The Residency Report: When can adalimumab be stopped in JIA-associated uveitis

In this installment of The Residency Report—a partnership between Ophthalmology Times and the Department of Ophthalmology at the New York University (NYU) Grossman School of Medicine—ophthalmology resident Trisha Miglani, MD, moderates a journal club discussion focused on uveitis research. Miglani is joined by Cesar Michael A. Samson, MD, MBA, Professor of Ophthalmology and Chief of the Division of Uveitis Services at NYU Grossman School of Medicine, and guest Jennifer E. Thorne, MD, PhD, the Cross Family Professor of Ophthalmology at the Wilmer Eye Institute, Johns Hopkins University School of Medicine in Baltimore, Maryland.

The discussion centers on the ADJUST trial (Stopping of Adalimumab in Juvenile Idiopathic Arthritis [JIA]–Associated Uveitis), which examined outcomes following the discontinuation of adalimumab therapy in patients with juvenile idiopathic arthritis–associated uveitis.¹ The conversation addresses a common and clinically consequential question in pediatric uveitis care: when, if ever, is it appropriate to discontinue adalimumab in children with sustained disease control.

Thorne frames the rationale succinctly, noting that the trial addresses “how chronic is chronic?” JIA-associated uveitis is the most common systemic condition associated with uveitis in children and carries a significant risk of vision-threatening complications, often necessitating long-term immunosuppression. Adalimumab is widely used, but families frequently ask, “My child has done really well on this drug for 2 to 3 years. Can we stop it now?”

The ADJUST trial was the first randomized controlled trial to prospectively evaluate outcomes after discontinuation of immunomodulatory therapy in chronic uveitis.¹ Children were eligible after at least 12 months of quiescent disease, though approximately 75% had been controlled for 2 years or longer. Participants were randomly selected to continue adalimumab or discontinue therapy. Those who stopped adalimumab experienced significantly higher rates of recurrence of uveitis, arthritis, or both, leading to early termination of the trial based on prespecified stopping rules.

Thorne highlights that nearly 70% of patients who discontinued therapy had a recurrence, with a median time of 3–4 months and most flares occurring within 6 months—“not a great drug holiday.” Importantly, however, there were key “silver linings.” Patients who flared generally regained disease control after restarting adalimumab, typically within 3–4 months, and visual acuity outcomes did not differ between those who discontinued therapy and those who remained on treatment.

The discussion also explores why pediatric patients were chosen as the study population, emphasizing more uniform disease phenotypes and earlier biologic use compared with adult uveitis, which is often more heterogeneous. Looking forward, the panel notes the potential value of post-hoc analyses, biomarkers, microbiome data, and age-related signals—particularly the observation that children under 12 years were more likely to relapse—to better identify patients who may safely discontinue therapy in the future.

Reference

1. Acharya NR, Ramanan AV, Coyne AB, et al. Stopping of adalimumab in juvenile idiopathic arthritis-associated uveitis (ADJUST): a multicentre, double-masked, randomised controlled trial. Lancet. 2025;405(10475):303-313. doi:10.1016/S0140-6736(24)02468-1