Effect of Adalimumab for the Treatment of Uveitis in Juvenile Idiopathic Arthritis
Effect of Adalimumab for the Treatment of Uveitis in Juvenile Idiopathic Arthritis
The investigators propose to study the efficacy of adalimumab versus placebo (double-blind
 randomization on inclusion into 2 equal groups) on reduction of ocular inflammation
 quantified by laser flare photometry after two months of treatment in patients with active
 uveitis despite well conducted treatment with steroid eye drops and MTX. The primary
 objective is to demonstrate a higher response rate at 2 months in the adalimumab arm versus
 the placebo arm. Will be considered as responding patients those in whom the evaluated eye, 2
 months after inclusion, presents at least 30% reduction of inflammation on laser flare
 photometry and improvement or a stable appearance on slit lamp examination. After the second
 month, all patients wishing to continue the trial and presenting a satisfactory clinical
 state will be treated with adalimumab for a total of one year after inclusion to
 descriptively evaluate the efficacy and safety of treatment over 10 to 12 months.
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).
Inclusion Criteria:

 1. Active uveitis associated with juvenile idiopathic arthritis, with the exclusion of
 systemic JIA, juvenile-onset rheumatoid arthritis, and enthesitis-related JIA

 2. Uveitis resistant to well conducted topical steroid therapy comprising either
 dexamethasone or rimexolone at a dose adapted to the patient's situation as validated
 by one of the investigating ophthalmologists.

 3. Failure of systemic treatment with methotrexate at a dose of 0.3 to 0.6 mg.kg (without
 exceeding 25 mg) once a week for at least 3 months (except in the case of methotrexate
 intolerance).

 4. Patient who can be evaluated by laser flare photometry.

 5. Patient at least 4 years old on initiation of trial medication and weighing a minimum
 of 15 kg

 6. Signed informed consent both parents and/or patient's agreement

 7. Patient has a social security or similar

 Exclusion Criteria:

 1. Systemic JIA, juvenile-onset rheumatoid arthritis, enthesitis-related JIA (with a risk
 of red eye uveitis).

 2. History of treatment with anti-TNF alpha monoclonal antibody (either adalimumab or
 infliximab).

 3. Any contraindication to administration of immunosuppressive therapy (immune deficit,
 opportunistic infection, other severe chronic disease)

 -  History of cancer or lymphoproliferative disease other than successfully and
 completely resected squamous cell or basal cell skin cancer,

 -  Any uncontrolled disease: unstable diabetes with documented history of recurrent
 infections, unstable ischaemic heart disease, moderate to severe heart failure
 (NYHA stage III/IV), recent stroke and any other disease or condition inducing,
 in the investigator's opinion, a risk for the patient related to his/her
 participation in the trial,

 -  Positive hepatitis B or C serology indicating active infection,

 -  History of positive HIV serology,

 -  Persistent infection or severe infections requiring hospitalisation or IV
 antibiotic therapy during the 30 days prior to inclusion in the trial or oral
 antibiotic therapy during the 14 days prior to inclusion in the trial,

 -  History of clinically significant alcohol or other substance abuse during the
 previous year,

 -  Previous diagnosis or signs of demyelinating disease of the central nervous
 system,

 -  History of active tuberculosis, histoplasmosis or listeriosis,

 -  Signs of latent tuberculosis (based on a history of nontreated contamination, or
 an opacity greater than 1 cm on chest x-ray, or a positive intradermal reaction
 to 5 IU of tuberculin ≥ 5 mm).

 -  Negative urine pregnancy test in girls with childbearing potential

 4. Chronic rupture of the blood-aqueous barrier with marked flare on the initial
 examination but not modified by one month of anti-inflammatory therapy.

 5. Impossibility to monitor flare:

 -  Children < 4 years

 -  False flare due to the presence of giant cells on the surface of an artificial
 lens or in an aphakic child.

 6. Children presenting complications such as refractory glaucoma or cataract rapidly
 requiring surgery.

 7. Phthisis bulbi with hypotonia and atrophy of the ciliary body.

 8. Any other situation raising problems for maintenance of stable doses of steroids and
 immunosuppressive drugs during the period between 4 weeks before D0 and the M2
 evaluation. Authorized immunosuppressive therapies that must be maintained at stable
 dose are steroid eye drops, systemic steroid therapy and once weekly oral or
 subcutaneous MTX at a dose of 0.3 to 0.6 mg (without exceeding 25 mg).

 9. Any ophthalmologic contraindication

 10. If female and childbearing potential should have an appropriate contraceptive method
 during all study period and 5 months after last adalimumab dose. Abstinence with no
 oral contraception can be considered.