Eyeworld

EW NEWS & OPINION 22 November 2016 by Vanessa Caceres EyeWorld Contributing Writer biologic agent (31% of rheumatolo- gists and 38% of ophthalmologists); the selection of a biologic agent increased significantly once cost and prior authorization issues were removed. Among the biologics, anti- tumor necrosis factor (TNF) agents were selected by 81% of rheumatol- ogists and 94% of ophthalmologists before equalization of cost and authorization factors. A significant number of more rheumatologists than ophthalmol- ogists chose methotrexate (28% of rheumatologists and 11% of oph- thalmologists) and azathioprine (22% of rheumatologists and 3% of ophthalmologists) as a first-choice therapy. "After assuming there were no concerns with cost or prior autho- rization, rheumatologists were still more likely to choose azathioprine compared with ophthalmologists, and ophthalmologists were more likely to choose local steroid im- plants," the authors wrote. However, when cost issues and prior authorization were removed from the scenario, physicians from both specialties increased their selec- tion of an anti-tumor necrosis factor. Comparing the specialties It surprised the study authors to learn that the majority of special- ists would still use anti-TNF agents even though they are not approved by the FDA for this disease and are more expensive than disease-mod- ifying anti-rheumatic drug alterna- tives, Dr. Palestine said. "There were no FDA-approved drugs for Behçet's disease and no comparative trials showing that one drug is superi- or to the other at the time of the survey. However, since July 1, 2016, adalimumab has been approved for posterior uveitis and panuveitis and it would be interesting to see how opinions may have changed," he said. Study authors were also sur- prised by the disparity in azathio- prine use as there are strong rec- ommendations from the European Union League Against Rheumatism (EULAR) supporting the use of azathioprine. However, this could be because more rheumatologists than ophthalmologists are familiar with 3) What the first and second treat- ment choices would be if the cost to the patient was the same for all medications and prior authoriza- tion was not an issue. The treatment choices given were: dexamethasone implant, fluocinolone acetonide implant, methotrexate, cyclosporine, myco- phenolate mofetil, infliximab, adali- mumab, rituximab, and "other." The survey was sent via email to members of the American Uveitis Society discussion group, the Macu- lar Society, the American Society of Retinal Specialists, and one-sixth of the members of the larger American College of Rheumatology. A total of 106 ophthalmologists and 90 rheu- matologists responded to the survey. Sixty percent of ophthalmology respondents and 76% of rheuma- tology respondents were willing to recommend treatment instead of deferring to another provider. The most common first-choice therapy from both specialties was a severe visual loss when left untreat- ed, according to the study. There are no systemic steroid-sparing agents currently approved by the U.S. Food and Drug Administration (FDA) for severe uveitis and intraocular inflammation, the authors wrote. There are also no large randomized controlled trials that compare treat- ment for this ocular disease. Study details The study authors, led by Alan Palestine, MD, professor, Depart- ment of Ophthalmology, Rocky Mountain Lions Eye Institute, Uni- versity of Colorado Denver, devised an email questionnaire with the brief case example of ocular Behçet's disease. Respondents were asked: 1) Whether they would manage the patient or refer to another specialist; 2) If they chose to manage the patient, what would be their first- and second-choice treatment options; and Study reveals a rift in treatment by specialty H ow would you treat the following patient? There is a 45-year-old man with a history of three episodes of retinal vasculitis and severe recurrent oral and genital ulcers consistent with Behçet's disease. His vision is 20/30 and 20/40, and he is currently on prednisone 40 mg orally for 6 weeks. What would your treatment be? Do you think your colleagues in rheumatology—who also treat Behçet's disease—would make the same choice? Results of a study found that specialists from rheumatology and ophthalmology had different treat- ment choices for the case scenario. 1 Ocular Behçet's disease is ac- companied with the recurrence of retinal vasculitis and anterior and posterior uveitis, which can lead to Treatment choice for ocular Behçet's disease continued on page 24

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