Uveitis

Prescribing Notes:

• Antimuscarinics dilate the pupil (mydriasis) and paralyse the ciliary muscle (cycloplegia). They are used in the treatment of anterior uveitis.
• Atropine is the most potent and has the longest duration of action (7 days or more).
• Cyclopentolate is less potent and of shorter duration (up to 24 hours).
• Phenylephrine may be used to supplement the mydriatic effect of these.
• Contact dermatitis may occur relatively frequently if atropine is used long term.
• Phenylephrine is used as a mydriatic prior to ophthalmic procedures. Its effect lasts up to seven hours.
• Toxic systemic reactions to atropine and cyclopentolate in the very young and very old are possible.
• Patients should be warned not to drive for several hours after mydriasis.

Prescribing Notes:

• The first line treatment of anterior uveitis is corticosteroid drops – see the ‘Treatment with corticosteroids’ pathway within Inflammatory eye conditions page.
• A minority of patients require systemic therapy for sight threatening disease. Treatment of sight threatening disease is managed by an ophthalmologist experienced in the management of uveitis. For more information refer to Scottish Uveitis Network guidelines.
• Systemic corticosteroids may be used for management of sight threatening disease, immunosuppressive therapies are used for their steroid sparing effect or to induce remission of disease. For more information on use of systemic corticosteroids refer to Scottish Uveitis Network guidelines. For formulary choices of corticosteroids refer to formulary recommendations for treatment with corticosteroids.
• There is limited evidence of comparative efficacy to choose between conventional non-biologic steroid sparing agents. Locally preferred options include mycofenolate mofetil, mycophenolic acid or tacrolimus in preference to other alternative options due to the favourable tolerability and side-effect profiles. Mycofenolate mofetil, mycophenolic acid or tacrolimus are appropriate for shared care, refer to local board policies.
• Mycophenolic acid 720mg is approximately equivalent to mycophenolate mofetil 1g but the two should not be considered interchangeable.
• Adalimumab is recommended as an option for treating non-infectious uveitis in the posterior segment of the eye in adults with inadequate response to corticosteroids, only if there is:

• • active disease (that is, current inflammation in the eye) and
  • inadequate response or intolerance to immunosuppressants and
  • systemic disease or both eyes are affected (or 1 eye is affected if the second eye has poor visual acuity) and
  • worsening vision with a high risk of blindness (for example, risk of blindness that is similar to that seen in people with macular oedema).

• For intravitreal steroid implants see the ‘Treatment with corticosteroids’ pathway within Inflammatory eye conditions page.

Prescribing Notes:

See also the child ‘Treatment with corticosteroids’ pathway within Inflammatory eye conditions page.”

Prescribing Notes:

• Antimuscarinics dilate the pupil (mydriasis) and paralyse the ciliary muscle (cycloplegia). They are used in the treatment of anterior uveitis. 
• Atropine is the most potent and has the longest duration of action (7 days or more).
• Cyclopentolate is less potent and of shorter duration (up to 24 hours).
• Contact dermatitis may occur relatively frequently if atropine is used long term
• Toxic systemic reactions to atropine and cyclopentolate in the very young and very old are possible.
• Patients should be warned not to drive or cycle for several hours after mydriasis. 

Prescribing Notes:

• The majority of paediatric patients presenting with uveitis require systemic therapy for sight threatening disease. Treatment of sight threatening disease is managed by an ophthalmologist experienced in the management of uveitis. 
• Paediatric uveitis is managed jointly between specialist paediatric rheumatology teams and ophthalmologists experienced in the management of the condition, use is in line with relevant local or national guidance.
• Systemic corticosteroids may be used for management of sight threatening disease; immunosuppressive therapies are used for their steroid sparing effect or to induce remission of disease. For formulary choices of corticosteroids refer to formulary recommendations for treatment with corticosteroids. 
• There is limited evidence of comparative efficacy to choose between conventional non-biologic steroid sparing agents. 
• Risks/benefits of disease modifying antirheumatic drugs (DMARDs) should be discussed with patients before commencing using a written information sheet available from Versus Arthritis. 
• DMARDs are appropriate for shared care arrangements to facilitate the seamless transfer of individual patient care from secondary care to general practice. 
• The MHRA has received reports of prescription and dispensing errors for methotrexate that have resulted in serious and fatal adverse reactions. Methotrexate tablets should be prescribed in 2.5mg strength only. The 10mg strength should not be used since they may be confused with the 2.5mg tablets.
• The use of oral methotrexate for non-malignant conditions such as rheumatoid arthritis has been highlighted nationally as a potential risk for fatal medication errors. New measures have been implemented to prompt healthcare professionals to record the day of the week for intake and to remind patients of the dosing schedule and the risks of overdose due to continued reports of inadvertent overdose. For further advice, see MHRA Drug Safety Update September 2020. 
• Patients who have a partial response to or intolerance of oral methotrexate may be switched to subcutaneous methotrexate under the guidance of a rheumatologist. 
• Subcutaneous methotrexate should only be given by individuals trained to administer methotrexate competently. 
• Methotrexate is the first choice in the majority of rheumatic diseases, but in certain conditions other agents may be preferred first e.g. lupus.
• Providing monitoring procedure is followed, NSAIDs may be prescribed with methotrexate. However, the need for NSAID therapy should be reviewed once methotrexate becomes effective. 
• Calcium folinate (folinic acid) 15mg orally or by injection may be an alternative for children who are unwilling to take folic acid due to gastro-intestinal intolerance or its unpalatability. 
• All children must be adequately monitored. Refer to SPARN guidelines/BNFc/SPC for full details for the medication in question.
• Adalimumab is recommended as an option for treating non-infectious uveitis in the posterior segment of the eye in those with inadequate response to corticosteroids, only if there is:
  • active disease (that is, current inflammation in the eye) and
  • inadequate response or intolerance to immunosuppressants and
  • systemic disease or both eyes are affected (or 1 eye if affected if the second eye has poor visual acuity) and
  • worsening vision with a high risk of blindness (for example, risk of blindness that is similar to that seen in people with macular oedema).