How would you approach the management of HLA-B27-associated recurrent uveitis and inflammatory back pain with a recent history of melanoma?

This is a very practical question (and challenging to answer succinctly as well!). Like many scenarios seen in clinical practice, there is unfortunately less data in the literature than we would like to guide us here. While decent data exists on the risk of incident cancer following exposure to biological agents such as TNF inhibitors, the risk of cancer recurrence is less well established (likely due to many factors, such as challenges in recruiting such patients to an RCT and the selection bias that would likely occur in non-randomized cohort studies). I'll offer some thoughts on a possible approach:

1. The clinical scenario does not explicitly say the patient has axial spondyloarthritis. I raise this as a point to consider, as several stud...

Drs. @Dr. First Last, @Dr. First Last, and @Dr. First Last have provided thoughtful and scholarly responses. I agree completely that most patients with recurrent B27-related AAU can be managed with topical therapy which can usually be started safely even before seeing the ophthalmologist - provided that the patient has enough experience with AAU to recognize the prodrome accurately.

There are at least 3 randomized trials on sulfasalazine to prevent recurrent AAU in association with B27. Each is quite small, but each reached the same conclusion: sulfasalazine is very effective in reducing the likelihood of a recurrent attack, roughly as good as a monoclonal anti-TNF and probably better than anti-IL-17. I do not expect sulfasalazine to improv...

Dr. @Kolfenbach's answer is very much appreciated. In this specific case, the patient's history involves recent melanoma rather than other types of skin cancer. Nearly every biologic and immunosuppressant has associated case reports indicating melanoma recurrence post-immunosuppression or biologic use. However, it remains unclear whether these recurrences would have occurred regardless or were induced by immune suppression. Knowing the stage of melanoma is crucial, as more advanced stages might deter my recommendation for immune suppressive therapy. Notably, the only immune suppressant lacking reported melanoma recurrence is cyclosporine, though it isn't recognized as effective in axial spondyloarthropathy. I agree that this is a shared dec...

As for isolated acute anterior HLA-B27-associated uveitis (AAU), I agree that topical therapy is the mainstay of uncomplicated cases of AAU that are not severe. However, patients with AAU that have more than 2+ cell grade on slit lamp exam in the anterior chamber (not a rare occurrence at all), impending synechiae formation, or other signs of intense intraocular (IO) inflammation and its immediate complications during flares, temporary systemic immunosuppression (taper from 1 mg/kg/day prednisone equivalent over one month or slightly more) may limit permanent damage to the blood eye barrier(s) and thus the recurrence rate and other long-term sequelae. The indication for such time-limited immunosuppressive treatment does not automatically in...