with infliximab had a “good” response, defined by a 50% or greater reduction in
corticosteroid and immunosuppressive use, while 54% had a moderate response
in which either the corticosteroid or immunosuppressive was reduced by ≥ 50
[ 29 ]. Those treated with infliximab had a trend towards fewer complications and
a higher rate of improvement of glaucoma and visual acuity than those treated
with etanercept [ 29 ].
The data for adalimumab are more limited than for infliximab. A retrospective
study of 18 children with chronic uveitis treated with adalimumab after failing other
immunosuppressive therapies showed an 88% percent response rate as measured by
the frequency of relapse. As in the other studies, most of these children had juvenile
idiopathic arthritis, and none had IBD [ 26 ].
Although most of the available evidence for anti-TNF treatment of uveitis is
from studies of uveitis unrelated to IBD, the data can certainly be extrapolated to
uveitis associated with IBD and some smaller studies do show a benefit in this popu-
lation. The decision to use an anti-TNF for refractory uveitis, however, should
always be made in conjunction with an ophthalmologist.
Pyoderma Gangrenosum
Pyoderma gangrenosum (PG) is a rare chronic cutaneous ulcerating skin condition
that is sometimes associated with pathergy [ 32 ]. The use of anti-TNFs for this EIM
of IBD has not been widely studied; however, the quality of the data is among the
most robust for EIM and clearly demonstrates a benefit.
In one of the few placebo-controlled randomized trials examining the use of anti-
TNF therapy for the treatment of EIMs, infliximab was given to 13 patients with PG
at 5 mg/kg as a single dose. Effectiveness compared to 17 placebo controls was
D.I. Fudman and S.N. Flier