Difficult situation: anyone with similar experience?

[Midknight]

Hi

I’m a HLA-B27 positive male who just turned 40 with a history of anterior uveitis that has occurred about once per year in my left eye since my mid-20s. I've seen specialists in ocular immunology (Dzerko and Rabinovitch in Toronto) and been told my iritis is ‘mild’ (a few cells) and it clears up within a week if I start Pred Forte right away (of course tapering afterwards). I've been diagnosed with mild AS by a rheumatologist who gave me Celebrex ‘as needed’, but felt that there was no need for treatment beyond that. Cataracts at this point are minimal. Other than a few aches and pain, I'm in good health.

Recently, however, I've been dealing with mild iritis (again a few cells) jumping back and forth between my eyes and I can’t seem to get off Pred Forte. The eye clears fast but as soon as I taper, it flares again. This happened 4 times with my left eye since May—each time it took only about 3 weeks to re-flare again. During this time, I've also had my right eye flare and re-flare again (I've only had it in my right once before.) At present the ophthalmologist says I’m clear (doing two drops a day) but my pressures are high 28/20 (L/R).

Here’s my problem: I'm working overseas at the moment, so there’s a bit of a communication barrier with the ophthalmologist. I've tried to get into a uveitis clinic, but since I’m considered ‘mild’ I’m still waiting. The ophthalmologist has given me lotemax, timolol 0.5% for the pressure and said I can stop the Pred Forte cold turkey or start that. He’s kind of left it up to me, so I’m really not sure what to do.

I should also mention a rheumatologist has put me on etoricoxib (Arcoxia) about a month ago after he felt that Celebrex wasn't working. It’s helped with some increased stiffness I've been having, but hasn't done too much for the iritis. We've spoken about a biologic, but it seems complicated because I’m leaving the country in 6 months and I don’t know if I could maintain treatment smoothly after I relocate (cost is also a factor).

I’d be really grateful if you could give me your thoughts on the following:

1. It seems kind of crazy to stop the PredForte without doing 1 drop for a few weeks. Does anyone have any experience with pressures reducing after going down to 1 drop a day?

2. The ophthalmologist gave me Lotemax instead of Pred Forte this time. I know this generally causes less pressure spikes, but does anyone have experience with pressures lowering after switching to Lotemax?

3. In my years of iritis, I've always been able to avoid taking any kind of pressure drop. An IOP of 28 seems borderline for treatment. Can I try reducing the steroid and following up in 2 weeks? Or am I taking a big gamble? Anyone with experience in this?

I will continue to seek medical advice from qualified practitioners, but seeing the wealth of experience shared by people on Iritis.org (and that I need all the luck I can get), I’m just wondering if anyone has been in a similar predicament or sees anything I'm forgetting.

Sorry for the huge post--needed to get that off my chest.

Jeff

[Mike Bartolatz]

Jeff. we are not doctors so it is impossible for us to tell you what to do or take. that said a pressure of 28 can cause problems so If it were me, I would take the pressure lowering drop. a very slow taper off of steroids is often what is required to prevent renewed inflammation. lotemax is still a steroid and it adds to the pred you have been taking for the potential side effect of cataracts and glaucoma. this on again off again cycle you are now undergoing would indicate that you might be a very good candidate for DMARD drugs for both the AS and the uveitis. most try methotrexate, Cellcept or Imuran before going onto the TNF A blocking drugs Remicade or Humira (Enbrel is useless for uveitis BTW).

I am not familiar with the NSAID you are taking.

wish you quiet eyes,
Mike

[Midknight]

Thanks, Mike. I'm going to follow up with the ophthalmologist at the end of this week re: pressure and make my decision about timolol, then. I hope I can avoid adding another drop to my regimen. I'll see tjhe rheumatologist shortly and ask him about Dmards vs. Anti-TNFs. This sudden increased and persistent flaring has me worried.

[Mike Bartolatz]

insurance companies require you to fail at least 2 different DMARD drugs before they will pay for the TNF A blocking drugs. the TNF A blocking drugs cost many thousands of dollars a MONTH to infuse or supply to the patient. they are not approved to take for uveitis but they are for AS, psoriasis, crohn's disease and ulcerative colitis.

take care,
mike