After anti-TNF failure in uveitis, switching class may work better than switching within the class

Design

Systematic review and meta-analysis of 136 studies (129 case reports or series, 7 comparative)

Population

466 patients with anti-TNF-refractory noninfectious uveitis in the pooled analysis

Primary outcome

Pooled response rate after biologic switching

Effect

Overall 83% (95% CI 76 to 90%); intraclass 77% vs interclass 89% (P = 0.0995); low certainty

This systematic review and meta-analysis looked at switching biologic in noninfectious uveitis that had not responded to anti-TNF therapy. It included 136 studies, of which 129 were case reports or series and 7 comparative; 89 contributed to the pooled analysis (466 patients).

The overall pooled response after switching was 83% (95% CI 76 to 90%). Switching to another anti-TNF agent gave 77% (65 to 87%), and switching to a different class gave 89% (80 to 96%), a difference with P = 0.0995. In a sensitivity analysis the figures were 71% and 85%, with P = 0.044. Certainty of evidence was low.

The data come largely from uncontrolled reports, which favour positive outcomes, and response definitions varied. A switch of class is a reasonable option after anti-TNF failure, but the choice of agent depends on the underlying disease, access and cost, and the review does not identify which drug to choose.

• Confirm adherence, dosing interval and anti-drug antibodies before calling anti-TNF therapy a failure.
• Consider a different biologic class after anti-TNF failure, based on the underlying disease and local access.
• Treat a switch within the anti-TNF class as a reasonable alternative, with a somewhat lower pooled response.
• Rule out infection mimics and review the diagnosis if uveitis is refractory.
• Involve rheumatology when systemic disease is present.

Why it matters

Up to a third of patients fail first-line biologic therapy, and the next step has had little structured evidence.

Don't overread it

Most data came from case reports and series, so the pooled response rates should be treated as optimistic.

The statistics, in plain English

The main difference between switching types had a P value of 0.0995, which is not significant, and only reached 0.044 in a sensitivity analysis. Pooled response rates from case reports are inflated by publication of successes, so the real-world figures are likely lower.

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