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Nguyen QD, Merrill PT, Jaffe GJ, Dick AD, Kurup SK, Sheppard J, Schlaen A, Pavesio C, Cimino L, Van Calster J, Camez AA, Kwatra NV, Song AP, Kron M, Tari S, Brézin AP. Adalimumab for prevention of uveitic flare in patients with inactive non-infectious uveitis controlled by corticosteroids (VISUAL II): a multicentre, double-masked, randomised, placebo-controlled phase 3 trial. Lancet 2016; 388:1183-92. [PMID: 27542302 DOI: 10.1016/s0140-6736(16)31339-3] [Citation(s) in RCA: 322] [Impact Index Per Article: 40.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 07/19/2016] [Accepted: 07/21/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Non-infectious uveitis is a potentially sight-threatening ocular disorder caused by chronic inflammation and its complications. Therapeutic success is limited by systemic adverse effects associated with long-term corticosteroid and immunomodulator use if topical medication is not sufficient to control the inflammation. We aimed to assess the efficacy and safety of adalimumab in patients with inactive, non-infectious uveitis controlled by systemic corticosteroids. METHODS We did this multicentre, double-masked, randomised, placebo-controlled phase 3 trial at 62 study sites in 21 countries in the USA, Canada, Europe, Israel, Australia, and Latin America. Patients (aged ≥18 years) with inactive, non-infectious intermediate, posterior, or panuveitic uveitis controlled by 10-35 mg/day of prednisone were randomly assigned (1:1), via an interactive voice and web response system with a block size of four, to receive either subcutaneous adalimumab (loading dose 80 mg; biweekly dose 40 mg) or placebo, with a mandatory prednisone taper from week 2. Randomisation was stratified by baseline immunosuppressant treatment. Sponsor personnel with direct oversight of the conduct and management of the study, investigators, study site personnel, and patients were masked to treatment allocation. The primary efficacy endpoint was time to treatment failure, a multicomponent endpoint encompassing new active inflammatory chorioretinal or inflammatory retinal vascular lesions, anterior chamber cell grade, vitreous haze grade, and visual acuity. Analysis was done in the intention-to-treat population. This trial is registered with ClinicalTrials.gov number NCT01124838. FINDINGS Between Aug 10, 2010, and May 14, 2015, we randomly assigned 229 patients to receive placebo (n=114) or adalimumab (n=115); 226 patients comprised the intention-to-treat population. Median follow-up time was 155 days (IQR 77-357) in the placebo group and 245 days (119-564) in the adalimumab group. Treatment failure occurred in 61 (55%) of 111 patients in the placebo group compared with 45 (39%) of 115 patients in the adalimumab group. Time to treatment failure was significantly improved in the adalimumab group compared with the placebo group (median not estimated [>18 months] vs 8·3 months; hazard ratio 0·57, 95% CI 0·39-0·84; p=0·004). The 40th percentile for time to treatment failure was 4·8 months in the placebo group and 10·2 months in the adalimumab group. No patients in either group had opportunistic infections (excluding oral candidiasis and tuberculosis). No malignancies were reported in the placebo group whereas one (1%) patient in the adalimumab group reported non-serious squamous cell carcinoma. The most common adverse events were arthralgia (12 [11%] patients in the placebo group and 27 [23%] patients in the adalimumab group), nasopharyngitis (16 [17%] and eight [16%] patients, respectively), and headache (17 [15%] patients in each group). INTERPRETATION Adalimumab significantly lowered the risk of uveitic flare or loss of visual acuity upon corticosteroid withdrawal in patients with inactive, non-infectious intermediate, posterior, or panuveitic uveitis controlled by systemic corticosteroids. No new safety signals were observed and the rate of adverse events was similar between groups. These findings suggest that adalimumab is well tolerated and could be an effective treatment option in this patient population. An open-label extension study (NCT01148225) is ongoing to provide long-term safety data for adalimumab in patients with non-infectious uveitis. FUNDING AbbVie.
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Affiliation(s)
- Quan Dong Nguyen
- Ocular Imaging Research and Reading Center (OIRRC), Omaha, NE, USA.
| | | | | | - Andrew D Dick
- University of Bristol, Bristol Eye Hospital, Bristol, UK; National Institute for Health Research (NIHR) Biomedical Research Centre, London, UK
| | | | - John Sheppard
- Lions Medical Eye Bank of Eastern Virginia, Eastern Virginia Medical School and Virginia Eye Consultants, Norfolk, VA, USA
| | | | - Carlos Pavesio
- Moorfields Eye Hospital and University College London, Institute of Ophthalmology, London, UK
| | - Luca Cimino
- Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia RE, Italy
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Lance KD, Good SD, Mendes TS, Ishikiriyama M, Chew P, Estes LS, Yamada K, Mudumba S, Bhisitkul RB, Desai TA. In Vitro and In Vivo Sustained Zero-Order Delivery of Rapamycin (Sirolimus) From a Biodegradable Intraocular Device. Invest Ophthalmol Vis Sci 2015; 56:7331-7. [PMID: 26559479 PMCID: PMC4642602 DOI: 10.1167/iovs.15-17757] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 10/16/2015] [Indexed: 12/16/2022] Open
Abstract
PURPOSE We created implantable intraocular devices capable of constant and continuous rapamycin release on the scale of months to years. METHODS Polycaprolactone (PCL) thin films were used to encapsulate rapamycin to create implantable and biodegradable intraocular devices. Different film devices were studied by modifying the size, thickness, and porosity of the PCL films. RESULTS In vitro release of rapamycin was observed to be constant (zero-order) through 14 weeks of study. Release rates were tunable by altering PCL film porosity and thickness. In vivo release of rapamycin was observed out through 16 weeks with concentrations in the retina-choroid in the therapeutic range. Rapamycin concentration in the blood was below the lower limit of quantification. The drug remaining in the device was chemically stable in vitro and in vivo, and was sufficient to last for upwards of 2 years of total release. The mechanism of release is related to the dissolution kinetics of crystalline rapamycin. CONCLUSIONS Microporous PCL thin film devices demonstrate good ocular compatibility and the ability to release rapamycin locally to the eye over the course of many weeks.
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Affiliation(s)
- Kevin D. Lance
- University of California at Berkeley–University of California, San Francisco Bioengineering Graduate Program, San Francisco, California, United States
| | - Samuel D. Good
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California, United States
| | - Thaís S. Mendes
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California, United States
| | - Mynna Ishikiriyama
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California, United States
| | - Patrick Chew
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, United States
| | - Laurel S. Estes
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, United States
| | - Kazuhito Yamada
- Pharmaceutical Development Group, Pharmaceutical Development Center, Santen Pharmaceutical Co., Ltd., Nara, Japan
| | - Sri Mudumba
- Pharmaceutical Development, Santen, Inc., Emeryville, California, United States
| | - Robert B. Bhisitkul
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California, United States
| | - Tejal A. Desai
- University of California at Berkeley–University of California, San Francisco Bioengineering Graduate Program, San Francisco, California, United States
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, United States
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Lu Y, Parker N, Kleindl PJ, Cross VA, Wollak K, Westrick E, Stinnette TW, Gehrke MA, Wang K, Santhapuram HKR, You F, Hahn SJ, Vaughn JF, Klein PJ, Vlahov IR, Low PS, Leamon CP. Antiinflammatory Activity of a Novel Folic Acid Targeted Conjugate of the mTOR Inhibitor Everolimus. Mol Med 2015; 21:584-96. [PMID: 26181632 PMCID: PMC4656201 DOI: 10.2119/molmed.2015.00040] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 07/08/2015] [Indexed: 02/02/2023] Open
Abstract
Folate receptor (FR)-β has been identified as a promising target for antimacrophage and antiinflammatory therapies. In the present study, we investigated EC0565, a folic acid-derivative of everolimus, as a FR-specific inhibitor of the mammalian target of rapamycin (mTOR). Because of its amphiphilic nature, EC0565 was first evaluated for water solubility, critical micelle formation, stability in culture and FR-binding specificity. Using FR-expressing macrophages, the effect of EC0565 on mTOR signaling and cellular proliferation was studied. The pharmacokinetics, metabolism and bioavailability of EC0565 were studied in normal rats. The in vivo activity of EC0565 was assessed in rats with adjuvant arthritis, a "macrophage-rich" model with close resemblance to rheumatoid arthritis. EC0565 forms micellar aggregates in physiological buffers and demonstrates good water solubility as well as strong multivalent FR-binding capacity. EC0565 inhibited mTOR signaling in rat macrophages at nanomolar concentrations and induced G0/G1 cell cycle arrest in serum-starved RAW264.7 cells. Subcutaneously administered EC0565 in rats displayed good bioavailability and a relatively long half-life (~12 h). When given at 250 nmol/kg, EC0565 selectively inhibited proliferating cell nuclear antigen expression in thioglycollate-stimulated rat peritoneal cells. With limited dosing regimens, the antiarthritic activity of EC0565 was found superior to that of etanercept, everolimus and a nontargeted everolimus analog. The in vivo activity of EC0565 was also comparable to that of a folate-targeted aminopterin. Folate-targeted mTOR inhibition may be an effective way of suppressing activated macrophages in sites of inflammation, especially in nutrient-deprived conditions, such as in the arthritic joints. Further investigation and improvement upon the physical and biochemical properties of EC0565 are warranted.
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Affiliation(s)
- Yingjuan Lu
- Endocyte, Inc., West Lafayette, Indiana, United States of America
| | - Nikki Parker
- Endocyte, Inc., West Lafayette, Indiana, United States of America
| | - Paul J Kleindl
- Endocyte, Inc., West Lafayette, Indiana, United States of America
| | - Vicky A Cross
- Endocyte, Inc., West Lafayette, Indiana, United States of America
| | - Kristin Wollak
- Endocyte, Inc., West Lafayette, Indiana, United States of America
| | - Elaine Westrick
- Endocyte, Inc., West Lafayette, Indiana, United States of America
| | | | - Mark A Gehrke
- Endocyte, Inc., West Lafayette, Indiana, United States of America
| | - Kevin Wang
- Endocyte, Inc., West Lafayette, Indiana, United States of America
| | | | - Fei You
- Endocyte, Inc., West Lafayette, Indiana, United States of America
| | - Spencer J Hahn
- Endocyte, Inc., West Lafayette, Indiana, United States of America
| | - Jeremy F Vaughn
- Endocyte, Inc., West Lafayette, Indiana, United States of America
| | - Patrick J Klein
- Endocyte, Inc., West Lafayette, Indiana, United States of America
| | - Iontcho R Vlahov
- Endocyte, Inc., West Lafayette, Indiana, United States of America
| | - Philip S Low
- Department of Chemistry, Purdue University, West Lafayette, Indiana, United States of America
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Lee K, Bajwa A, Freitas-Neto CA, Metzinger JL, Wentworth BA, Foster CS. A comprehensive review and update on the non-biologic treatment of adult noninfectious uveitis: part I. Expert Opin Pharmacother 2014; 15:2141-54. [PMID: 25226529 DOI: 10.1517/14656566.2014.948417] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Treatment of adult, noninfectious uveitis remains a challenge for ophthalmologists around the world. The disease accounts for almost 10% of preventable blindness in the US and can be idiopathic or associated with infectious and systemic disorders. Strong evidence is still emerging to indicate that pharmacologic strategies presently used in rheumatologic or autoimmune disease may be translated to the treatment of intraocular inflammation. Corticosteroid monotherapy is widely regarded as wholly inappropriate, due to the unfavorable risk/benefit profile and poor long-term outcomes. Treatment plans have shifted away from low-dose, chronic corticosteroid therapy for maintenance, towards medium- to high-dose therapy for acute inflammation, followed immediately by initiation of immunomodulatory therapy. These therapies follow the 'stepladder approach', whereby least to more aggressive therapies are trialed to induce remission of inflammation, eventually without corticosteroids of any form (topical, local and systemic). AREAS COVERED This two-part review gives a comprehensive overview of the existing medical treatment options for patients with adult, noninfectious uveitis, as well as important advances for the treatment of ocular inflammation. Part I covers classic immunomodulation and latest information on corticosteroid therapy. EXPERT OPINION The hazard of chronic corticosteroid use for the treatment of adult, noninfectious uveitis is well-documented. Corticosteroid-sparing therapies, which offer a very favorable risk-benefit profile when administered properly, should be substituted.
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Affiliation(s)
- Kyungmin Lee
- Massachusetts Eye Research and Surgery Institution , 5 Cambridge Center, 8th Floor, Cambridge, MA 02142 , USA +1 617 621 6377 ; +1 617 494 1430 ;
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Barry RJ, Nguyen QD, Lee RW, Murray PI, Denniston AK. Pharmacotherapy for uveitis: current management and emerging therapy. Clin Ophthalmol 2014; 8:1891-911. [PMID: 25284976 PMCID: PMC4181632 DOI: 10.2147/opth.s47778] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Uveitis, a group of conditions characterized by intraocular inflammation, is a major cause of sight loss in the working population. Most uveitis seen in Western countries is noninfectious and appears to be autoimmune or autoinflammatory in nature, requiring treatment with immunosuppressive and/or anti-inflammatory drugs. In this educational review, we outline the ideal characteristics of drugs for uveitis and review the data to support the use of current and emerging therapies in this context. It is crucial that we continue to develop new therapies for use in uveitis that aim to suppress disease activity, prevent accumulation of damage, and preserve visual function for patients with the minimum possible side effects.
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Affiliation(s)
- Robert J Barry
- Academic Unit of Ophthalmology, Centre for Translational Inflammation, Research, University of Birmingham, UK
| | - Quan Dong Nguyen
- Stanley M Truhlsen Eye Institute, University of Nebraska Medical Center, Omaha, NE, USA
| | - Richard W Lee
- Inflammation and Immunotherapy Theme, National Institute for Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Philip I Murray
- Academic Unit of Ophthalmology, Centre for Translational Inflammation, Research, University of Birmingham, UK
| | - Alastair K Denniston
- Academic Unit of Ophthalmology, Centre for Translational Inflammation, Research, University of Birmingham, UK ; Department of Ophthalmology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Reiff A, Kadayifcilar S, Özen S. Rheumatic Inflammatory Eye Diseases of Childhood. Rheum Dis Clin North Am 2013; 39:801-32. [DOI: 10.1016/j.rdc.2013.05.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Emerging therapies for the treatment of uveitis: clinical trial observations. ACTA ACUST UNITED AC 2013. [DOI: 10.4155/cli.13.87] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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