LETTER TO THE EDITOR
Thank you to Drs. Biscette, Fine, and Flynn for their comprehensive review article on uveitis in the May issue of Retinal Physician. I would like to comment on the section on daclizumab, an IL-2 receptor antagonist. A substantial body of work1,2 has now accumulated supporting the use of daclizumab for intermediate and posterior uveitis patients unresponsive to or intolerant of more traditional steroid-sparing therapies. The medication is FDA-approved for transplantation and will likely never carry an FDA label for uveitis (in fact, there are no medications with an FDA label for uveitis; all the steroid-sparing medications used in the treatment of uveitis are being utilized off-label). This lack of an FDA label will make the routine use of daclizumab for uveitis in clinical practice difficult as insurance companies will label such therapy as "experimental" and refuse to pay. However, for the patient with potentially blinding granulomatous intermediate or posterior disease who cannot tolerate therapy with agents such as cyclosporine, azathioprine, or mycophenolate, I would encourage ophthalmologists to consider daclizumab.
Sam S. Dahr, MD, Oklahoma City
1. Nussenblatt RB, Thompson DJ, Li Z, Chan CC, et al. Humanized anti-interleukin-2 (IL-2) receptor alpha therapy: long-term results in uveitis patients and preliminary safety and activity data for establishing parameters for subcutaneous administration. J Autoimmunol. 2003;21:283-293.
2. Nussenblatt RB, Peterson JS, Foster CS, et al. Initial evaluation of subcutaneous daclizumab treatments for noninfectious uveitis: a multicenter noncomparative interventional case series. Ophthalmology. 2005;112:764-770.
We thank Dr. Dahr for his comments on daclizumab. It has proved particularly useful in patients with refractory MS and sight-threatening intermediate and posterior uveitis, allowing a few patients to avoid using multiple immunomodulators. We look forward to using the biologic agents, with appropriate caution, in more patients in the future.
We would thank Dr. Dahr also for his comments on the FDA labeling status of all drugs (except steroids) for treating sight-threatening uveitis. The "orphan disease" designation applies to uveitis, making the cost of getting a label far greater than any financial reimbursement a pharmaceutical company could expect to recover from the "uveitis market." The real challenge to treating uveitis patients is matching a justifiably high standard of care with the restrictions on "off label" use of drugs. A long-running battle between managed care companies and treating physicians will be a challenging feature of uveitis care for the foreseeable future.
O'Neil M. Biscette, MD, MSCmpE
Howard F. Fine, MD, MHSc
Thomas E. Flynn, MD