Corticosteroids with C-DMARD lower risk of treatment failure in nonanterior sarcoidosis uveitis

Treatment with corticosteroid (CTC) plus conventional disease-modifying antirheumatic drug (C-DMARD) demonstrates an acceptable safety profile and appears to be more efficient than CTC alone in patients with nonanterior sarcoidosis-related uveitis, reports a study. 

"Use of CTC-DMARD treatment as first-line therapy is associated with a decreased risk of treatment failure and a greater corticosteroid-sparing effect,” the investigators said. “Prospective randomized studies are needed to validate these results.”

A total of 163 patients with nonanterior sarcoidosis-related uveitis were included in this multicentre, retrospective study. The investigators compared first-line therapy with systemic CTC alone (n=122) with CTC-DMARD (n=41). Treatment failure-free survival (TFFS), the primary outcome, was defined by the discontinuation of treatment for inefficiency or the occurrence of relapse.

At 12 months, TFFS was 0.83 (95 percent confidence interval [CI], 0.67–0.91) in the CTC-DMARD group and 0.65 (95 percent CI, 0.55–0.72) in the CTC group. [Ophthalmology 2025;132:1125-1133]

Multivariable analysis, adjusted on multifocal choroiditis and baseline dose of CTCs, revealed a significantly higher TFFS with CTC-DMARD than CTC alone (hazard ratio, 2.21, 95 percent CI, 1.18–4.14; p=0.01). In addition, a significant steroid-sparing effect was observed in the CTC-DMARD vs the CTC group at 3 and 6 months (p<0.05).

In terms of safety, at least one adverse event occurred in 14 patients (34 percent) in the CTC-DMARD group and in 50 patients (41 percent) in the CTC group.

CTC dependence

“In sarcoidosis-associated uveitis, C-DMARDs often are introduced in the context of relapses associated with tapering corticosteroid treatment, leading to high-dose corticosteroid dependence (>7.5–10 mg/day of prednisone equivalent),” the investigators said. [Graefes Arch Clin Exp Ophthalmol 2019;257:2495-2503]

In other studies, CTC-sparing therapy was used in 5 percent to 27 percent of patients. [Eye (Lond) 1999;13:748-753; Am J Ophthalmol 2019;198:30-36]

“In the present study, the use of first-line C-DMARDs was associated with a 2.2-fold reduction of treatment failure risk as compared with CTC therapy alone, pointing out the frequent CTC dependence in sarcoidosis-associated uveitis,” the investigators said.

Vision loss

The main cause of vision loss in about one in five (22.6 percent) patients with nonanterior sarcoidosis-related uveitis is cystoid macular edema (CME). A previous study has already shown the efficacy of C-DMARD in the control of CME. [Jpn J Ophthalmol 2022;66:447-454; Ophthalmology 2022;129:661-667]

“Interestingly, our study suggests the superiority of CTC-DMARD treatment over CTC treatment alone in the early control of CME, but lacks the power to demonstrate a difference,” the investigators said. “Nevertheless, the subgroup analysis regarding patients with CME at the onset of uveitis flare has revealed a significantly greater TFFS in C-DMARD-treated patients.”

Among those with CME at diagnosis, 66 percent of patients in the CTC-DMARD group and 52 percent of those in the CTC group had a decrease in CME at 3 months. However, CME persisted in 4.5 percent and 12.9 percent of patients, respectively, at 12 months.