Methotrexate and Mycophenolate Mofetil for UVEITIS

Study Overview
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Brief Summary
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In the First-line Antimetabolites as Steroid-sparing Treatment (FAST) Uveitis Trial, the investigators propose to establish which immunosuppressive therapy, methotrexate or mycophenolate mofetil, is more effective as a first-line, corticosteroid-sparing agent for the treatment of non-infectious uveitis in a block-randomized, observer-masked, comparative effectiveness trial.

Detailed Description
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This is a randomized comparative effectiveness trial to determine which treatment, methotrexate or mycophenolate mofetil, is more effective as first-line corticosteroid-sparing treatment for patients with non-infectious intermediate, posterior and panuveitis requiring corticosteroid-sparing therapy. The primary outcome is treatment success assessed at the 6 month visit (Phase 1, 0-6 months). If patients are a treatment success, they continue on the medication for another 6 months (Phase 1, 6-12 months). Patients who are a treatment failure can crossover to the other medication (Phase 2, 0-6 months).

Official Title
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First-line Antimetabolites as Steroid-sparing Treatment (FAST) Uveitis Trial

Conditions
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Uveitis

Intervention / Treatment
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* Drug: Mycophenolate mofetil
* Drug: Methotrexate
* Drug: Prednisone


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: All the following criteria must be met at enrollment: Historical non-infectious intermediate, anterior and intermediate, posterior or panuveitis in at least one eye Active inflammation within the last 180 days, defined by the presence of any of the following (in at least one eye) according to SUN criteria: ≥ 2+ anterior chamber cells ≥ 2+ vitreous haze active retinal or choroidal lesions Active inflammation at enrollment, defined by the presence of any of the following (in at least one eye) according to SUN criteria: ≥1+ anterior chamber cells and/or ≥1+ vitreous haze and/or active retinal/choroidal lesions At least one of the following criteria must be met before or at enrollment: Active inflammation after 4 weeks of high-dose (1mg/kg prednisone equivalent) corticosteroid treatment or 4 weeks following a regional corticosteroid injection Treatment with oral corticosteroids resulting in a reduction of inflammation, followed by an increase in inflammation (of at least 1 grade in anterior chamber cells or vitreous haze or a change of non-active to active lesions) when corticosteroid is tapered, in the 180 weeks prior to enrollment Active inflammation after long-acting corticosteroid injection 4 weeks to 180 days prior to enrollment Active inflammation after treatment with >10mg/day oral prednisone for at least the past 90 days prior to enrollment Known chronic condition necessitating corticosteroid-sparing immunosuppressive treatment: Behcet's disease with posterior segment involvement, multifocal choroiditis with panuveitis, serpiginous choroidopathy, birdshot retinochoroidopathy, diffuse retinal vasculitis, Vogt-Koyanagi-Harada with bullous serous retinal detachments and/or choroidal detachments, sympathetic ophthalmia. No prior therapy required for these patients Willingness to start corticosteroid treatment at 1mg/kg or 60mg a day of prednisone, whichever is less Willingness to limit alcohol consumption Willingness to use an acceptable method of contraception during the study period (i.e. pharmacologics, devices, barrier methods) or abstinence. Exclusion Criteria: Any of the following Any infectious cause of uveitis Prior immunosuppressive therapy other than corticosteroids in the past 12 months Prior intolerability or safety issues with methotrexate or mycophenolate mofetil Prior failure to control ocular or other inflammation using methotrexate or mycophenolate mofetil Prior biologic therapy at any time Media opacity (such as cataract and/or corneal scar) and/or extensive posterior synechiae such that examination of the posterior segment is not possible in both eyes Chronic hypotony (IOP < 5 mm Hg for > 3 months) in both eyes Periocular or intravitreal corticosteroid injection in the past 4 weeks Fluocinolone acetonide implant in either eye in < 3 years Intraocular surgery in < 30 days, or planning on getting surgery within the next 6 months Best spectacle-corrected visual acuity (BSCVA) of hand motions or worse in better eye < 16 years of age at enrollment Planning to conceive during the study period, pregnant or breast-feeding (blood or urine pregnancy test for all females, excluding those who are post-menopausal is mandatory)* Any history of cancer (If a patient has a history of non-melanoma skin cancer they can still be considered for inclusion in this study, provided it is not currently active). Systemic autoimmune disease anticipated to dictate treatment course Abnormal Complete blood count (≤ 2,500 white blood cells and/or ≤ 75,000 platelets and/or ≤9 hemoglobin) within 4 weeks prior to enrollment* Abnormal alanine aminotransferase (ALT) and/or aspartate aminotransferase (AST) ≥ 2 times the upper limit of normal for the lab and/or creatinine ≥ 1.5 within 4 weeks prior to enrollment* Evidence of active tuberculosis, HIV infection, syphilis, or hepatitis B or C (patients must have a tuberculin skin test, or interferon-gamma release assay, a chest radiograph, RPR/VDRL, FTA-ABS, or other treponemal tests, Hepatitis B surface antigen, Hepatitis C antibody tests, and HIV test within 90 days prior to enrollment)** *Testing required within 4 weeks prior to enrollment; **Testing required within 90 days prior to enrollment.

Ages Eligible for Study
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Minimum Age: 16 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Crossover Assignment
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Methotrexate<br>oral methotrexate | Drug: Methotrexate<br>* For the first two weeks, an introductory dose of 15 mg/week (7.5mg BID once a week) orally. After two weeks, the dose will be increased to 25 mg/week (12.5mg BID once a week)<br>Drug: Prednisone<br>* All patients enrolled in the study will be initially taking concomitant oral corticosteroids at 1 mg/kg or 60 mg daily, whichever is less. Initial corticosteroid dose will be continued for 2 to 4 weeks at which point prednisone will be gradually tapered. Prednisone will be tapered to and held at 7.5 mg/day for the first 6 months of the study.<br>|
| Experimental: Mycophenolate Mofetil<br>oral mycophenolate mofetil | Drug: Mycophenolate mofetil<br>* For the first two weeks, an introductory dose of 500 mg BID orally. After two weeks, the dose will be increased to 1.5 g BID.<br>* Other names: Cellcept;Drug: Prednisone<br>* All patients enrolled in the study will be initially taking concomitant oral corticosteroids at 1 mg/kg or 60 mg daily, whichever is less. Initial corticosteroid dose will be continued for 2 to 4 weeks at which point prednisone will be gradually tapered. Prednisone will be tapered to and held at 7.5 mg/day for the first 6 months of the study.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of Participants Achieving Treatment Success at 6 Months (Phase I, 0-6 Months) | Controlled ocular inflammation (≤ 0.5+ anterior chamber cells, ≤ 0.5+ vitreous haze, no active retinal/choroidal lesions in both eyes) with 7.5 mg/day of oral prednisone and ≤ 2 drops/day of topical 1% prednisolone acetate. | 6 Months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of Participants Achieving Treatment Success at 12 Months on Same Medication (Phase I, 6-12 Months) | Controlled ocular inflammation (≤ 0.5+ anterior chamber cells, ≤ 0.5+ vitreous haze, no active retinal/choroidal lesions in both eyes) with 7.5 mg/day of oral prednisone and ≤ 2 drops/day of topical 1% prednisolone acetate in patients who were a treatment success at the primary outcome of 6 months. | 12 Months | 
| Number of Participants Achieving Treatment Success After Switching to Other Medication (Phase II, 0-6 Months) | Controlled ocular inflammation (≤ 0.5+ anterior chamber cells, ≤ 0.5+ vitreous haze, no active retinal/choroidal lesions in both eyes) with 7.5 mg/day of oral prednisone and ≤ 2 drops/day of topical 1% prednisolone acetate for patients who crossed over to other medication following treatment failure at 6 months (or earlier). | 6 Months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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antimetabolite, noninfectious