San Francisco—A more expensive drug is not necessarily better for treating noninfectious uveitis, according to a new study.

Results of the study, funded by the National Eye Institute, were published in JAMA. University of California San Francisco (UCSF)–led researchers compared methotrexate and mycophenolate mofetil in a head-to-head clinical trial, determining that the two drugs performed similarly in treating an eye disease that causes up to 15% of blindness in the United States.

In fact, in cases of more severe disease, posterior uveitis and panuveitis, the international trial actually documented methotrexate was more effective in controlling inflammation.

“This study gives doctors and their patients with uveitis a starting point when considering treatment beyond corticosteroids,” said lead study author Nisha Acharya, MD, MS, of UCSF.

The randomized clinical trial of 216 patients with active noninfectious intermediate uveitis, posterior uveitis, and panuveitis determined that 66.7% of patients in the methotrexate group achieved corticosteroid-sparing control of inflammation versus 57.1% in the mycophenolate group, a difference that was not statistically significant.

The study points out that methotrexate and mycophenolate mofetil are commonly used immunomodulatory therapies for achieving corticosteroid-sparing control of noninfectious uveitis. It has not been clear, however, which drug is more effective.

To help answer that question, the study team compared the effect of methotrexate and mycophenolate for achieving corticosteroid-sparing control of noninfectious intermediate uveitis, posterior uveitis, and panuveitis.

The First-line Antimetabolites as Steroid-sparing Treatment uveitis trial screened 265 adults with noninfectious uveitis requiring corticosteroid-sparing immunosuppressive therapy from nine referral eye centers in India, the U.S., Australia, Saudi Arabia, and Mexico between August 22, 2013, and August 16, 2017. Follow-up ended on August 20, 2018. While 107 patients were randomized to receive oral methotrexate 25 mg weekly, another 109 received oral mycophenolate mofetil 3 g daily.

Defined as the primary outcomes were control of inflammation in both eyes, no more than 7.5 mg prednisone daily and less than or equal to two drops of prednisolone acetate 1%, and no treatment failure due to safety or intolerability.

Researchers report that patients underwent follow-up to 12 months while receiving the same treatment or switched to the other antimetabolite, depending on their 6-month outcome.

“Among adults with noninfectious uveitis, the use of mycophenolate mofetil compared with methotrexate as first-line corticosteroid-sparing treatment did not result in superior control of inflammation,” study authors conclude.

“Further research is needed to determine if either drug is more effective based on the anatomical subtype of uveitis.”

The study points out that both methotrexate and mycophenolate mofetil can cause side effects such as fatigue, nausea, and headaches, but serious side effects are rare.

“Based on this head-to-head clinical trial, methotrexate is as good as or better than mycophenolate for treating uveitis. That’s important because the prior literature and a survey on treatment preferences suggests most clinicians believe the opposite. Now we have a randomized trial to provide guidance on treatment.” Dr. Acharya said.

“Additionally, there’s a cost difference in the U.S. where mycophenolate to control uveitis is over five times more expensive.”

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