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What is immunomodulatory therapy?

An immunomodulator or immunosuppresor is a medication that blocks some of the human body's defense system functions and, therefore, it is administered to regulate the patient's immune response.

When is this treatment indicated?

Immunomodulators are used to prevent the rejection of a transplanted organ or for the treatment of autoimmune diseases like vasculitis, rheumatoid arthritis, IBS, psoriasis, lupus and many others. With regard to the eyes, they can be useful for patients with a cornea transplant to prevent rejectsion, with inflammatory eye diseases associated with autoimmune diseases or with chronic or recurring non-infectious uveitis to avoid reactivation and reduce to the minimum the need for corticoids and their undesired effects.

The end objective is to preserve the integrity of all the eye's structures needed for good visual functioning. 

How is it performed?

Classic or conventional immunosuppressors like AzathioprineMethotrexate, Cyclosporine and Mycophenolate mofetil are generally adminstered orally, although some of them, for example methotrexate, can also be administered subcutaneously (an injection under the skin). 

Other more recent immunomodulators are biological drugs and they contain specific antibodies aimed at neutralising substances in our body that cause inflammation. These produce a more "selective" type of immunomodulation. They are administered endovenously or subcutaneously and some of the most commonly used in ophthalmology are Adalimumab and Infliximab. 

Immunomodulatory drugs can be administered alone or in combination with others. The specialist will decide ont he dose based on the patient's weight, response to treatment and other specific factors involved in each drug.

Once the amount of each drug necessary has been determined for each patient, in some cases it may be necessary to perform a blood test to check the dose is right or adjust it if necessary. 

Results

Under the current guidelines for immunomodulatory therapy, the control of inflammatory eye diseases has improved considerably, flare-ups have reduced and the need for long-term corticoids has lowered and, with it, the side effects arising therefrom. 

Therefore, by avoiding gradual damage to the intraocular structures in cases of long-term inflammation, the visual prognosis has signficantly improved.

Possible risks

These types of medication are not exempt from side effects, therefore, they must be used in combination with strict monitoring by a multidisciplinary team that carry out regular blood tests and check-ups with a rheumatologist/internal medicine doctor during follow-up. 

Due to the fact that the majority of them do not act selectively, the immune system may lose its ability to fight off infections which implies an increase in risks, the majority mild. Therefore, before starting immunosuppressant treatment, updating your vaccination schdule is recommended. 

In addition, depending on the drug uses, there may be side effects like digestive intolerance (abdominal discomfort, vomitting, diarrhea...), high blood pressure, liver and renal toxicity, hirsutism (excess body hair development among women), etc. 

Professionals who perform this treatment

Frequently asked questions

  • Ideally, you should update your vaccination schedule at least 4 weeks before starting immunomodulatory therapy. If a vaccination is required during treatment, you should consider the following: 

    • Live attenuated vaccines are contraindicated in these patients as there is a risk of contracting the disease. These include the MMR vaccine, the chickenpox vaccine and the oral antipolio virus vaccine. To administer these vaccines, a minimum of 3 months must have passed from the end of your treatment.
    • Inactivated vaccines (hepatitis A and B, tetanus, flu, pneumococcal vaccines, etc) can be administered safely although the immune response attained might be lower than in healthy people. Therefore, they should preferably be administered before the start of the immunosuppression to guarantee the best possible immune response 
  • Immunomodulatory drugs may take weeks to reach their maximum efficacy. The time will vary depending on the drug used, but generally they are not helpful in treating an acute flare-up of inflammation but rather for controlling the disease over the long-term.