- Design
- Systematic review and meta-analysis, mostly case series
- Population
- 466 patients with anti-TNF-refractory non-infectious uveitis in 89 studies
- Primary outcome
- Pooled response rate after biologic switch
- Effect
- Overall 83% (76 to 90%); interclass 89% vs intraclass 77% (P = .10)
This systematic review, published in Ophthalmology, included 136 studies (129 case reports or series, 7 comparative) of patients with non-infectious uveitis who failed an anti-TNF agent, with 89 studies (466 patients) in the meta-analysis.
Overall, 83% (95% CI 76 to 90%) responded after switching. Switching to another anti-TNF agent gave 77% and switching to a different class 89%, a difference not statistically significant in the main analysis (P = .10). In a sensitivity analysis, response was 71% vs 85% (P = .044). Certainty was graded low.
Up to a third of patients do not respond adequately to adalimumab or infliximab, so the question of what to try next is common. This suggests moving to a different mechanism — such as IL-6 blockade or JAK inhibition — is at least as good as trying a second anti-TNF, and possibly better. The evidence is mostly case series, so the choice should still reflect the underlying disease, systemic features and access.
- Consider switching to a different biologic class when uveitis fails a first anti-TNF agent.
- Check adherence, drug levels and antibodies before labelling anti-TNF failure, where available.
- Coordinate the choice with rheumatology when there is associated systemic disease.
- Expect most patients to respond after a switch; about 8 in 10 did in this review.
Why it matters
It guides a common decision that currently rests largely on habit.
Don't overread it
Mostly case reports and series with low-certainty evidence; the main comparison was not statistically significant.
The statistics, in plain English
A P value of .10 in the main analysis means the difference between 77% and 89% could be chance. The sensitivity analysis reached significance (P = .044), but choosing among analyses weakens that result.
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