Original article
Immunosuppressive Drug Discontinuation in Noninfectious Uveitis From Real-Life Clinical Practice: A Survival Analysis

https://doi.org/10.1016/j.ajo.2016.06.007Get rights and content

Purpose

To assess in uveitis patients the rate of immunosuppressive drug (ISD) discontinuation in real-life clinical practice, comparing this rate among ISDs.

Design

Longitudinal retrospective cohort study.

Methods

We included uveitis patients attending a tertiary eye referral center from Madrid (Spain) between 1989 and 2015, prescribed any ISDs (cyclosporine, methotrexate, azathioprine, anti-TNF drugs, or others). Our main outcome was discontinuation of all ISDs owing to clinical efficacy, inefficacy, adverse drug reaction (ADR), and other medical causes. Discontinuation rates (DRs) per 100 patient-years were estimated. Variables associated with specific-cause discontinuations were analyzed using Cox bivariate and multivariate models.

Results

We analyzed 110 patients with 263 treatment courses and 665.2 patient-years of observation. Cyclosporine (66.4%), methotrexate (47.3%), azathioprine (30.9%), and anti-TNFs (30.9%) were the most frequently used ISDs. Treatment was suspended in 136 cases (mostly owing to clinical efficacy [38.2%], inefficacy [26.5%], and ADRs [22.8%]). All-cause DR with 95% confidence interval was 20.4 [17.3–24.2]. Retention rates at 1 and 10 years were 74% and 16%, respectively. In the multivariate analysis, combined treatment exhibited higher DRs owing to clinical efficacy than other ISDs in monotherapy. Conversely, nonbiologic combination therapy with azathioprine exhibited the highest DR owing to ADRs.

Conclusions

Clinical efficacy was the most frequent cause for ISD discontinuation, followed by inefficacy and ADRs. DR owing to efficacy was higher for combination therapy. Furthermore, nonbiologic combination therapy with azathioprine was associated with a higher DR owing to ADRs.

Section snippets

Methods

We performed a longitudinal retrospective cohort study, with subjects included between October 1989 and November 2015 and followed up until December 31, 2015, with a maximum follow-up time of 26 years. Patients were collected from the Hospital Clinico San Carlos Uveitis Clinic (HCSC-UC), a tertiary eye referral center in Madrid (Spain), composed of a multidisciplinary team of ophthalmologists and rheumatologists17 (Supplementary Text, Setting Description; Supplemental Material available at //AJO.com

Cohort Description

We identified 145 patients treated with ISDs between 1989 and 2015. We excluded 10 patients diagnosed with other inflammatory eye diseases; 8 patients treated with ISDs owing to extraocular manifestations; and 17 patients lacking information regarding dates of prescription or discontinuation. We included in our study 110 patients, with a total follow-up time of 665.2 patient-years and a median (IQR) follow-up time per patient of 4.4 years (2.5–9.1). Demographic and clinical characteristics are

Discussion

We have described the crude DRs for ISDs in a tertiary care uveitis clinic, including patients followed up to 26 years. Clinical efficacy was the most frequent cause for discontinuation, followed by inefficacy and ADRs. When analyzed by ISD, anti-TNFs and AZA exhibited the highest crude rates of discontinuation, while CSA and MTX exhibited the lowest. When analyzed by the particular ISD or combination prescribed and after adjustment for several demographic and clinical variables, we observed

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Supplemental Material available at AJO.com.

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