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Intravitreal Dexamethasone Implants for Non-infectious Uveitis: A Review of Clinical Effectiveness, Cost-effectiveness, and GuidelinesYu C; MacDougall DIntravitreal Dexamethasone Implants for Non-infectious Uveitis: A Review of Clinical Effectiveness, Cost-effectiveness, and Guidelines-/-CADTH Rapid Response Reports 2020[Mar]; ä (ä): äUveitis is a disease characterized by inflammation of the uvea. Uvea is the middle layer of the eye wall. The anterior uvea segment includes the iris and ciliary body, intermediate uvea includes vitreous humor, and posterior uvea segment is known as the choroid. Based on the location of the Inflammation, uveitis can be classified as anterior uveitis (AU), intermediate uveitis (IU), posterior uveitis (PU) and panuveitis. Panuveitis is defined as uveitis involving all parts of uvea. Based on the etiology, uveitis can be divided into infectious uveitis and non-infectious uveitis (NIU). NIU includes uveitis caused by systemic immune-mediated disease, immune-related drug reactions, or some syndromes resulting in uveitis. The common complications of uveitis include cystoid macular edema (CME), cataract, intraocular pressure elevation, and glaucoma; the risk of specific complications of uveitis depends on the underlying illness.(,) Treatment of NIU is still clinically challenging. There is very limited information from controlled trials. The treatment choice for NIU depends upon the location of the uveitis (such as AU/IU/PU). In the literature, it has been indicated that the initial treatment for non-infectious posterior uveitis is corticosteroids administered locally or systemically. Non-infectious anterior uveitis is commonly treated with topical glucocorticoids. However, posterior uveitis is generally not responsive to topical medication. Intravitreal dexamethasone implant (IDI, 0.7 mg, Ozurdex) is usually used for patients with uveitis, when underlying systemic disease is well controlled or is not present. Following corticosteroids, immunosuppressive drugs including methotrexate and azathioprine are commonly used. Long-term use of systemic corticosteroids above 7.5 mg per day is not recommended due to potential adverse effects such as cataract, glaucoma, etc. In Canada, intravitreal dexamethasone implants (IDI) are indicated for the treatment of NIU affecting the posterior segment of the eye. The pivotal trial used to support the Health Canada's indication was a single, multicenter, masked RCT for the treatment of NIU affecting the intermediate and posterior segment of the eye.(,) In the treatment of NIU, the Health Canada recommended dose regimen of IDI is one dose. The product monograph notes that for uveitis, there is no experience with reinjection and it is therefore not recommended (p. 4) but also notes that the need for IDI reinjection is determined by physician based on patient's clinical need. For other indications (e.g. diabetic macular edema), reinjection at an interval of six months between two injections has been recommended. IDI is not recommended by Health Canada for pediatric use. The purpose of this report is to review the clinical effectiveness, safety, cost-effectiveness of IDI in the treatment of NIU. Of particular interest is evidence on different dose regimens of IDI (e.g., a single implant or two implants with approximately six months between doses, or continual treatment (i.e., three or more implants) or implants at intervals of less than every six months). In addition, this report also reviews the evidence-based guidelines on the treatment of NIU.ä |
