Noninfectious Uveitis: Immunomodulatory Agents and Biologicals

Abstract

While corticosteroids are the typical first-line systemic medication used for immediate control of noninfectious uveitis, chronic or frequently recurrent disease, significant side effects related to corticosteroids, or intolerability warrant advancement of therapy to immunomodulatory therapy, including the broad classes of antimetabolites, calcineurin inhibitors (T-cell inhibitors), alkylating agents, and, more recently, biologics. While antimetabolites, calcineurin inhibitors, and alkylating agents have a long history of use in the setting of noninfectious uveitis, in the United States, they have all been used off-label. The only US Food and Drug Administration (FDA)-approved therapy for noninfectious uveitis (intermediate, posterior, or panuveitis) outside of corticosteroids is a biologic, adalimumab. Nevertheless, antimetabolites are most frequently used for corticosteroid-sparing control of uveitis. While calcineurin inhibitors and alkylating agents are still used, some agents, in particular, the alkylating agents, are reserved for extremely aggressive and sight-threatening ocular inflammatory diseases. The advent of biologics with targets for specific inflammatory pathway molecules signals a new era in managing uveitis more precisely.