Department of Ophthalmology, Guideline of the German Ophthalmological Society (DOG), St. Franziskus Hospital, Hohenzollernring 74, 48145 Muenster, Germany.
The Society for Paediatric Rheumatology (GKJR), Germany.
Semin Arthritis Rheum. 2019 Aug;49(1):43-55. doi: 10.1016/j.semarthrit.2018.11.004. Epub 2018 Dec 4.
Uveitis in juvenile idiopathic arthritis (JIAU) is frequently associated with the development of complications and visual loss. Topical corticosteroids are the first line therapy, and disease modifying anti-rheumatic drugs (DMARDs) are commonly used. However, treatment has not been standardized.
Interdisciplinary guideline were developed with representatives from the German Ophthalmological Society, Society for Paediatric Rheumatology, Professional Association of Ophthalmologists, German Society for Rheumatology, parents' group, moderated by the Association of the Scientific Medical Societies in Germany. A systematic literature analysis in MEDLINE was performed, evidence and recommendations were graded, an algorithm for anti-inflammatory treatment and final statements were discussed in a consensus meeting (Nominal Group Technique), a preliminary draft was fine-tuned and discussed thereafter by all participants (Delphi procedure).
Consensus was reached on recommendations, including a standardized treatment strategy according to uveitis severity in the individual patient. Thus, methotrexate shall be introduced for uveitis not responding to low-dose (≤ 2 applications/day) topical corticosteroids, and a TNFalpha antibody (preferably adalimumab) used, if uveitis inactivity is not achieved. In very severe active uveitis with uveitis-related deterioration of vision, systemic corticosteroids should be considered for bridging until DMARDs take effect. If TNFalpha antibodies fail to take effect or lose effect, another biological should be selected (tocilizumab, abatacept or rituximab). De-escalation of DMARDs should be preceded by a period of ≥ 2 years of uveitis inactivity.
An interdisciplinary, evidence-based treatment guideline for JIAU is presented.
幼年特发性关节炎（JIAU）相关葡萄膜炎常伴有并发症和视力丧失。局部皮质类固醇是一线治疗药物，疾病修饰抗风湿药物（DMARDs）也常用。然而，治疗尚未标准化。
德国眼科协会、儿科风湿病学会、眼科医生专业协会、德国风湿病学会、家长团体的代表参与制定了多学科指南，由德国科学医学协会联合会进行协调。在 MEDLINE 上进行了系统的文献分析，对证据和建议进行了分级，并在共识会议（名义群体技术）中讨论了抗炎治疗算法和最终陈述，初步草案随后由所有参与者（德尔菲程序）进行微调并讨论。
就建议达成了共识，包括根据个体患者葡萄膜炎的严重程度制定标准化治疗策略。因此，如果低剂量（≤2 次/天）局部皮质类固醇治疗无效，应引入甲氨蝶呤治疗葡萄膜炎；如果无法实现葡萄膜炎无活动，应使用 TNFα 抗体（首选阿达木单抗）。对于非常严重的活动性葡萄膜炎，伴有与葡萄膜炎相关的视力下降，应考虑在 DMARDs 起效前使用全身皮质类固醇进行桥接。如果 TNFα 抗体无效或失效，应选择另一种生物制剂（托珠单抗、阿巴西普或利妥昔单抗）。DMARDs 的降级应在葡萄膜炎无活动期≥2 年后进行。
提出了一种针对 JIAU 的多学科、基于证据的治疗指南。
