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 PostPoslano: 16-12-2010 21:48  Citiraj (i odgovori)  
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Ovo su faktori koji ukazuju na težu borbu s uveitisom, po dr.Fosteru:

The following features are predictive of a protracted, difficult-to-control JIA-associated uveitis:
1. Female
2. Onset at very young age
3. ANA positive
4. Personal or family history of psoriasis
5. HLA-DR5 positive
6. HLA-DR1 negative
7. Posterior synechiae formation on first episode of uveitis

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 PostPoslano: 18-12-2010 00:06  Citiraj (i odgovori)  
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Hello Dr. Foster,

My daughter was diagnosed with JRA when she was 2 yrs old. She is ANA positive and has had flares in her left eye off and on. She is almost 10 now. She is always treated with Pred Forte for a period of time, the dose slowly tapered, and she is sometimes without a flare for quite some time. She even went over a year without a flare. She is on Methotrexate 15 mg. sq weekly to control her inflammation in her knees and ankles and mostly for her eyes. She has had several joint injections which have helped. This go around, the Pred Forte and Cyclogyl does not seem to be working. Her Rheumatologist suggested Remicade which I would llike to avoid if at all possible. I have discussed a sub tenon injection with her Ophthalmologist and she said she would give it a try but it would probably only be a temporary aid. I am not sure if she would use Kenalog or Decadron. I am a COA with 18 years experience in Ophthalmology and realize the importance of getting her condition under control. A retina specialist I used to work with suggested a combination of Pred Forte mixed with a non-steroidal such as Voltaren or Acular, and to change the Cyclogyl to Atropine bid. Another option that was mentioned would be a Medrol Dose pack to see if that would quiet the inflammation. She always has her flares in the left eye only for some reason and her va is 20/20 ou. She has a trace PSC, but not all docs agree so it must be minimal. She has a small area of band keratopathy in the os as well. I know it is difficult without seeing her but any thoughts???


fostercs #1 [-]
The idea that topical therapy, steroids and cycloplegic, can get you and your daughter where you REALLY want to be, i.e., in durable remission off steroids, is completely misdirected, in my opinion. I see no hope, ZERO HOPE, for that strategy really getting you what you want. Your daughter can be cured. It may take years to do it. It may take multiple changes in medication to do it. It may take scary-sounding strategies to do it. But I can promise you (and do promise you) that cure is absolutely possible in cases such as your daughters. My wife is a case in point. Dr. Miller's daughter is a case in point. Hundreds of our patients and those of others are cases in point. All it takes is determination: the determination to do whatever it takes to induce steroid-free remission and to maintain that for a minimum of 2 years before making any attempt to taper or tamper with the recipe that accomplished induction of steroid-free remission. Topical and regional injection therapy and sytemic steroid and Remicade will not accomplish that.

Stephen Foster

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 PostPoslano: 18-12-2010 00:15  Citiraj (i odgovori)  
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6 year old JRA patient with uveitis

My now 6 1/2 year old daughter was diagnosed with Pauciarticular JRA at age 2, and developed uveitis at age 3 1/2. For the past 2 years, her eyes have been completely controlled with weekly injections of Methotrexate (0.9cc). The Methotrexate was commenced about 3 months after diagnosis because she had flare-ups upon tapering the Predforte drops. She had one flare up while on Methotrexate (just over 2 years ago) which I personally attribute to a flu shot.

Now that we have been inflammation-free for 2 years, her rheumatologist and opthomologist have suggested that the next step is to slowly taper the Methotrexate dose and see if the inflammation returns. While I certainly don't want my daughter on medication she doesn't need, I'm quite hesitant to mess with apparent success. When I asked our doctors what the likelihood is that we will be able to decrease the Methotrexate without the inflammation returning, they said it is rather rare that the medication can be completely eliminated. I would really appreciate your insight on whether, and when, tapering should be commenced. Thank you very much.

fostercs #1 [-]
My Recent Posts Has she been inflammation free off all steroids for 2 years? If so, she has a reasonable (70%) chance of slowly reducing the methotrexate, making the reduction every 3 months, without relapse. Stephen Foster

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 PostPoslano: 18-12-2010 00:23  Citiraj (i odgovori)  
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JIA related uveitis - remission only with drops?

My Recent Posts Have you ever accomplished permanent remission (off all medications), only with eye drops (cortico) for JIA related uveitis or immunosuppressive agents were always implemented?
Regards, Kate


Not every child with JIA-associated uveitis requires systemic immunosuppressive chemotherapy. As Kanski showed in England many years ago, 25% do not have chronic or recurrent uveitis; steroid eye drops snuffing out the uveitis, with subsequent tapering and discontinuation of the drops may be all that is required. It is the other 75%, who have chronic or multiply recurrent inflammation who are appropriately counseled to move along to systemic immunomodulation, given the very poor long term outcomes experiences of many, many uveitis experts around the world with use only of chronic or repeated corticosteroid monotherapy.

Stephen Foster

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