Adalimumab vs. Conventional Immunosuppression for Uveitis Trial
a study on Uveitis
Non-infectious intermediate, posterior, and panuveitides are chronic, potentially-blinding diseases. Vision-threatening cases require long-term therapy with oral corticosteroids and immunosuppression. Based upon preliminary data, adalimumab, a fully-human, anti-TNF-α monoclonal antibody, now US FDA-approved for uveitis treatment, may be a superior corticosteroid-sparing agent than conventional immunosuppressive drugs. The ADVISE Trial is multicenter randomized, parallel-treatment, comparative effectiveness trial comparing adalimumab to conventional (small molecule) immunosuppression for corticosteroid spring in the treatment of non-infectious, intermediate, posterior, and panuveitides.
Abstract from protocol: The uveitides are a collection of diseases characterized by intraocular inflammation. Collectively, they are the 5th leading cause of blindness in the US, and the estimated cost of treating them is similar to that of treating diabetic retinopathy. Non-infectious intermediate, posterior, and panuveitides have the highest rates of visual loss and typically are treated with oral corticosteroids and immunosuppression. The Multicenter Uveitis Steroid Treatment (MUST) Trial (a randomized, comparative effectiveness trial, which compared 2 treatment paradigms for these diseases, systemic therapy with corticosteroids and immunosuppression vs. regional therapy [the fluocinolone acetonide implant]), and Follow-up Study demonstrated the superiority of the systemic approach to the regional ocular approach in terms of long-term visual outcomes with essentially no increase in systemic side effects in the systemic group. One key to systemic therapy's success was the use of systemic immunosuppression in 88% of participants, coupled with tapering the prednisone to <7.5 mg/day, a relatively safe dose. Non-alklyating agents are typically the first choice and the most often used are azathioprine, methotrexate, mycophenolate, cyclosporine, and tacrolimus. The alkylating agents, cyclophosphamide and chlorambucil, are used less often because of concerns about potential increased malignancy risk. Data from the Systemic Immunosuppressive Therapy for Eye Diseases (SITE) Cohort Study suggest that each of the conventional, non-alkylating agent immunosuppressive drugs is effective in controlling the inflammation while permitting tapering prednisone in ~40-55% of patients; hence combination therapy often is needed. Furthermore, minimizing the daily dose of prednisone is important, as the risk of cardiovascular disease and mortality increase with the cumulative dose of oral corticosteroids. In June 2016, the fully-human, anti-TNF-α monoclonal antibody, adalimumab, was approved by the US Food and Drug Administration (FDA) for the treatment of uveitis. Anti-TNF-α monoclonal antibody therapy has revolutionized the management of the rheumatic diseases largely due to its superior efficacy compared to conventional Disease Modifying Anti-Rheumatic Drugs. Data from VISUAL III, the extension of the two phase 3 trials that led to the FDA approval of adalimumab for the treatment of uveitis, suggest that adalimumab may be superior to conventional immunosuppression, as ~75% of participants had controlled inflammation with prednisone doses <5 mg/day. The ADalimumab Vs. conventional ImmunoSupprEssion for uveitis (ADVISE) Trial is a randomized, comparative effectiveness trial comparing adalimumab to conventional agent immunosuppression for patients with non-infectious, intermediate, posterior, and panuveitides. The primary outcome is the ability to successfully taper prednisone to <7.5 mg/day by 6 months after randomization while maintaining control of the inflammation. Secondary outcomes include prednisone discontinuation by 1 year, visual acuity, and complications of uveitis and its treatment.
ADVISE is being conducted under IND 132532. Adalimumab was FDA approved for the treatment of non-infectious intermediate, posterior, and panuveitides in adult patients in 2016 and in pediatric patients 2 years of age and older in 2018. In 2016, prior to the approval for pediatric patients, the FDA determined that use of adalimumab for the treatment of non-infectious intermediate, posterior, and panuveitides in adolescent patients in the ADVISE Trial does not increase risk for these patients as the drug is approved for treatment of pediatric patients for other indications. Although conventional immunosuppressive drugs are the standard approach and in widespread use, these drugs are not FDA approved for treatment of non-infectious intermediate, posterior, and panuveitides, and therefore an IND has been issued for this trial.
Uveitis Methotrexate Azathioprine Cyclosporine Tacrolimus Cyclosporins Mycophenolic Acid Adalimumab Adalimumab (ADA) Conventional immunosuppression (CON)
You can join if…
Open to people ages 13 years and up
- Age 13 years or older
- Active or recently active (≤ 60 days) non-infectious, intermediate, posterior, or panuveitis
- Prednisone indication meets one of the following:
- Active uveitis requiring one of the following i. Initiation of prednisone at dose greater than 7.5 mg/day ii. Increasing prednisone dose to greater than 7.5 mg/day iii.Currently receiving dose greater than 7.5 mg/day
- Inactive uveitis on current dose greater 7.5 mg/day
- Initiation or addition of an immunosuppressive drug (i.e., a conventional immunosuppressive drug or adalimumab) is indicated
- If currently receiving a conventional immunosuppressive drug, the drug and dose have been stable for at least 30 days
- Patient able and willing to self-administer subcutaneous injections or have a qualified person available to administer subcutaneous injections
- If posterior segment disease is present, ability to assess activity in at least one eye with uveitis
- Visual acuity of light perception or better in at least one eye with uveitis
You CAN'T join if...
- Active tuberculosis or untreated latent tuberculosis (e.g., positive interferon-γ release assay [IGRA] test, such as Quantiferon-gold)
- Untreated active hepatitis B or C infection
- Behçet disease
- Multiple sclerosis
- For patients with intermediate uveitis, abnormal magnetic resonance imaging (MRI) of the brain consistent with demyelinating disease
- Use of anti-TNF monoclonal antibody therapy within past 60 days
- History of adalimumab intolerance or ineffectiveness
- Current treatment with an alkylating agent
- Current treatment with more than one immunosuppressive drug, not including oral corticosteroids
- . Shorter-acting regional corticosteroids administered within the past 30 days in any eye(s) with uveitis
- . Long-acting ocular corticosteroid implants, i.e., fluocinolone acetonide implant(e.g., Retisert®, YutiqTM, Iluvien®) placed within past 3 years unless uveitis is active in all eye(s) with an implant
- . Systemic disease that is sufficiently active such that it dictates therapy with systemic corticosteroids or immunosuppressive agents at the time of enrollment
- . Immunodeficiency disease for which immunosuppressive therapy would be contraindicated according to best medical judgment
- . Pregnancy, lactation, or for women of child-bearing potential unwillingness to use appropriate birth control for the duration of the trial
- . Medical problems or drug or alcohol dependence problems sufficient to prevent adherence to treatment and study procedures.
- University of California, San Francisco not yet accepting patients
San Francisco California 94143 United States
- Jules Stein Eye Institute, UCLA not yet accepting patients
Los Angeles California 90095 United States
Lead Scientist at UCSF
- Nisha Acharya
Nisha Acharya is the Director of the Uveitis and Ocular Inflammatory Disease Service and the Uveitis Fellowship at the F.I. Proctor Foundation. Her clinical expertise is the diagnosis and management of patients with infectious and inflammatory eye diseases. She is experienced with the latest treatments for uveitis, including treatment with new immunomodulatory drugs and biologic therapies.
- not yet accepting patients
- Start Date
- Completion Date
- JHSPH Center for Clinical Trials
- Phase 4
- Study Type
- Last Updated
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