ASTUTE – a new clinical trial starting

We are pleased to tell you about a new clinical trial called ASTUTE which is due to start in England in 2021. BUS has been involved in helping plan this trial.   

ASTUTE will use an adalimumab biosimilar as the study medication. This will be added on to existing standard treatments for non-infectious autoimmune uveitis. Adalimumab biosimilars are newer, highly similar versions of the original adalimumab, Humira. 

The ASTUTE trial will be looking at how effective the study medication is, how well it is tolerated and how cost-effective it is. 

ASTUTE is designed to help doctors find out how the use of an adalimumab biosimilar might improve the treatment of a broad group of non-infectious autoimmune uveitis patients. The trial should also show which patients would benefit the most from adalimumab treatment.

Birdshot patients who do not currently meet the NICE criteria in England for adalimumab treatment may be considered for enrolment in the ASTUTE trial, as well as those who do.

To find out more about ASTUTE and to read the patient information leaflet, go to https://bristoltrialscentre.blogs.bristol.ac.uk/details-of-studies/astute/

Future newsletters will include updates on how the ASTUTE trial is progressing, and we will also let you know which hospital sites have opened for recruitment to the trial. 

July 2021

Birdshot ABC project July 2021

 The Birdshot ABC study is now re-opening at sites after temporarily pausing due to COVID-19. We are very excited to re-open the study and also to implement a brand-new database which has been specifically designed for the study. 

If you have alreadyconsented to the study, the research team that you see may be in touch to re-consent you to the new version of the study documents; this may be via post, telephone or at your next clinic visit. You will be asked to re-consent because there have been some minor changes to the study, and we need to make sure you are happy with the changes. Re-consenting involves reading the new Participant Information Sheet (PIS) and then signing a new updated consent form if you agree to the changes. 

The main changes are: 

Recruitment: Participants can now be sent information about the study in the post and can consent to the study on the telephone

Data collection: The study now collects anonymised eye images as well as data 

Data collection tool: The study now uses a new database provided by an external company called Big Picture Medical. Big Picture are experts in data collection for ophthalmic diseases, and University Hospitals Birmingham, as study sponsor, has a contract in place with them to make sure data is used only for the purposes of the research study. 

If you haven’t yet consented to the study and want to take part, the sites below are currently open for recruitment: 

  • Guy’s and St Thomas’ NHS Foundation Trust – Miles Stanford
  • Manchester University NHS Foundation Trust – Laura Steeples
  • University Hospitals Birmingham NHS foundation Trust – Alastair Denniston
  • Moorfields Eye Hospital NHS Foundation Trust – Narciss Okhravi

The sites below are taking park but are currently still paused to recruitment. However, they should be opening soon:

  • University Hospitals Bristol NHS Foundation Trust – Andrew Dick
  • Leeds Teaching Hospitals NHS Trust – Kanchan Bhan

If you want to take part in the study, please ask at your next hospital appointment or ask for your details to be passed on to the research team, who should then follow up with you.

If your hospital isn’t taking part yet, don’t worry. Our long term vision is to have all UK hospitals that care for birdshot patients signed up to the study. This does, however, take time, so we will keep you updated when new centres come on board.

Birdshot research update March 2020

Medical research takes money, and we’re grateful that BUS members continue to find imaginative ways to fundraise for research. However, research also takes time, so we thought you might like to know how some of our BUS-sponsored research projects are progressing.

Genetic control of iron levels in birdshot uveitis

What Dr Graham Wallace, University of Birmingham, wants to investigate is the association between the presence of HLA-A29 (which is carried by nearly all patients with birdshot) and an alteration in another gene which can cause iron overload in the body. Iron is essential for retinal function, and its levels are controlled by iron-regulating proteins. However, too much iron in eye tissues can cause damage. Dr Wallace intends to examine the genetic makeup of 75 birdshot uveitis patient samples from the UK Birdshot Biobank and also investigate the samples’ iron levels, looking for any connections between iron levels and birdshot. 

Doing medical research often meets obstacles. In Dr Wallace’s study, the obstacle has been a lack of birdshot patient blood samples because setting up the UK Birdshot Biobank took much longer than expected. As the number of patient blood samples increases in the biobank, the study should be able to proceed. 

We look forward to hearing more about this project.

A closer look at birdshot retinal cells

Changes in the retina occur in birdshot uveitis, particularly in the retinal pigment epithelium (RPE) cells. Until now, it has been very difficult to obtain samples of eye tissue from birdshot patients for studies. Dr Gonzales-Cordero and colleagues at University College London Institute of Ophthalmology wanted to find out if it was possible to use a technique called induced pluripotent stem-cell (iPS) modelling to generate RPE cells from birdshot patient’ blood samples. This would enable the cells to be studied in detail.

The investigators have successfully achieved this, even though the birdshot patients who donated blood samples were all receiving immunosuppressant treatment. The birdshot-derived RPE cells were found to be HLA-A29 positive, as were the birdshot blood sample donors.

These results are an exciting step forward because the iPS-derived RPE cell lines will become a continuing birdshot research resource. The researchers hope that these cell lines might eventually provide a laboratory method for testing new uveitis treatments or gene therapies. 

Are there any early signs or symptoms that predict birdshot’s course?

This is a question that, till now, has been frequently asked but for which there have been few definite answers because birdshot’s progress is very unpredictable, even when treatment is started early. Mr Mark Westcott and colleagues at Moorfields Eye Hospital, London, have studied a large number of their birdshot patients’ medical records to look for possible answers.

They found that birdshot patients who at diagnosis had either normal Humphrey visual fields, or good dark-adapted electroretinogram (ERG) test results, or the absence of retinal atrophy, were most likely to have good treatment outcomes. Reassuringly, having birdshot diagnosed at a young age, or having macular oedema and poor vision at diagnosis, did not appear to affect the chances of eventually achieving a good treatment result. 

These findings should allow ophthalmologists to be able to give newly-diagnosed patients some guidance on the possible progress of their birdshot.

Creating a Health Utility Value for birdshot

Receiving a diagnosis of birdshot, learning to live with its effects on vision and dealing with the side-effects of treatments all contribute to alterations in health-related quality of life (QoL). Professor Philip Murray and colleagues at University of Birmingham set out to identify the effects of birdshot on QoL, not only to assist doctors in understanding their patients’ problems better, but also to assist in wider official decision-making in evaluating treatments for birdshot. Creating a Health Utility Value specifically for birdshot – a patient estimate of their overall health state – would be a valuable evaluation tool.

Birdshot patients were recruited to complete a series of internationally recognised standardised QoL questionnaires. The results were combined with a set range of eye-related clinical observations made on each patient.

Preliminary results indicate that QoL is affected in birdshot patients, but not to the same extent as in patients with other types of uveitis affecting both eyes, Future studies could include asking patients to complete specific depression and anxiety questionnaires. This would add to the value of this pioneering research into QoL in birdshot.

Birdshot Day 2018, SESSION 2

Interviews with Jennifer Thorne and Marina Mesquida

BUS was fortunate to have Professor Andrew Dick to undertake these interviews.

We were delighted and honoured to welcome Professor Jennifer Thorne to the 2018 Birdshot Day.  She and several of her birdshot patients had made the journey to the UK from Baltimore in the USA specially to take part. Professor Dick asks Jennifer Thorne about her work:  what led her to specialising in birdshot uveitis and other inflammatory eye diseases.

Dr Marina Mesquida, a former research student of Professor Andrew Dick, travelled from Switzerland to attend the Birdshot Day. Here she is being quizzed by Andrew Dick about her move from the world of birdshot research in a hospital setting to a very different environment in one of the larger pharmaceutical companies based in Switzerland



Brief notes on the participants:

Professor Andrew Dick BSc(Hons), MBBS, MD, FRCP(Ed), FRCS(Ed & Lond), FRCOphth, FMedSci, FRSB, FARVOwho is Duke Elder Chair and Director of University College London, Institute of Ophthalmology, Faculty of Brain Sciences. He is Head and Chair of Ophthalmology, University of Bristol, and the lead clinician for the Regional Ocular Inflammatory Service, South West England. He also serves on Faculty and is Theme Lead for Inflammation and Immunotherapeutics, Biomedical Research Centre – Ophthalmology, Moorfields Eye Hospital and UCL Institute of Ophthalmology, UCL.


Professor Jennifer E Thorne, MD, PhD is Chief, Division of Ocular Immunology and Uveitis Cross Family Professor of Ophthalmology and Epidemiology at the Wilmer Eye Institute, Johns Hopkins Hospital, Baltimore, Maryland, US. She is a board-certified ophthalmologist and an expert in the evaluation and management of patients with uveitis and other related immune-mediated disorders. Dr Thorne participates in numerous research projects on the clinical and treatment outcomes of uveitis, including white spot syndromes such as birdshot chorioretinitis and paediatric uveitis. She is national protocol chair of the MUST-sponsored POINT study on uveitic macular oedema; principal investigator of a study in the effectiveness of the dexamethasone implant in the treatment of uveitis. Her research, funded by the National Institutes of Health (NIH) and other agencies, is focused on understanding which treatments for uveitis offer the best balance of effectiveness and safety to preserve patients’ vision and quality of life in a cost-effective manner.

Marina Mesquida MD MSc PhD is an ophthalmologist clinician scientist. She obtained her degree in medicine and surgery at the University of Lleida, Spain, then completed her residency in ophthalmology at the Hospital Clinic Barcelona, where she graduated with numerous research awards. After undertaking a Master’s degree (MSc) in autoimmune diseases, she studied for a PhD in ocular immunology and inflammation at the University of Barcelona, followed by postdoctoral training at the University of Bristol, UK. She served as a consultant ophthalmologist specialising in medical retina and uveitis at the Hospital Clinic of Barcelona for 10 years, where she was also appointed head of the Ophthalmology Clinical Research Unit at the Fundació Clínic per a la Recerca Biomèdica.Marina has authored more than 50 peer-reviewed publications and 20 book chapters, with her major scientific interests being the role of interleukin 6 in the pathogenesis of macular oedema and immunological dysregulation in retinal diseases. In 2017 she received the Early Career Clinician Scientist Award from the Association for Research in Vision and Ophthalmology (ARVO) Foundation. She currently serves as Translational Medicine Leader in Ophthalmology as part of the Roche Pharma Research and Early Development team in Basel, Switzerland, where she develops new treatments for retinal diseases, a job which combines her enthusiasm and passion for science with a strong commitment to patients.

Next Session (3)

A chance for UK birdshotters to help birdshot research

If you attended the Birdshot Day no 4 recently in London, you will have heard Mr Mark Westcott talk about the British Ophthalmological Surveillance Unit (BOSU) surveillance study of birdshot.

For those of you who couldn’t attend, the BOSU researchers are busy collecting anonymised data on all UK patients newly diagnosed with birdshot. The researchers can then start to calculate how rare birdshot is. They are also recording patients’ eye symptoms at diagnosis.

To get the best results, the researchers want to be sure that they receive details of everybody who could be included in the study.

This is where you can help.

  • Were you diagnosed with birdshot after May 2017?
  • Were you diagnosed with birdshot in UK (England, Scotland, Wales, Northern Ireland)?

If you answered ‘yes’ to BOTH questions, this is what the researchers would like you to do:

  • Ask your consultant if your data has been sent to the BOSU birdshot study investigators. (Your consultant will know about BOSU and its work).
  • If your consultant is not sure if your details have been sent to BOSU, please contact Mr Westcott’s secretary: marilyn.gilbert-campbell@nhs.net  who will check.

Note that this study is only for UK birdshotters diagnosed after May 2017.

Small Grants Award Scheme for Birdshot Research

We are delighted to announce that this year we have three awards available under the jointly funded small research projects scheme which Fight for Sight run.

Details about these awards are below:

Awards under this scheme are designed to provide support for birdshot clinical research studies only. The studies are to be conducted into any of the charity’s six research priority areas as detailed in the Charity’s Research Strategy 2012-2017. In addition the charity is keen to address the priorities identified by the Sight Loss and Vision Priority Setting Partnership

Fight for Sight is an NIHR Partner Organisation which means that clinical studies we fund are eligible for inclusion in the NIHR Clinical Research Network Portfolio. This allows the study team to have access to clinical infrastructure/NHS Service Support through the NIHR Clinical Research Networks.

Fight for Sight operates a Peer Review system that the charity believes enables an equitable and efficient way to review grant applications. Fight for Sight is unable to provide feedback for the Small Grant Awards Schemes.

Eligibility

  • Applicant must be affiliated with a UK academic or medical institutions.
  • Applicants must have a contract which extends beyond the termination date of the award.
  • These awards are limited to clinical research projects in the field of ophthalmology and vision science. Clinical research is research that either directly involves human participants or uses materials from patients (including human samples and human data).
  • These awards must not involve the use of animals or animal derived cell lines / samples.

Financial support and duration

  • Awards for up to £15,000.
  • Includes the costs of
    • employment (except Applicants; clinical applicants are expected to have protected research time in their NHS contracts);
    • consumables; and
    • equipment essential for the project.
  • Excludes indirect costs and any other non-attributable overhead costs.
  • These awards are tenable for up to 12 months.
  • These awards are not to be used to top-up existing grants.

Deadline

The call for “Small Grant Awards” is now open. The closing date for application submissions is 5pm on Wednesday 23 August 2017.

Application must be submitted via our online system grants.fightforsight.org.uk
Late applications will not be considered.

Better options for treating Birdshot

New research funding partnership between Fight for Sight and Birdshot Uveitis Society

Birdshot uveitis is a rare autoimmune disorder that has the potential to blind. It’s notoriously hard to treat. The UK’s main eye research charity Fight for Sight is partnering with Birdshot Uveitis Society to try to change that with new grants to researchers in London and Birmingham, to fund pioneering research that could lead to better treatments.

In birdshot, which is strongly linked to the gene HLA-A29, the immune system attacks two critical structures at the back of the eye: the retina and the choroid. The retina contains the photoreceptor cells that detect light and send visual signals to the brain, while the choroid is a layer of blood vessels that supplies the retina with oxygen and nutrition. When this supply is interrupted as during an inflammatory immune response, the photoreceptors can’t function normally.

Current options for treatment are limited to steroids and drugs to suppress the immune system. However in the long term these can cause sight-threatening complications such as cataract and glaucoma. We need some better options.

Stem cells from patients

Dr Anai Gonzalez Cordero at UCL Institute of Ophthalmology is leading one of the two new studies. The team will study a layer of cells in the retina called the retinal pigment epithelium (RPE) in tissue developed from birdshot patient stem cells.

“Subtle changes to RPE can be seen in some patients during the early stages of birdshot. This is not an obvious feature of the condition but current examination methods are limited, identifying only severe dysfunction,” says Dr Gonzalez Cordero.

“We do know that RPE can modulate the choroid and that RPE cells show HLA-A29 gene activity. Almost everyone with birdshot has a particular variation of this gene. Post-mortem tissue from birdshot patients is both scarce and unsuitable for detailed analysis. However we can develop mature RPE in the lab from stem cells derived from blood of living patients. This will allow us to explore the role of RPE in detail as well as providing a much-needed test bed for future treatments that can also be used by other researchers in the field.”

Iron overload is treatable

Dr Graham Wallace at the University of Birmingham will lead the second study. Here the focus is on genetic control of iron levels in birdshot.

“Iron is essential in the retina for photoreceptor cell function and is generally controlled by iron-regulating proteins. However free iron is highly toxic for photoreceptors, leading to an increase in oxidative stress. Iron is also involved in inflammation as it is essential for the proliferation of immune cells,” says Dr Wallace.

“Given a recent association between HLA-A29 and HFE H63D – a gene implicated in patients with iron overload – we think this could be an important route to explore with regard to birdshot. Iron overload is treatable and so may give us other options.”

Dr Dolores Conroy is Fight for Sight’s Director of Research. She says: “Understanding the root causes of birdshot is ultimately what will lead us to targeted, effective treatments. The Sight Loss and Vision Priority Setting Partnership tells us that this is what’s important to patients and so we are delighted to partner with Birdshot Uveitis Society to see the priorities addressed.”

Annie Folkard, a founder of the Birdshot Uveitis Society, said: “We are excited to support this innovative research. Studies likes these give our members great hope that in the future, improvements will be made to the current toxic treatments. Maybe even a cure will be found.”

Update on Humira and Ozurdex

HUMIRA NOW LICENSED FOR POSTERIOR UVEITIS

BUS learned this week that AbbVie, the manufacturer of Humira (adalimumab), has received approval from the European Medicines Agency for an extension of its marketing authorisation for Humira to treat certain forms of non-infectious uveitis. This means that in Europe, including the UK, and also in the US, “Humira is indicated for the treatment of non-infectious intermediate, posterior and panuveitis in adult patients who have had an inadequate response to corticosteroids, in patients in need of corticosteroid-sparing, or in whom corticosteroid treatment is inappropriate.”

AbbVie’s press release is attached here.

The updated ‘Summary of Product Characteristics’ (SPC) – the official product data sheet for Humira – can be found here: https://www.medicines.org.uk/emc/medicine/31860

The patient information leaflet for the Humira pen can be found here: PIL Humira July 2016

NICE MULTIPLE TECHNOLOGY APPRAISAL

BUS has also been invited to participate in the NICE Multiple Technology Appraisal which is looking at Ozurdex (dexamethasone) intravitreal implant and Humira (adalimumab) injection with a view to getting NHS funding approved for them to be prescribed for non-infectious posterior uveitis. We are currently preparing our ‘patient organisation statement’ to submit to NICE in August.  We have also nominated a number of ‘patient experts’ and a ‘consultant expert’ and we hope that one or two of them may be invited to put the patient’s viewpoint across at the Appraisal Meeting in February 2017.

We would like to thank those members who took part in our short survey last year about Humira and Ozurdex.  The anonymised information from these questionnaires has been very helpful in preparing BUS’s ‘organisation statement’.

Watch this space as this story unfolds.

POSSIBLE FORTHCOMING HUMIRA TRIAL

BUS is also trying to help get a trial under way to provide the practical evidence that Humira (adalimumab) can work for certain hard-to-treat cases of Birdshot as well as for other complicated, rare forms of autoimmune posterior uveitis.   Our team of experts led by Professor Andrew Dick, Ms Srilakshmi Sharma and Mr Alastair Denniston hope to put in an application in September to the National Institute for Health Research (NIHR) for possible funding, and we will know if we are successful by early next year.  We are all aware we need to provide as strong evidence as possible and in particular to show which groups of patients are best treated or will best benefit from treatment in order to convince NICE and commissioners to support use of expensive treatments for other conditions. The Birdshot team is going to give this its best shot, and we will keep you posted.

GPOUS STUDY

Research Study: Genetic polymorphism and outcome in uveoretinitis syndromes (also known for short as GPOUS Study)

This is just a heads up that over the next few months, people with Birdshot Uveitis attending Moorfields and other eye clinics may be asked if they would like to take part in the above study. The aim is to get another 100 people with Birdshot from the Moorfields cohort to join in. On the particular day in June when I was asked, there was at least one other Birdshotter that I know who also took part.

The researchers are looking at a number of different eye conditions, but if they have a largish cohort of Birdshot Uveitis patients, they may well get some useful pointers as to why some cases of Birdshot are more severe than others, and why some are easier to treat. The information may well be useful in helping to determine less toxic treatment strategies.

There are a number of other participating eye hospital sites, including St Thomas’ (London), Birmingham, Bristol, Brighton and Manchester.

It is encouraging that we are managing to utilize the National Birdshot Research Network to get the various different hospitals to work together so that there are sufficient patients that can be studied in a meaningful way.

After I had donated my ’two tablespoonfuls’ of blood, I subsequently had the opportunity to quiz Professor Miles Stanford. I asked him if it would be possible for the information about Birdshotters’ DNA and blood samples to be fed into the Birdshot Database.

The answer, unfortunately, was no, but he indicated that ethical approval had been granted so that the anonymised DNA samples could be retained and used by other researchers to look at other genetic risk factors.

Here is some background information taken from the patient information sheet that the researchers gave me to read, so if a researcher approaches you when you are in the eye clinic and asks you if you are interested in participating, you have a little more information in advance.

Background and Purpose:

Uveoretinitis syndromes are a group of diseases that affect the eye and cause inflammation within it. In approximately half of the cases, the inflammation appears to be confined to the eye, and in the other half it appears in association with inflammation elsewhere in the body, commonly arthritis. It is not a very common disease and if the inflammation gets severe it may threaten vision permanently. In these cases it is necessary to treat patients with drugs which, whilst usually effective, often have unpleasant side effects or require regular hospital visits for monitoring.

We do not know why patients develop these diseases or what causes one patient to have a mild form and another to have a more severe form. Our research over the last ten years has suggested that the outlook for vision is determined in part by the genetic make up of the patient, particularly in a group of genes that control the production of molecules that either make the inflammation worse or others that make it better. It is now possible to target these molecules with specific drugs, so the ability to know whether an individual’s disease is driven by an excess of molecules that cause inflammation or by a lack of molecules that make it better is becoming very relevant for treatment.

The aim of the current research study is to relate the different genes that a patient has to the outcome of their disease at 5 and 10 years. By using various combinations of the genes we hope to produce a test that can predict the outcome of the disease in 5 and 10 years time. If we can do this then we will be able to reassure patients with a good outlook and devise more appropriate treatments for those where the outlook is less good.

 What will happen to me if I take part?

If you do decide to take part, your examination is exactly the same as would happen when you are seen in the eye clinic. After your routine eye examination, we will then ask you to sign a consent form to show you have agreed to take part and we will then take a small blood sample (2 tablespoonfuls) from you for our research study. These samples will then be available to researchers who are investigating the genes and markers that may influence the sort of eye disease that you have and its severity. We will also require your medical history from your GP or hospital records and we will continue to monitor your disease’s progress over 10 years. We will let your GP know that you have agreed to take part in the study

What are the side-effects and possible disadvantages of taking part?

If you take part in the study you will spend longer in the clinic than if you do not, as the doctors will be spending time explaining the study to you and taking the blood sample. There are no other disadvantages to taking part in the study.

What will happen to the blood sample?

The blood sample will be processed in the laboratory to extract the genetic material (DNA) from the cells. This DNA can then by analysed to look for genes that we think may have an effect on the risk of developing uveoretinitis. Your sample will then be frozen in a locked freezer in a secure laboratory.

What will happen to the results of the study?

Any results that emerge from the study will be published in scientific and medical journals. The results from the study will be anonymous and the identity of individuals taking part will not be declared. It will not be possible for you to learn of the results of tests on your blood sample in this study.

 Who is funding the research?

The research is being funded by a grant from the Guide Dogs for the Blind Association and the research will be carried out jointly between St Thomas’ Hospital and the University of Birmingham. Future studies on the blood samples from this collection will be undertaken by various other groups and funded separately. The future use of your sample in other studies will only be allowed if ethical approval for individual projects had been obtained first.

How long will the research last?

The aim is to record how your eye disease progresses over a 5 year period to determine the eventual outcome. We already know from previous studies that the vision at this time predicts the outcome at 10 and, in some cases, 15 years. It is intended that the large number of blood samples generated from this collection will be available for many years afterwards to doctors and scientists as more genes that might cause or influence the severity of uveoretinitis are discovered. However, the identity of the people providing the blood samples would remain unknown to them.

Birdshot Day No 3 talks – November 2015

All of the birdshot talks from both Birdshot day No 2 and No 3 are published on the  Birdshot Uveitis Society Youtube channel Birdshot100 at https://www.youtube.com/user/Birdshot100/videos

Session 1

Birdshot – Where we are now: medications and keeping yourself well

Session 2

Fight for Sight and Birdshot Uveitis Society joint small grants initiative and progress updates

Session 3

Session 4

Session 5

Introduction to the National Birdshot Research Network and future developments