TÍTULO

EFFECTIVENESS OF BIOLOGIC AGENTS IN STEROIDS REFRACTORY IMUNOLOGIC SCLERITIS

OBJETIVO

This report is about a female patient presenting RPC with ocular involvement that showed unsatisfactory response to oral and intravenous steroid treatments and an effective response when this treatments was made in association with Tocilizumab (Actemra®), an interleukin-6 monoclonal antibody inhibitor.

RELATO DO CASO

A 63-year-old causian female was seen in the clinic at the Hospital do Servidor Público Estadual (HSPE), São Paulo, SP, Brazil, to evaluate a consumptive syndrome, thrombocytopenia and dysphasia. She also complained of being afflicted with conjunctival hyperaemia, epiphora and oedema in both eyes for about a month, initially noted in the right eye. Best visual acuity was 20/40 in both eyes. It was observed diffuse and painless scleritis in both eyes (Figure 1), worse in the left. Intraocular pressure was 18mmHg bilaterally and no acute visual loss was reported. Biomicroscopy did not show anterior chamber reaction. A nuclear 2+ opacity of lens was observed in both eyes. Fundoscopy was normal.
Within one month after the first evaluation, she developed edema and hyperaemia in the left ear. RPC was suggested and intravenous methylprednisolone, 1g/daily for 3 days, was prescribed. Partial response was observed within a week and the treatment protocol was replaced with use of Tocilizumab associated with oral prednisone 1mg/kg/day. Expressive ocular and systemic improvement were observed. Audiometry revealed bilateral and persistent neurosensitive deficit, worse in the ear without active chondritis. Best visual acuity remained 20/40 BE. After 12 months of follow up, no more ocular or systemic inflammatory activity was observed.

CONCLUSÃO

Steroids are still the drugs with the most supporting evidence in the control of the active disease, but their short and long term side effects justify the intense search for drugs to replace its use.
Alkylating and antimetabolites agents, regulatory lymphocytes T and B and others biologic agents are considered as alternative therapies to steroid use. although their side effects require special attention. Biologic agents, which aims to provide greater specificity in the mechanisms of aggression and defense and, consequently, less side effects.
Case reports suggests tumoral necrosis fator blocker as the most thoroughly studied biological agent, followed by rituximab, anakinra, tocilizumab and abatacept. Apparently, biological agents are effective in 46.5% of cases, but negative outcomes use are reported.

Palavras Chave

Scleritis; Biological Agents; Tocilizumab; Rituximab;