特定葡萄膜炎, 建議直接使用最強的標靶藥

林口長庚醫學中心 眼科部 視網膜與葡萄膜炎主任 黃奕修

美國葡萄膜炎學會(AUS)建議, 某些特別嚴重的葡萄膜炎, 應跳過傳統用藥, 直接使用生物製劑類藥物 (如 adalimumab, 或 infliximab), 文獻發表於12/18出版的眼科學期刊 (Ophthalmology)
這篇研究來自於AUS成立了一執行委員會, 針對此議題進行系統性研究後所得到的結論
這個建議很重要的提醒了保險給付單位, 應考慮給這些特別病症的病人, 給付以生物製劑做為第一線用藥的治療方法.

這個建議的詳細內容如下:
1. 對於Behcet’s disease的病人, 如果出現危及視力的症狀時, 應即早使用adalimumab 或 infliximab (建議強度:強)
2. 對於少年原發性關節炎(JIA) 所致的小兒葡萄膜炎, 當methotrexate失效時, 即應使用adalimumab或infliximab作為二線用藥 (建議強度:強)
3. 對於僵直性脊椎炎類的慢性葡萄膜炎, 如果出現危及視力的症狀時, 應即早使用adalimumab 或 infliximab (建議強度:強)
4. 對於已有類固醇依賴性的慢性葡萄膜炎病患,如果出現危及視力的症狀, 同時第一線用藥已失敗時, 應即早使用adalimumab 或 infliximab (建議強度:最強)
5. 對於使用恩博病患 (Etanercept)治療葡萄膜炎, 或因而出現葡萄膜炎患者, 應考慮及早轉換至adalimumab或infliximab. 或是當決定初次投予anti-TNF製劑用於葡萄膜炎患者於, 應優先考慮使用adalimumab或infliximab.(建議強度:強)

AUS歷時二年, 整體研究了至少400篇文獻研究,方得到以上的結論

德國眼科醫學會與歐洲免疫學會之前也提出了類似的結論 

原文 如下: 

Consider infliximab or adalimumab early in the management of patients with vision-threatening ocular manifestations of Behçet’s disease, a multisystem disorder. (Strong recommendation)

Consider infliximab or adalimumab as second-line therapy for children with vision-threatening uveitis secondary to juvenile idiopathic arthritis (JIA) when methotrexate therapy is ineffective or not tolerated. If tolerated, however, methotrexate therapy can be combined with infliximab. (Strong recommendation)

Consider infliximab or “potentially” adalimumab as second-line therapy for patients with vision-threatening chronic uveitis from seronegative spondyloarthropathy. (Strong recommendation)

Consider infliximab or adalimumab for patients with vision-threatening corticosteroid-dependent disease whose first-line therapy failed. (Discretionary recommendation)

Consider infliximab or adalimumab before etanercept for treatment of ocular inflammatory disease. Consider switching patients currently taking etanercept to infliximab or adalimumab. (Strong recommendation)

“This was a long process, taking over 2 years from start to finish,” Dr. Van Gelder noted. “The field is moving quickly, and each time we revised, there were more important studies to add to this review.”

The German Ophthalmological Society and the European League Against Rheumatism have made similar recommendations previously, but this is the first set of such recommendations for the United States.

Reflection of Current Practice

“I think the data pretty much reflect my experience,” Wendy M. Smith, MD, assistant professor of ophthalmology and a uveitis expert at the Mayo Clinic in Rochester, Minnesota, told Medscape Medical News. “I work with rheumatologists to prescribe these medications for my patients. Hopefully it will be easier to get these medications approved by insurance companies.”

She is proactive in getting her patients’ medicines covered by insurance companies. “I usually write a letter, and I review the existing literature, and probably 8 or 9 times out of 10, I’m able to get it approved, but we usually have to appeal once or twice. Hopefully, this paper will help. I certainly will be including this paper among the papers that I cite, probably top on the list, although many of the conditions I treat are not yet among the strong recommendations.”

However, especially for Behçet’s disease and JIA, the recommendations “will probably move people toward using these medications even faster. In particular, in JIA, already clinicians move quickly to the TNF inhibitors. I hope what it will do eventually for us clinically is more of us will do studies on those other conditions of uveitis where we don’t have good data. This is a very good starting point, and it’s a great paper summarizing the existing literature and also showing us where we still need to do more work.”

Ophthalmology. Published online December 18, 2013. Abstract

以上部份文章節錄自Medscape

更多眼科資訊, 請見: 
www.uveitis.tw葡萄膜炎虹彩炎資訊網
www.dmeye.org糖尿病眼病變資訊網
www.dreye.net醫師的眼科醫師-眼科高端醫療資訊網
www.retina.tw黃奕修醫師-視網膜病變資訊網