It is not always clear when to begin treatment, and not every consultant feels that every patient needs to be treated. However more and more there is a move towards aggressive treatment. This is something that has to be discussed with the doctors treating you. It is different in every case.
When treatment is decided upon, the following types of drugs can be used to treat birdshot depending on its severity and depending on how the individual reacts to the chosen drugs. They are listed in order of what is most commonly tried first.
High dose steroids are nearly always used initially when there is a need to quell inflammation rapidly. Other medications or drugs used for Birdshot often take time to become effective, so steroids are often used at high doses initially, with or without other forms of medication or drugs. Once other medications become effective, steroids may continue to be used in combination, and usually at lower doses. Because of the side effects of high dose steroids on the eye (cataract formation and glaucoma) and the body, attempts are made to reduce steroids as quickly as the inflammation will allow. (See the fact sheet on Steroid for more details).
Individuals who require long term treatment are likely to be switched to an immunosuppressant such as cyclosporine, mycophenolate, methotrexate, azathioprine or others. (see below)
Methotrexate, Azathioprine (Imuran) and Mycophenolate (cellcept) are Antimetabolite drugs. In particular Cellcept has been found to be effective in controlling Birdshot, but Birdshot patients may require a second agent added from the next group of drugs and some will also continue with low dose steroid.
Ciclosporin and Tacrolimus are T-Cell/calcineurin inhibitors, commonly used to treat Birdshot. These may be effective as single drug therapy, but some patients will require combination therapy with an antimetabolite from the group above and possibly low dose steroid as well. It has been found that tacrolimus may work when a patient fails therapy with cyclosporine.
Infliximab (Remicade) and Adalimumbab (Humira) are biologics, given by infusion or injection. These can be known as TNF antagonists or anti TNFs (Tumour Necrosis Factor) and may be used in cases where the antimetabolites and T-cell inhibitors have failed to be effective, or side effects have made their use difficult. Infliximab is given through iv infusion and adalimumab by self injection every two weeks. These agents are expensive and rheumatologists may have to present a special case to get their patient’s treatment funded.
Interleukin -2 receptor antagonists include Dacluzimab (Zenapax) which is a monoclonal antibody and Interferon Alpha which is an endogenous cytokine, are other agents that change the immune system response. Both of these drugs were proving effective, but, side effects and cost need to be considered by our doctors before prescribing. In 2010 Dacluzimab was withdrawn from the market, we gather that this was due to commercial considerations.
Polyclonal immunoglobulin IVIg is given through iv infusion. The Department of Health Clinical guidelines for the use of IVIg, May 2008, make reference to small studies in the use ofIVIg for auto immune uveitis, but do not recommend its use as treatment. The product is very expensive and not readily available as a choice in the UK although it is used in France and the US with some good results reported.