Multiple drugs

Abstract

Various toxicities: case report A adult woman [exact age at onset stated] exhibited lack of efficacy during treatment with adalimumab, ciclosporin, dexamethasone, methotrexate and prednisone. She developed hypersensitivity reaction and corneal oedema secondary to infliximab and migration of the intravitreal dexamethasone implant, respectively. She also received off-label treatment with tocilizumab [not all dosages and routes stated; outcomes not stated]. The woman was diagnosed with idiopathic panuveitis and received treatment with ciclosporin [cyclosporine A] 150mg bid, prednisone 7.5 mg/day and methotrexate 15 mg weekly for 12 years. She had undergone total three-port pars plana vitrectomy with lensectomy of both eyes in 2001. However, her inflammatory condition relapsed with severe bilateral CME in 2009. Hence, treatment with IV infliximab 5 mg/kg infusion was initiated, but she developed hypersensitivity reaction. Hence, infliximab was switched to adalimumab 40mg every two weeks. However, the CME was persistent in both eyes. In 2011, the woman received intravitreal injection of dexamethasone implant in her left eye. Thereafter, the implant migrated into the anterior chamber and she developed Descemet’s folds with corneal oedema. In April 2012, anterior segment test disclosed 2+ cells in anterior chamber, and fundus biomicroscopy showed 1+ vitreous cells along with CME in her right eye. Central retinal thickness (CRT) of the right eye was 896μm. Optic coherence tomography of the left eye could not be performed because of corneal oedema. Her visual acuity was light perception in the left eye and counting fingers at 1m in the right eye. Treatment with adalimumab was discontinued. Her idiopathic panuveitis with CME was refractory to previous systemic and local treatments. Four weeks after discontinuation of adalimumab, she received off-label treatment with IV tocilizumab infusion 8 mg/kg/month along with oral prednisone 7.5 mg/day. Following six infusions of tocilizumab, she was asymptomatic and no sign of active inflammation was noted. Her CRT also decreased and visual acuity improved in the right eye. At 6-month follow-up, no side effects were reported.