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Induction Therapy With Anti-TNFα vs Cyclophosphamide in Severe Behçet Disease (ITAC)

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ClinicalTrials.gov Identifier: NCT03371095
Recruitment Status : Not yet recruiting
First Posted : December 13, 2017
Last Update Posted : February 27, 2018
Sponsor:
Information provided by (Responsible Party):
Assistance Publique - Hôpitaux de Paris

Brief Summary:

Behçet's disease (BD) is a systemic vasculitis of arterial and venous vessels of any size, involving young patients (from 15 to 45 years). BD significantly increases morbidity and mortality. Therapeutic management of BD depends on the clinical presentation and organ involved. Although colchicine, nonsteroidal antiinflammatory agents and topical treatments are often sufficient for mucocutaneous and joint involvement, more aggressive approach with immunosuppressive agents is warranted for severe manifestations. Early recognition and vigorous use of immunosuppressives with high dose steroids have changed the prognosis of patients with severe BD. BD is a severe systemic vasculitis leading to blindness in up to 20% at 4 years and a 5-year mortality rate of 15% in patients with major vessel or neurological involvement. Cyclophosphamide has been used for life-threatening BD for 40 years. However, the outcome of severe complications of BD is poor. The European League Against Rheumatism (EULAR) recommendation for the management of BD advocated cyclophosphamide plus glucocorticoids for life-threatening manifestations (i.e neurological and/or major vessel involvement). TNFa antagonists have been used with success in severe and/or resistant cases. In addition, the incidence of blindness in BD has been dramatically reduced in the recent years with the use of anti-TNF. However, there is no firm evidence or randomized controlled trials directly addressing the best induction immunosuppressive therapy in severe BD manifestations. The investigators therefore aimed to assess the best induction therapy in severe and difficult to treat BD patients. The investigators hypothesize that up to 70% of the patients with life-threatening manifestations of BD receiving these compounds [anti-TNFa or cyclophosphamide] will achieve a complete remission of BD at 6 months and with less than 0.1 mg/kg/day of prednisone.

ITAC, is the first randomized prospective, head to head study, comparing infliximab, to cyclophosphamide in severe manifestations of BD. There is no firm evidence or randomized controlled trials directly addressing the best induction immunosuppressive therapy in severe BD. Cyclophosphamide failed to demonstrate sustainable remission over 70 % of life threatening BD cases. There is little published information on use of immunosuppressants other than cyclophosphamide for severe BD. TNFa antagonists have been used with success in severe and/or resistant cases. TNFa expression correlates with BD activity and other immunological data provide a strong rationale for targeting BD with biologics. Despite a strong rationale, these compounds are not yet approved in BD, which guarantees the innovative nature of this study that aims selecting or dropping any arm when evidence of efficacy already exists.


Condition or disease Intervention/treatment Phase
Behcet's Disease Vasculitis Drug: Infliximab Drug: Cyclophosphamide Phase 3

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Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 52 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: Multicenter, Randomized, Prospective Trial Comparing the Efficacy and Safety of Infliximab to That of Cyclophosphamide in Severe Behçet's Disease. ITAC : Induction Therapy With Anti-TNFα vs Cyclophosphamide in Severe Behçet Disease
Estimated Study Start Date : March 15, 2018
Estimated Primary Completion Date : June 1, 2021
Estimated Study Completion Date : January 1, 2022


Arm Intervention/treatment
Experimental: Infliximab
Infliximab 5mg/kg intravenously at week 0, 2, 6, 12, and 18
Drug: Infliximab
Use of infliximab instead of cyclophosphamide

Active Comparator: Cyclophosphamide
Cyclophosphamide 0.7g/m2 intravenously at week 0, 4, 8, 12, 16 and 20
Drug: Cyclophosphamide
Use of cyclophosphamide




Primary Outcome Measures :
  1. Complete clinical response [ Time Frame: At week 22 after randomization ]
    The complete clinical response is defined by the remission of all affected organs involved at baseline with a prednisone ≤ 0.1mg/kg per day


Secondary Outcome Measures :
  1. Complete clinical response [ Time Frame: At week 12 after randomization ]
    The complete clinical response is defined by the remission of all affected organs involved at baseline with a prednisone ≤ 0.1mg/kg per day

  2. Complete clinical response [ Time Frame: At week 48 after randomization ]
    The complete clinical response is defined by the remission of all affected organs involved at baseline with a prednisone ≤ 0.1mg/kg per day

  3. Remission of CNS and/or cardiovascular involvement [ Time Frame: At week 12 after randomization ]
  4. Remission of CNS and/or cardiovascular involvement [ Time Frame: At week 22 after randomization ]
  5. Remission of CNS and/or cardiovascular involvement [ Time Frame: At week 48 after randomization ]
  6. Percent meeting the target of ≤ 0.1 mg/day/kg of prednisone [ Time Frame: At week 22 after randomization ]
  7. Percent meeting the target of ≤ 0.1 mg/day/kg of prednisone [ Time Frame: At week 48 after randomization ]
  8. Mean dose of prednisone [ Time Frame: At week 12 after randomization ]
  9. Mean dose of prednisone [ Time Frame: At week 22 after randomization ]
  10. Mean dose of prednisone [ Time Frame: At week 48 after randomization ]
  11. Cumulative dose of prednisone [ Time Frame: At week 12 after randomization ]
  12. Cumulative dose of prednisone [ Time Frame: At week 22 after randomization ]
  13. Cumulative dose of prednisone [ Time Frame: At week 48 after randomization ]
  14. Time to response onset [ Time Frame: At week 48 after randomization ]
  15. C-reactive protein [ Time Frame: Every 4 weeks ]
    CRP in blood sample

  16. Time to relapse [ Time Frame: At week 48 after randomization ]
    Relapse will be defined as the reappearance of clinical and/or paraclinical features of active disease or by the occurrence of new lesions at week 48

  17. Rate of relapse [ Time Frame: At week 48 after randomization ]
  18. Time to occurrence of worsening [ Time Frame: At week 48 after randomization ]
    Worsening will be defined as the progression of preexisting lesions) at week 22 and 48

  19. Rate of worsening [ Time Frame: At week 48 after randomization ]
  20. Overall survival [ Time Frame: At week 48 after randomization ]
  21. Event Free Survival [ Time Frame: At week 48 after randomization ]
  22. Frequency of adverse clinical events [ Time Frame: At week 22 after randomization ]
    Incidence of Treatment related Adverse Events

  23. Severity of adverse clinical events [ Time Frame: At week 22 after randomization ]
  24. Change in quality of life [ Time Frame: At week 12 after randomization ]
    Change in quality of life (QOL) (SF-36V2TM Health Survey)

  25. Change in quality of life [ Time Frame: At week 22 after randomization ]
    Change in quality of life (QOL) (SF-36V2TM Health Survey)

  26. Changes in CNS involvement [ Time Frame: At week 12 after randomization ]
    Changes in CNS involvement on physical exam, and cerebral and/or medullar MRI.

  27. Changes in CNS involvement [ Time Frame: At week 22 after randomization ]
    Changes in CNS involvement on physical exam, and cerebral and/or medullar MRI.

  28. Changes in vascular involvement [ Time Frame: At week 12 after randomization ]
    Changes in vascular involvement on physical exam, vascular Doppler US, and angio-CT imaging and biologically (normalization of C reactive protein)

  29. Changes in vascular involvement [ Time Frame: At week 22 after randomization ]
    Changes in vascular involvement on physical exam, vascular Doppler US, and angio-CT imaging and biologically (normalization of C reactive protein)

  30. Changes in cardiological involvement [ Time Frame: At week 12 after randomization ]
    Changes in cardiological involvement on physical exam, echocardiography (normalization of left ventricular function and/or disappearance of cardiac thrombosis), and cardiac magnetic resonance imaging (disappearance of gadolinium enhancement and normalization of left ventricular function) and biologically (normalization of troponin and of C reactive protein)

  31. Changes in cardiological involvement [ Time Frame: At week 22 after randomization ]
    Changes in cardiological involvement on physical exam, echocardiography (normalization of left ventricular function and/or disappearance of cardiac thrombosis), and cardiac magnetic resonance imaging (disappearance of gadolinium enhancement and normalization of left ventricular function) and biologically (normalization of troponin and of C reactive protein)

  32. Serum concentration measurement of TNFa inhibitor at week 22 [ Time Frame: At week 12 after randomization ]
  33. Change in Behcet's Disease Current Activity Form [ Time Frame: At week 12 after randomization ]
  34. Change in Behcet's Disease Current Activity Form [ Time Frame: At week 22 after randomization ]


Information from the National Library of Medicine

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Ages Eligible for Study:   12 Years and older   (Child, Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • Age ≥ 12 years old
  • Written inform consent (Informed Consent should be obtained from the legal guardian in accordance with regional laws or regulations for patients 12 to 17 years of age)
  • Diagnosis of BD according to international criteria for BD (ICBD) (see Appendix 1).
  • Life threatening active BD defined as 1 of the following disease categories and according to the validated international definition:

    • Major vessel disease: arterial aneurysms or arterial stenosis, myocarditis and/or major deep vein thrombosis (i.e. inferior vena cava, superior vena cava, cardiac cavity thrombosis, pulmonary embolism, supra-hepatic vessels, renal and mesenteric vessels). Diagnosis of major vessel involvement will be done using vascular doppler sonography, echocardiography, angio-CT scan and/or cardiac magnetic resonance imaging (MRI).
    • Central nervous system involvement: encephalitis or meningoencephalitis or myelitis. The diagnosis of neuro-Behçet's (CNS involvement) will be based on objective neurological symptoms that were associated with neuroimaging (CNS and/or medullar MRI) findings suggestive of BD-related CNS involvement. Cerebrospinal fluid (CSF) findings showing aseptic inflammation may be associated.
  • Chest X-ray results (postero-anterior and lateral) within 12 weeks prior to inclusion with no evidence of active Tuberculosis, active infection, or malignancy
  • For female subjects of child-bearing age, a negative pregnancy test
  • 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 and 6 months after stopping therapy. Adequate contraceptive measures include hormonal methods used for two or more cycles prior to Inclusion (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.
  • A potential subject with a positive interferon-gamma release assay (IGRA) (e.g., QuantiFERON®-TB Gold or T-spot TB® Test) or a positive tuberculin skin test (≤6 months) is eligible if her/his chest X-ray does not show evidence suggestive of active tuberculosis (TB) disease and there are no clinical signs and symptoms of pulmonary and/or extra-pulmonary TB disease. These subjects with a latent TB infection who have not already received a prophylactic TB treatment must agree in advance to complete such a treatment course.
  • HIV negative serology and negative HBs Ag test (≤1 month)

Exclusion Criteria:

  • Evidence of active Tuberculosis
  • HIV or active HBV infection (HBs Ag+).
  • Pregnancy or lactation
  • Have been taking an oral daily dose of a glucocorticoid of more than 20 mg prednisone equivalent for more than 6 weeks continuously prior to the inclusion visit or taking more than 3000 mg methylprednisolone 4 weeks prior to the inclusion visit
  • Alcohol or drug dependance
  • Severe renal (creatinine clearance <30ml/min/1,73m2) or pre-existing hemorrhagic cystitis or liver insufficiency (hepatic encephalopathy, ascites)
  • Heart failure ≥ stage III / IV NYHA,
  • History of malignancy within 5 years prior to Inclusion other than carcinoma in situ of the cervix or excised basal cell or squamous cell carcinoma of the skin.
  • History of multiple sclerosis and/or demyelinating disorder
  • History of severe allergic or anaphylactic reactions to cyclophosphamide or infliximab
  • Infectious disease:

    • Infection requiring treatment with antibiotics within 2 weeks prior to Inclusion
    • History of recurrent infection
  • Laboratory values assessed during Inclusion:

    • Hemoglobin < 8 g/dL
    • WBC < 2.0 x 103/mm3
    • Platelet count < 70 x 103/mm3
  • Use of the following systemic treatments during the specified periods:

    • Treatment with systemic biologic therapy or with cyclophosphamide within 3 months prior to Inclusion
    • if on azathioprine, mycophenolate mofetil, or methotrexate at the time of inclusion, these drugs must be withdrawn prior to receiving the cyclophosphamide or infliximab dose on Day 1
  • Any live (attenuated) vaccine within 4 weeks prior inclusion; recombinant or killed virus vaccines are permitted.
  • Lack of affiliation to a social security benefit plan (as a beneficiary or assignee)

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT03371095


Contacts
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Contact: David SAADOUN, Pr 142178088 ext +33 david.saadoun@psl.aphp.fr
Contact: Matthieu RESCHE-RIGON, Pr 142499742 ext +33 matthieu.resche-rigon@univ-paris-diderot.fr

Sponsors and Collaborators
Assistance Publique - Hôpitaux de Paris

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Responsible Party: Assistance Publique - Hôpitaux de Paris
ClinicalTrials.gov Identifier: NCT03371095     History of Changes
Other Study ID Numbers: P160932J
First Posted: December 13, 2017    Key Record Dates
Last Update Posted: February 27, 2018
Last Verified: December 2017
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: Undecided

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Studies a U.S. FDA-regulated Drug Product: No
Studies a U.S. FDA-regulated Device Product: No

Keywords provided by Assistance Publique - Hôpitaux de Paris:
Behcet's Disease
Vasculitis
Biotherapy
immunosuppressant
Infliximab

Additional relevant MeSH terms:
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Vasculitis
Behcet Syndrome
Vascular Diseases
Cardiovascular Diseases
Mouth Diseases
Stomatognathic Diseases
Uveitis, Anterior
Panuveitis
Uveitis
Uveal Diseases
Eye Diseases
Hereditary Autoinflammatory Diseases
Genetic Diseases, Inborn
Skin Diseases, Genetic
Skin Diseases
Skin Diseases, Vascular
Cyclophosphamide
Infliximab
Immunosuppressive Agents
Immunologic Factors
Physiological Effects of Drugs
Antirheumatic Agents
Antineoplastic Agents, Alkylating
Alkylating Agents
Molecular Mechanisms of Pharmacological Action
Antineoplastic Agents
Myeloablative Agonists
Dermatologic Agents
Gastrointestinal Agents