Methotrexate and Chronic Uveitis Associated with Juvenile Idiopathic Arthritis

[Guest guest]

The following appeared as a letter to the editor; comments regarding an

article published recently in the Journal of Rheumatology. Below it, a

response from the author(s) of the study - Georgina

Methotrexate and Chronic Uveitis Associated with Juvenile Idiopathic

Arthritis

http://www.jrheum.com/subscribers/06/01/198-a.html

To the Editor:

We read with interest the article by Dr. Foeldvari and colleagues1 about the

efficacy of methotrexate (MTX) in the management of chronic uveitis in

patients with juvenile idiopathic arthritis. It is to our understanding that

ophthalmic data were derived from a review of the patients' charts. The

authors have solicited a thorough pool of information, but 2 areas of

important information seem to be overlooked.

First, the standard treatment for chronic bilateral anterior uveitis usually

comprises topical corticosteroids and mydriatics, followed by

immunosuppressive agents in severe cases, and surgical intervention in the

event of ophthalmic complications2. It is important to note that even with

the commencement of systemic immunosuppressive agents, concomitant topical

corticosteroids are usually retained, with frequency of topical application

adjusted with observation of anterior chamber inflammation2. In the study in

question, information on topical corticosteroid regimens during concurrent

MTX therapy was largely lacking. The authors reported a good treatment

response with MTX and attributed treatment remission solely to MTX, while

disregarding the antiinflammatory therapeutic benefit of concomitant topical

corticosteroid. This will undoubtedly incur significant bias and confounding

influence.

Second, MTX is an immunosuppressive agent not without adverse reactions3.

For instance, it was found that as many as 20% of the pediatric patients

taking regular MTX developed distressing side effects like nausea3. Hence,

inquiries into the potential untoward side effects and the associated

precautionary measures for early detection of drug toxicity are almost

mandatory in patients taking regular methotrexate3. These important pieces

of information were, however, not clearly stated in the article.

ALICE Y.K. CHAN, MRCP, FHKAM(Rheumatology), Social Hygiene Service,

Department of Health, Hong Kong; DAVID T.L. LIU, MRCS, Department of

Ophthalmology and Visual Sciences, Prince of Wales Hospital, Shatin, Hong

Kong, People's Republic of China. Address reprint requests to Dr. Liu.

E-mail: david_tlliu@...

1. Foeldvari I, Wierk A. Methotrexate is an effective treatment for chronic

uveitis associated with juvenile idiopathic arthritis. J Rheumatol

2005;32:362-5.

2. Kotaniemi K, Savolainen A, Karma A, Aho K. Recent advances in uveitis of

juvenile idiopathic arthritis. Surv Ophthalmol 2003;48:489-502.

3. Malik AR, Pavesio C. The use of low dose methotrexate in children with

chronic anterior and intermediate uveitis. Br J Ophthalmol 2005;89:806-8.

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Methotrexate and Chronic Uveitis Associated with Juvenile Idiopathic

Arthritis Dr. Foeldvari and Ms Wierk reply

To the Editor:

We read with interest the comments from Dr. Chan and Dr. Liu. In response to

their questions: all patients in our cohort were treated before the start of

MTX with topical steroids, and some received topical steroids when MTX was

initiated and if a flare occurred during the MTX treatment. The current

treatment concept, as suggested1, is that higher doses of topical steroid

treatment over 3 months should be avoided because of the known longterm side

effects, such as cataracts and increased intraocular pressure. Need for

surgery of the eye should be reduced with the immunosuppressive treatment,

because surgery, while it temporarily corrects the damage of inflammation,

does not control the inflammation. MTX treatment prevents the threat of

inflammation in the eyes. Some patients even need the addition of a tumor

necrosis factor-a inhibitor, as did some patients in our study. We defined

remission as being achieved if we managed to reduce the topical steroid

treatment to less than one drop per day.

Regarding the concerns about MTX as an immunosuppressive agent, we can say

that the longterm side effects of MTX in the treatment of JIA or

JIA-associated uveitis are insignificant, and current studies suggest a

decrease in the frequency of laboratory monitoring2. Chan and Liu are

correct that nausea is a common side effect of MTX treatment, but in many

patients, as in our study population, the switch to parenteral MTX

application resolved this problem. In some patients the gastrointestinal

side effects were the reason patients were switched from MTX to leflunomide,

as mentioned in our report.

All patients received regular monitoring of laboratory values, according to

the German treatment guidelines for MTX in the treatment of JIA3. They did

not experience any serious laboratory side effects. We should point out that

all patients received folic acid supplement 2.5 mg every 3 days.

IVAN FOELDVARI, MD; ANGELA WIERK, Study Nurse, Pediatric Rheumatologic

Clinic, Allgemeinen Krankenhaus Eilbek, Friedrichsberger Strasse 60, D-22081

Hamburg, Germany.

1. Samson CM, Waheed N, Baltatzis S, CS. Methotrexate therapy for

chronic noninfectious uveitis: analysis of a case series of 160 patients.

Ophthalmology 2001;108:1134-9.

2. Ortiz-Alvarez O, Morishita K, Avery G, et al. Guidelines for blood test

monitoring of methotrexate toxicity in juvenile idiopathic arthritis. J

Rheumatol 2004;31:2501-6.

3. Niehues T, Horneff G, Michels H, Sailer-Höck M, Schuchmann L.

Evidenzbasierter Einsatz von Methotrexat bei Kindern mit rheumatischen

Erkrankungen. Monatsch Kinderheilkd 2003;151:881-90.