To the Editor:
Leandro et al. [1] are to be congratulated on highlighting the risks of chronic systemic steroid usage in patients with intraocular inflammation and they are correct to assert that alternatives are not plentiful. However, there are issues with their methodology which invite comment. The authors retrospectively enumerate ‘adherence to international consensus guidance’ when in fact, for the patient group studied, no consensus exists for the standards described. Reference was made to a publication [2] which recommended a different (i.e. ≤10 mg/day) dosage in patients with uveitis. However, the authors then quoted two other papers, both of moderate grade evidence level (expert-opinion Delphi process following literature review) in rheumatic diseases [3] and gastroenterology [4] and claimed that ‘a maintenance dose of ≤7.5 mg/day…is considered an acceptable target for maintenance treatment by uveitis specialists and other physicians’. That conclusion could not be drawn from the two quoted references (which did not include patients with uveitis) and has not been agreed by the uveitis community. In addition, the use of >500 mg intravenous methyprednisolone within the previous 12 months was included, unreferenced, as being outside treatment guidelines.
There are sometimes significant differences in age groups involved and in the intrinsic risks of complications from corticosteroids in some systemic diseases (e.g., osteoporosis and osteonecrosis in inflammatory arthritis), compared to those with uveitis. While each potential complication exists and should be considered whatever the disease treated, neither the level of absolute risk nor relative risk may be comparable and it should not be assumed that a recommendation adopted within one specialty should be uncritically transferred to another.
This does not recommend complacency. Uveitis specialists should strive to minimise systemic steroid dosage, and every opportunity should be taken to identify learning points. However, the retrospective investigation of ‘adherence’ to guidance neither agreed nor even circulated, is pejorative and arguably, unhelpful. The uveitis community needs prospective data on the real risks of systemic corticosteroids for patients with uveitis, not arthritis or inflammatory bowel disease. The UK Uveitis National Clinical Study Group would appear ideally suited to this task. We await further data on this important topic.
Competing interests
The author has no conflicts of interest to report and has no interests, financial or otherwise, in any aspect of this submission.
Footnotes
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Leandro L, Beare N, Bhan K, Murray PI, Andrews C, Damato E, et al. Systemic corticosteroid use in UK Uveitis practice: results from the ocular inflammation steroid toxicity risk (OSTRICH) study. Eye. 2021;35:3342–9. doi: 10.1038/s41433-020-01336-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Jabs DA, Rosenbaum JT, Foster CS, Holland GN, Jaffe GJ, Louie JS, et al. Guidelines for the use of immunosuppressive drugs in patients with ocular inflammatory disorders: Recommendations of an expert panel. Am J Ophthalmol. 2000;130:492–513. doi: 10.1016/S0002-9394(00)00659-0. [DOI] [PubMed] [Google Scholar]
- 3.Hoes JN, Jacobs JW, Boers M, Boumpas D, Buttgereit F, Caeyers N, et al. EULAR evidence-based recommendations on the management of systemic glucocorticoid therapy in rheumatic diseases. Ann Rheum Dis. 2007;66:1560–7. doi: 10.1136/ard.2007.072157. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Lamb CA, Kennedy NA, Raine T, Hendy PA, Smith PJ, Limdi JK, et al. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut. 2019;68(Suppl 3):s1–s106. doi: 10.1136/gutjnl-2019-318484. [DOI] [PMC free article] [PubMed] [Google Scholar]