Evaluation of the Efficacy of Adalimumab for the Treatment of Uveitis in Juvenile Idiopathic Arthritis: Randomized Double-blind Placebo-controlled Trial
20% of patients with juvenile idiopathic arthritis (JIA) develop usually bilateral, chronic
anterior uveitis, dependent on steroid eye drops and sometimes systemic steroid therapy,
with a risk of complications such as cataract, band keratopathy and glaucoma, usually
responsible for loss of vision. No maintenance treatment has been demonstrated to be
effective. Methotrexate (MTX), the maintenance treatment most commonly used in JIA, could
have a beneficial effect, but this effect is not sufficient to stop progression of uveitis
in most patients. Our preliminary experience and that of other teams based on small series
of patients is in favour of the efficacy of anti-Tumour Necrosis Factor alpha (TNFalpha)
monoclonal antibodies (Ab) in JIA-associated uveitis. An international multicentre
randomized trial of a humanized monoclonal antibody, adalimumab, in JIA has demonstrated its
efficacy on joint lesions and its good safety as monotherapy or in combination with
methotrexate. However, children with active uveitis were excluded from this trial.
The investigators propose a French multicentre, randomized, double-blind, placebo-controlled
trial to evaluate the efficacy of adalimumab in JIA-associated uveitis in patients over the
age of 4 years. These patients must have active uveitis (Laser flare-cell meter score of at
least 30 photons/ms) despite topical steroid therapy, with intolerance or failure to at
least 3 months of MTX therapy. The dose of adalimumab will be 40 mg eow for children age 13
and over and for children younger than 13 adalimumab 24 mg per m2 BSA (up to a maximum
total body dose of 40 mg). The activity of uveitis will be evaluated by laser flare
photometry, a recently validated technique for follow-up of the efficacy of treatments of
anterior uveitis. Seven hospital ophthalmology departments in France are equipped with laser
flare photometry and have a sufficient experience to participate in this trial
(Paris-Pitie-Salpetriere, Paris-Cochin, Nantes, Lille, Grenoble, Bordeaux and Lyon). Several
teams of paediatric rheumatologists and hospital rheumatologists working with these
ophthalmology departments will also be able to include patients. The primary endpoint is an
at least 30% reduction of ocular inflammation after 2 months of treatment, quantified by
laser flare photometry, considering the more severely affected eye in the case of bilateral
uveitis. Based on the hypothesis of a response rate of at least 50% with adalimumab versus a
maximum of 10% with placebo, comparison of two groups of 19 patients would be sufficient to
conclude on a significant difference for a two-sided alpha risk of p=0.05 and a power of
80%. The investigators therefore plan to include 40 patients with randomization to two equal
groups, one receiving 4 subcutaneous injections of adalimumab and the other receiving 4
injections of placebo on D0, D14, D28, and D42 with assessment of the primary endpoint at
M2. The planned duration of inclusion is 2 years with a total duration of the trial of 3
years. From visit M2 onwards, all patients will be treated by adalimumab injections every 2
weeks and will be followed for 1 year of treatment. Clinical, laboratory and
ophthalmological evaluation including laser flare photometry and conventional slit lamp
examination will be performed at each visit (pre-inclusion, D0, D14, M1, M2, M3, M4, M5, M6,
M9 and M12). Deterioration of ocular inflammation during the first 2 months will justify
decoding for the patient concerned who will be considered to be a treatment failure.
A study will be conducted in parallel: gene expression profile studies on whole blood by a
team experienced in the study of JIA and other inflammatory diseases (Dr Pascual, Dallas,
USA).
Interventional
Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Crossover Assignment, Masking: Double Blind (Subject, Investigator), Primary Purpose: Treatment
To demonstrate that a higher proportion of subjects will have an improvement of uveitis on adalimumab versus placebo after 2 months relative to baseline
The primary objective is to demonstrate the efficacy of 2 months of treatment with adalimumab versus placebo on reduction of ocular inflammation in JIA-associated uveitis. By defining response to treatment as a reduction of at least 30% of ocular inflammation quantified by laser flare photometry in the initially more severely inflamed eye without deterioration of cell count or flare protein on slit lamp examination, we formulate the hypothesis that at least 50% of patients treated with adalimumab for 2 months will respond to treatment versus a maximum 10% of patients on placebo.
Final visit could occur at any point up to 78 weeks
Yes
Pierre Quartier dit Maire, MD, PhD
Principal Investigator
hospital Necker Enfants Malades
France: Ministry of Health
P081210
NCT01385826
June 2011
December 2014
Name | Location |
---|