Original article
Relapse Rate of Uveitis Post-Methotrexate Treatment in Juvenile Idiopathic Arthritis

https://doi.org/10.1016/j.ajo.2010.08.021Get rights and content

Purpose

To evaluate the efficacy of methotrexate (MTX) and the effect of its withdrawal on relapse rate of uveitis associated with juvenile idiopathic arthritis (JIA).

Design

Retrospective case series.

Methods

Data of 22 pediatric JIA patients who were being treated with MTX for active uveitis were studied retrospectively. Relapse rate after the withdrawal of MTX was established. Anterior chamber (AC) inflammation, topical steroid use during the first year of MTX treatment, and associations of relapses after the withdrawal were evaluated statistically. Duration of MTX treatment and its withdrawal was determined individually in collaboration with a rheumatologist with an intention to continue the treatment for at least 1 year and to withdraw in case of inactivity of uveitis and arthritis. Inactivity of uveitis was defined as the presence of ≤0.5+ cells in the AC.

Results

Eighteen patients (18/22; 82%) showed improvement of their uveitis with a significant decrease in activity of AC inflammation after a minimal period of 3 months of MTX treatment. A topical steroid–sparing effect was observed when MTX was administered for a period of 3 to 9 months. MTX was discontinued because of inactive uveitis in 13 patients. In 9 patients (8/13; 69%) a relapse of uveitis was observed after a mean time of 7.5 months (± SD 7.3). Six patients (6/13; 46%) had a relapse within the first year after the withdrawal. Relapse-free survival after withdrawal of MTX was significantly longer in patients who had been treated with MTX for more than 3 years (P = .009), children who were older than 8 years at the moment of withdrawal (P = .003), and patients who had an inactivity of uveitis of longer than 2 years before withdrawal of MTX (P = .033). Longer inactivity under MTX therapy was independently protective for relapses after the withdrawal (hazard ratio = 0.07; 95% confidence interval 0.01-0.86; P = .038), which means that 1-year increase of duration of inactive uveitis before the withdrawal of MTX results in a decrease of hazard for new relapse of 93%.

Conclusions

A high number of patients with inactive uveitis relapse quickly after the withdrawal of MTX. Our results suggest that a longer period of inactivity prior to withdrawal and a longer treatment period with MTX reduce the chance of relapse after withdrawal.

Section snippets

Patients and Methods

Medical data of MTX-treated patients with JIA-associated uveitis attending a tertiary center for (pediatric) uveitis between 1989 and 2009 were studied retrospectively. JIA was diagnosed and classified by a pediatric rheumatologist in agreement with the International League of Associations for Rheumatology criteria.16 Diagnosis of uveitis was made by an ophthalmologist specialized in pediatric uveitis. The diagnostic criteria for uveitis were those defined by the International Uveitis Study

Results

Twenty-two patients with active uveitis at initiation of MTX were included in the study. General baseline characteristics of the study population are listed in Table 1.

Discussion

Our study demonstrates that the majority (69%) of patients with inactive uveitis at the moment of withdrawal of MTX develop a relapse at a later stage. Most of them had a relapse of uveitis within the first year after discontinuation of MTX therapy. The data also indicate that a longer period of inactivity of uveitis before withdrawal, together with older age and/or longer treatment with MTX, might protect against relapses of uveitis. Furthermore, our study confirms the earlier results about

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