Juvenile idiopathic arthritis-associated chronic anterior uveitis — SCE Rheumatology MCQ

Correct answer: D — Continue adalimumab and methotrexate for at least another 6 months before considering systemic treatment reduction

The timing of de-escalation should be determined by ocular, not solely articular, remission. European SHARE recommendations advise that systemic immunosuppression should not be reduced until uveitis has remained inactive for 2 years without topical glucocorticoids. This patient has reached only 18 months, so adalimumab and methotrexate should be continued for at least another 6 months before a jointly planned, closely monitored reduction is considered. Stopping adalimumab now is premature. In ADJUST, children with controlled JIA-associated uveitis who discontinued adalimumab had substantially more treatment failure than those continuing it, although the trial evaluated abrupt withdrawal after at least 1 year rather than defining an optimal tapering strategy. Stopping methotrexate now is also inappropriate because the recommended steroid-free inactivity interval has not been completed, and the best order for withdrawing combination therapy remains uncertain. Simultaneous withdrawal would expose her to an still greater avoidable risk of ocular or articular recurrence. Etanercept is effective for some articular JIA phenotypes but has inferior efficacy for JIA-associated uveitis and is not an appropriate substitution for adalimumab. Once the 2-year ocular threshold is reached, the sequence and pace of reduction should be individualised with paediatric rheumatology and specialist ophthalmology follow-up.

Reference: Consensus-based recommendations for the management of uveitis associated with juvenile idiopathic arthritis: the SHARE initiative (2018) — https://ard.bmj.com/content/77/8/1107 Stopping of adalimumab in juvenile idiopathic arthritis-associated uveitis (ADJUST): a multicentre, double-masked, randomised controlled trial (25 January 2025) — https://pubmed.ncbi.nlm.nih.gov/39863370/