Immunomodulatory therapy is often the go-to for non-infectious uveitis, but in light of COVID-19, some are concerned about this treatment option and the increased risk of infections. Looking into this association, an international group of uveitis experts recommend not initiating systemic corticosteroids or immunosuppression as part of non-infectious uveitis treatment in sick patients with suspected or confirmed COVID-19, irrespective of the risk group.
The investigation, published in the British Journal of Ophthalmology, also found among sick patients receiving high-dose corticosteroids, the consensus was to taper the dose in all risk groups and to taper even low-dose corticosteroid in high-risk and very high-risk patients. The group also recommended tapering oral corticosteroids instead of an abrupt cessation due the risk of adrenal insufficiency.
The study suggests systemic corticosteroids might be harmful, given their mechanism of action that inhibits immune responses and affects the pathogen clearance. Instead, local therapy appears to be a better option since it targets the site of inflammation with high concentrations of the drug and may be as effective as systemic therapy while reducing systemic exposure. This allows at least temporary control of the sight-threatening complications of uveitis and delays initiation of second-line immunosuppression until further research on the impact of immunosuppressive agents in patients with COVID-19 is available, the researchers noted.
Using an interactive online questionnaire, the study polled 139 global uveitis experts on when to initiate, continue, decrease and stop systemic and local corticosteroids, conventional immunosuppressive agents and biologics in patients with non-infectious uveitis. The survey also considered the use of non-steroidal anti-inflammatory drugs (NSAIDs) and hydroxychloroquine.
The highest consensus among the experts was not to initiate immunomodulatory therapy in patients who have suspected or confirmed COVID-19, in addition to using local over systemic corticosteroid therapy in patients who are at high-risk and very high-risk for severe or fatal COVID-19. While there was a consensus in starting or initiating NSAIDs for the treatment of scleritis in healthy patients, there was no consensus in starting hydroxychloroquine in any risk groups.
“Importantly, with the unprecedented and dynamic nature of the COVID-19 pandemic, our understanding of the SARS-CoV-2 virus and the epidemiology of COVID-19 are rapidly evolving,” the researchers wrote in their paper. “Consensus options may change as we learn more about the virus and the effects of immunosuppression on the outcomes of patients with NIU [non-infectious uveitis] and they should be revisited regularly.”
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Agrawal R, Testi I, Lee CS, et al. Evolving consensus for immunomodulatory therapy in non-infectious uveitis during the COVID-19 pandemic. Br J Ophthalmol. June 25, 2020. [Epub ahead of print].