Steroid Sparing Effects of Methotrexate and Mycophenolate in Uveitis Save

Patients with noninfectious uveitis (intermediate, posterior uveitis, or panuveitis) often require high dose corticosteroids and therefore may need steroid-sparing DMARD therapy. The FAST study investigated the corticosteroid-sparing effect of methotrexate or mycophenolate mofetil in adults with noninfectious uveitis.

The First-line Antimetabolites as Steroid-sparing Treatment (FAST) uveitis trial enrolled 216 patients with active noninfectious intermediate uveitis, posterior uveitis, and panuveitis and they were randomized to either oral methotrexate, 25 mg weekly (n = 107), or oral mycophenolate mofetil, 3 g daily (n = 109). The primary outcome was treatment success at 6 months, which was defined as having control of inflammation in both eyes, no more than 7.5 mg prednisone daily and less than or equal to 2 drops of prednisolone acetate 1%, and no treatment failure after 12 mos.

With nearly 90% of patients completing follow-up through 6 months, treatment success was seen in 66.7% of methotrexate group compared with 57.1% in the mycophenolate group, a difference that was not statistically significant.

However, in those with posterior uveitis or panuveitis, treatment success was achieved in 74% on methotrexate versus 55% on mycophenolate (P = .02).

Intermediate uveitis was more likely to respond to mycophenolate (64%) compared to methotrexate (33.3%) treated patients (P = .07; P for interaction = .004).

Elevated liver enzymes were the most common nonserious laboratory adverse event, occurring in 14 patients (13.0%) in the methotrexate group and 8 patients (7.4%) in the mycophenolate group.

JAMA reports that both mycophenolate and MTX demonstrated steroid sparing effects in the majority of patients.  While there were no overall differences in treatment success (efficacy plus corticosteroid-sparing) intermediate uveitis tended to respond better to mycophenolate, while posterior and panuveitis responded better to MTX.