Multicentre, Randomized, Prospective Trial Evaluating the Efficacy and Safety of Infliximab to Tocilizumab in Refractory or Relapsing Takayasu Arteritis

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Brief Title

Multicentre, Randomized, Prospective Trial Evaluating the Efficacy and Safety of Infliximab to Tocilizumab in Refractory or Relapsing Takayasu Arteritis

Official Title

Multicentre, Randomized, Prospective Trial Evaluating the Efficacy and Safety of Infliximab to Tocilizumab in Refractory or Relapsing Takayasu Arteritis

Brief Summary

      Takayasu arteritis (TA) is a vasculitis of unknown origin, resulting in progressive
      thickening and stenosis of large and medium arteries (the aorta and its major branches, and
      the pulmonary arteries). First line therapy of TA consists of high dose corticosteroids (CS).
      Between 20 and 50% of cases respond to CS alone, with subsequent resolution of symptoms and
      stabilization of vascular abnormalities. Although second-line agents (methotrexate,
      azathioprine, mercaptopurine, mycophenolate mofetil) may result in initial remission,
      relapses remain common when prednisone is tapered. Thus, 50% of CS-resistant or relapsing TA
      patients may achieve sustained remission with the addition of methotrexate. During the last
      decade, biologics such as anti-tumor necrosis factor alpha (anti-TNFα) and anti-interleukin-6
      (anti-IL-6) have been used as third-line treatment in refractory or relapsing TA. Almost 90%
      of CS-methotrexate resistant TA cases responded to infliximab, an anti-TNFα, and sustained
      remission was obtained in 37 to 76% of the cases. Tocilizumab, an anti-IL-6 has given similar
      results with 68% of sustained remission in refractory TA. Irrespective of classical
      cardiovascular risk factors, the systemic inflammation and CS use play a pivotal role in the
      occurrence of cardiovascular thrombotic events (CVEs). As CVEs overlap with TA complications
      it is primordial to drastically taper CS in that vasculitis. We therefore hypothesize that
      Infliximab or Tocilizumab can achieve a remission in more than 70% of refractory/relapsing TA
      cases to CS associated to a second-line agent. INTOReTAK, first randomized prospective study
      in TA, has an original design testing Infliximab and Tocilizumab propensity to achieve over
      70% of sustained remission in refractory/relapsing TA and evaluating jointly the 2 arms. The
      primary objective of this study is to obtain, by arm, ≥ 70% of patients at 6 months after
      randomization with prednisone ≤ 0.1mg/kg per day and inactive disease (NIH score ≤ 1) during
      the last 3 months.
    


Study Phase

Phase 2

Study Type

Interventional


Primary Outcome

Proportion of patients with prednisone ≤ 0.1mg/kg per day and sustained inactive disease (NIH score ≤ 1) from M3 to M6 and same biological therapy from randomization

Secondary Outcome

 Incidence of relapse as defined by the NIH criteria

Condition

Takayasu Arteritis

Intervention

Infliximab

Study Arms / Comparison Groups

 A ( Infliximab)
Description:  Infliximab 5mg/kg intravenously at week 0; 2; 6; 14; 22 following prescription recommendations

Publications

* Includes publications given by the data provider as well as publications identified by National Clinical Trials Identifier (NCT ID) in Medline.

Recruitment Information


Recruitment Status

Drug

Estimated Enrollment

50

Start Date

September 2020

Completion Date

September 2023

Primary Completion Date

February 2021

Eligibility Criteria

        Inclusion Criteria:

          -  Diagnosis of Takayasu disease according to the international criteria of the American
             College of Rheumatology (ACR)

               -  Age at disease onset < 40 years

               -  Claudication of extremities

               -  Decreased brachial artery pulse (one or both arteries)

               -  Blood pressure difference of >10mm Hg between the arms

               -  Bruit over subclavian arteries or aorta

          -  Active disease according to the international criteria of the National Institute of
             Health (NIH)

          -  New onset or worsening of at least two of the following four criteria

               -  Systemic features

               -  Elevated erythrocyte sedimentation rate

               -  Features of vascular ischemia or inflammation

               -  Typical angiographic features

          -  Refractory/relapsing disease

               -  Failure of disease to respond to daily corticosteroids therapy (1mg/kg/day for >
                  1month), i.e. disease still active

               -  Inability to taper corticosteroids below 10mg/day within 6 months

               -  Inability to discontinue corticosteroids after 1 year of treatment

               -  Relapse of disease after gradual decrease of corticosteroids therapy

          -  Patients with one immunosuppressive agent (methotrexate, azathioprine, mercaptopurine
             or mycophenolate mofetil)

          -  Age of 18 years or older

          -  Weight 40 - 120 kg

          -  Medical follow-up in a university or general hospital in France

          -  Social insurance

          -  Willing and able to provide written informed consent

          -  Willing and able to comply with treatment and follow-up procedures required by the
             study protocol

          -  For female subjects of child-bearing age, a negative serum pregnancy test and no
             pregnancy plans within 12 months

          -  For subjects with reproductive potential, a willingness to use contraceptive measures
             adequate to prevent the subject or the subject's partner from becoming pregnant during
             the study. Adequate contraceptive measures include hormonal methods used for two or
             more cycles prior to Screening (e.g., oral contraceptive pills, contraceptive patch,
             or contraceptive vaginal ring), barrier methods (e.g., contraceptive sponge, diaphragm
             used in conjunction with contraceptive foam or jelly, or condom used in conjunction
             with contraceptive foam or jelly), intrauterine methods (IUD), sterilization (e.g.,
             tubal ligation or a monogamous relationship with a vasectomized partner), and
             abstinence.

          -  Chest X-ray results (postero-anterior and lateral) within 12 weeks prior to enrollment
             with no evidence of active tuberculosis, active infection, or malignancy

          -  Tuberculosis assessment:

               -  Active Tuberculosis infection treatment achieved

               -  Completion of at least 3 weeks treatment for Latent Tuberculosis infection

               -  Negative tuberculin skin test (TST) or interferon-gamma release assay (IGRA)
                  (e.g., QuantiFERON®-TB Gold or T-spot TB® Test)

        Exclusion Criteria:

          -  Active tuberculosis or untreated latent tuberculosis

          -  Evidence of active infection (includes chronic infection)

          -  Infection requiring treatment with antibiotics within 2 weeks prior to enrollment

          -  Infection with human immunodeficiency virus (HIV), hepatitis C, or a positive
             hepatitis B surface antigen.

          -  Pregnancy or lactation

          -  Inability to comply with study guidelines

          -  Inability to provide informed consent

          -  Immunosuppressant type or dose modification within 30 days prior to enrollment

          -  Alcohol or drug abuse, that, in the investigator's opinion, could prevent a subject
             from fulfilling the study requirements or that would increase the risk of study
             procedures

          -  Severe renal insufficiency (creatinine clairance <30mL/min/1,73m2)

          -  Hepatic dysfunction as shown by aspartate transaminase (AST) or alanine transaminase
             (ALT) levels >5-fold the upper limit of normal

          -  Heart failure ≥ stage III / IV NYHA,

          -  History of any malignant neoplasm except adequately treated basal or squamous cell
             carcinoma of the skin, or solid tumors treated with curative therapy and disease free
             for at least 5 years.

          -  History of multiple sclerosis and/or demyelinating disorder

          -  History of severe allergic or anaphylactic reactions to infliximab, any chimeric
             murine monoclonal antibody, tocilizumab, and their respective excipients or prednisone

          -  History of immediate hypersensitivity reaction to iodinated and gadolinium-based
             contrast media

          -  Cytopenia: Hemoglobin < 8.5 g/dL, absolute neutrophil < 1.5 G/L, Platelet count < 80
             G/L

          -  Any live (attenuated) vaccine fewer than 4 weeks before enrolment. Recombinant or
             killed virus vaccines fewer than 2 weeks before enrolment.

          -  Use of the following systemic treatments during the specified periods

               1. Treatment with biologic therapy (infliximab, adalimumab, certolizumab pegol,
                  golimumab, anakinra, tocilizumab, etanercept, abatacept, ixekizumab, secukinumab,
                  ustekinumab, alemtuzumab) within 6 months prior to enrollment

               2. Past treatment with rituximab within the past 12 months, or past treatment with
                  rituximab more than 12 months ago where the B lymphocytes count has not returned
                  to normal at time of enrollment

               3. Treatment with any systemic alkylating agents within 6 months prior to enrollment
                  (e.g., cyclophosphamide, chlorambucil)

          -  Lack of affiliation to a social security benefit plan (as a beneficiary or assignee)

          -  Presence of any of the following disease processes:

               -  Microscopic polyangiitis

               -  Granulomatosis with polyangiitis

               -  Eosinophilic granulomatosis with polyangiitis

               -  Polyarteritis nodosa

               -  Cogan's syndrome

               -  Behcet's disease

               -  Sarcoidosis

               -  Kawasaki's disease

               -  Atypical mycobacterial infections

               -  Deep fungal infections

               -  Lymphoma, lymphomatoid granulomatosis, or other type of malignancy tha mimics
                  vasculitis

               -  Cryoglobulinemic vasculitis

               -  Systemic lupus erythematosus

               -  Rheumatoid arthritis

               -  Mixed connective tissue disease or any overlap autoimmune syndrome

               -  Known constitutive immunodeficiency
      

Gender

All

Ages

18 Years - N/A

Accepts Healthy Volunteers

No

Contacts

, +33156093051, [email protected]



Administrative Informations


NCT ID

NCT04564001

Organization ID

P160909


Responsible Party

Sponsor

Study Sponsor

Assistance Publique - Hôpitaux de Paris


Study Sponsor

, , 


Verification Date

September 2020