Uveitis screening recommendations for JIA need to consider DMARD use
Uveitis is the most common extra-articular condition of juvenile idiopathic arthritis (JIA). Investigators evaluated the association between patient characteristics, medication usage, and incidence of new uveitis cases in patients with JIA.
This was a retrospective clinical cohort study of 382 consecutive pediatric patients diagnosed with JIA who were seen during an 8-year time period and had ≥18 months of follow-up. Class of JIA (e.g., oligoarthritis, polyarthritis), uveitis status, and medication use were assessed.
Patients on etanercept or methotrexate had the same incidence of new-onset uveitis as patients who were not on any disease-modifying antirheumatic drug (DMARD). There were no new cases of uveitis in patients on adalimumab or other biologic medication. Empirically determined criteria, including younger age at JIA diagnosis, shorter duration of JIA, and no use of adalimumab or other biologics, showed increased predictive power of uveitis development compared with current American College of Rheumatology (ACR) risk stratification guidelines.
A limitation of the study is that it was a retrospective chart review that had comparable numbers of patients on methotrexate, etanercept, and adalimumab, but many fewer patients were included together in the “other biologics” treatment group. Also, there were significant differences between some of the medication groups, including age at JIA diagnosis and JIA class.
Current ACR screening guidelines do not take into account the use of DMARD. With the increased use of biologics such as adalimumab, risk stratification and screening guidelines for uveitis should be reconsidered. Importantly, in this study patients taking etanercept and/or methotrexate did not have a lower rate of uveitis compared with patients not taking DMARDs. The alternative screening criteria used by the authors, which did take into account the use of DMARDs, was better at predicting who was most at risk for developing uveitis than the 2019 published ACR screening guidelines. A larger multicenter trial is needed to reevaluate screening guidelines that consider DMARD use. This is particularly relevant in light of workforce challenges in pediatric ophthalmology; i.e., if risk can be more easily stratified, clinicians may not need to see some children with JIA as frequently as the ACR guidelines recommend.
Financial Disclosures: Dr. Laura Enyedi discloses financial relationships with Cooper Vision, Nevakar, Novartis, Tarsus Pharmaceuticals (Consultant/Advisor).