Adalimumab vs. Conventional Immunosuppression for Uveitis Trial

Uveitis Clinical Trial

— ADVISE  

Official title:

Adalimumab vs. Conventional Immunosuppression for Uveitis Trial

Clinical Trial Details — Status: Active, not recruiting

Administrative data

• NCT number: NCT03828019
• Other study ID #: 9196
• Status: Active, not recruiting
• Phase: Phase 3
• Start date: September 16, 2019
• Est. completion date: September 17, 2024

Study information

• Verified date: November 2023
• Source: JHSPH Center for Clinical Trials
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

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.

Description:

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.

Recruitment information / eligibility

• Status: Active, not recruiting
• Enrollment: 222
• Est. completion date: September 17, 2024
• Est. primary completion date: April 12, 2024
• Accepts healthy volunteers: No
• Gender: All
• Age group: 13 Years and older

Eligibility

Inclusion criteria

1. Age 13 years or older

2. Weight 30 kg (66 lbs) or greater

3. Active or recently active (= 60 days) non-infectious intermediate, posterior, or panuveitis

4. Prednisone indication meets one of the following:

1. 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

2. Inactive uveitis on current dose greater 7.5 mg/day

5. Initiation or addition of an immunosuppressive drug (i.e., a conventional immunosuppressive drug or adalimumab) is indicated

6. If currently receiving a conventional immunosuppressive drug, the drug and dose have been stable for at least 30 days

7. Patient able and willing to self-administer subcutaneous injections or have a qualified person available to administer subcutaneous injections

8. If posterior segment disease is present, ability to assess activity in at least one eye with uveitis

9. Visual acuity of light perception or better in at least one eye with uveitis

Exclusion criteria

1. Active tuberculosis or untreated latent tuberculosis (e.g., positive interferon-? release assay [IGRA] test, such as Quantiferon-gold)

2. Untreated active hepatitis B or C infection

3. Any of the following baseline lab values

1. White blood count <3500 cells per microliter

2. Platelets <100,000 per microliter

3. Hematocrit <30%

4. AST or ALT >1.5X upper limit normal value

5. Serum creatinine >1.1X upper limit normal value

4. Behçet disease

5. Multiple sclerosis or other demyelinating disease

6. For patients with anterior/intermediate or intermediate uveitis without systemic disease, abnormal magnetic resonance imaging (MRI) of the brain consistent with demyelinating disease

7. Severe uncontrolled infection

8. Receipt of a live vaccine within past 30 days

9. Moderate to severe heart failure (NYHA class III/IV)

10. Active malignancy

11. Use of anti-TNF monoclonal antibody therapy within past 60 days

12. History of adalimumab intolerance or ineffectiveness

13. Hypersensitivity to any of the study treatments or their excipients

14. Current treatment with an alkylating agent

15. Current treatment with more than one immunosuppressive drug, not including oral corticosteroids

16. Shorter-acting regional corticosteroids administered within the past 30 days in any eye(s) with uveitis

17. 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

18. Systemic disease that is sufficiently active such that it dictates therapy with systemic corticosteroids or immunosuppressive agents at the time of enrollment

19. Immunodeficiency disease for which immunosuppressive therapy would be contraindicated according to best medical judgment

20. Pregnancy or lactation

21. For persons of child-bearing potential or impregnating potential, unwillingness to use appropriate birth control (abstinence, combination barrier and spermicide, hormonal, or intrauterine device) for the next 18 months or plans to become a biological parent within the next 18 months.

• In the UK, use of combination barrier and spermicide alone does not meet birth control requirements.

† UK female study participants must use highly effective methods of contraception.

UK male study participants must use condoms for at least 6 months after the end of study treatment and their female partners of child-bearing potential are recommended to use highly effective contraception for the same duration. In addition, male participants should not donate semen during therapy or for 6 months following discontinuation of study treatment.

22. Medical problems or drug or alcohol dependence problems sufficient to prevent adherence to treatment and study procedures.

Related Conditions & MeSH terms

• Uveitis

Intervention

Biological:
• Adalimumab (ADA)
Adalimumab is a fully-human monoclonal antibody to TNF-a, which is approved by the U.S. FDA for the treatment of non-infectious intermediate, posterior, and panuveitides in adults and children 2 years of age and older.

Drug:
• Conventional immunosuppression (CON)
The study ophthalmologist will select amongst the permissible drugs (methotrexate, mycophenolate mofetil or azathioprine for antimetabolites; cyclosporine or tacrolimus for calcineurin inhibitors) taking into account the side effect profile of each drug with respect to subject's clinical situation.

Locations

Country	Name	City	State
Australia	Centre for Eye Research Australia	East Melbourne	Victoria
Australia	University of Sydney	Sydney
Canada	McGill University	Montréal	Quebec
United Kingdom	Bradford Teaching Hospital NHS Foundation Trust	Bradford
United Kingdom	Cambridge University NHS Trust	Cambridge
United Kingdom	University Hospital Birmingham	Edgbaston	Birmingham
United Kingdom	University Hospitals of Leicester	Leicester
United Kingdom	Moorfields Eye Hospital NHS Foundation Trust	London
United States	University of Michigan Health System, Kellogg Eye Center	Ann Arbor	Michigan
United States	Emory University	Atlanta	Georgia
United States	Johns Hopkins University	Baltimore	Maryland
United States	Retinal Consultants of Texas	Bellaire	Texas
United States	National Eye Institute	Bethesda	Maryland
United States	Ophthalmic Consultants of Boston	Boston	Massachusetts
United States	Northwestern University	Chicago	Illinois
United States	Rush University Medical Center	Chicago	Illinois
United States	University of Iowa	Iowa City	Iowa
United States	Jules Stein Eye Institute, UCLA	Los Angeles	California
United States	Anne Bates Leach Eye Hospital, University of Miami Miller School of Medicine	Miami	Florida
United States	Tennessee Retina	Nashville	Tennessee
United States	Vanderbilt University Eye Institute	Nashville	Tennessee
United States	MidAtlantic Retina, Wills Eye Hospital	Philadelphia	Pennsylvania
United States	University of Pennsylvania	Philadelphia	Pennsylvania
United States	University of Pittsburgh Medical Center	Pittsburgh	Pennsylvania
United States	Washington University	Saint Louis	Missouri
United States	University of Utah, Moran Eye Center	Salt Lake City	Utah
United States	University of California, San Francisco	San Francisco	California
United States	University of Washington, Medicine Eye Institute	Seattle	Washington

Sponsors (1)

Lead Sponsor	Collaborator
JHSPH Center for Clinical Trials

Countries where clinical trial is conducted

United States,  Australia,  Canada,  United Kingdom, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Corticosteroid-sparing treatment success within the first 6 months after randomization	Corticosteroid-sparing success is defined as achieving inactive uveitis for two consecutive visits >= 28 days apart while on <= 7.5 mg/day of corticosteroids. Uveitis status (active vs inactive) is determined by the study ophthalmologist after reviewing the eye exam and imaging.	6 months
Secondary	Corticosteroid-sparing treatment success within the first 12 months after randomization	Corticosteroid-sparing success is defined as achieving inactive uveitis for two consecutive visits >= 28 days apart while on <= 7.5 mg/day of corticosteroids. Uveitis status (active vs inactive) is determined by the study ophthalmologist after reviewing the eye exam and imaging.	12 months
Secondary	Prednisone discontinuation success	Prednisone discontinuation success is defined as achieving inactive uveitis for two consecutive visits >= 28 days apart after discontinuing corticosteroids. Uveitis status (active vs inactive) is determined by the study ophthalmologist after reviewing the eye exam and imaging.	12 months
Secondary	Prednisone exposure	E.g., cumulative prednisone dose and/or mean prednisone dose	12 months
Secondary	Best corrected visual acuity	Best corrected visual acuity measured after a standardized refraction using logarithmic visual acuity charts	12 months
Secondary	Infections	Incidence of infections over 12 months of follow-up	12 months
Secondary	Systemic adverse events	Systemic adverse events over 12 months of follow-up	12 months
Secondary	Macular edema	Macular edema over 12 months of follow-up	12 months
Secondary	Health utility	Health utility will be measured using the EQ-5D	12 months
Secondary	Generic health-related quality of life	Generic health-related quality of life will be measured using the SF-36	12 months
Secondary	Vision-related quality of life	Vision-related quality of life will be measured using the NEI-VFQ-25	12 months