Spacing of TNF-blocker Injections in Rheumatoid Arthritis Study

Rheumatoid Arthritis Clinical Trial

— STRASS  

Official title:

Effect of TNF-blocker Injections Spacing on Rheumatoid Arthritis Inflammatory Activity in Patients in Clinical Remission or Low Disease Activity

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT00780793
• Other study ID #: AOM 07127
• Status: Completed
• Phase: Phase 4
• First received: October 27, 2008
• Last updated: February 1, 2012
• Start date: September 2008
• Est. completion date: September 2011

Study information

• Verified date: October 2008
• Source: Assistance Publique - Hôpitaux de Paris
• Contact: n/a
• Is FDA regulated: No
• Health authority: France: Ministry of Health
• Study type: Interventional

Clinical Trial Summary

Remission is nowadays the recommended therapeutic objective in rheumatoid arthritis. Once this objective is achieved thanks to TNF-blockers, the optimal therapeutic strategy remains unclear, either therapeutic maintenance or progressive DMARD tapering (with a non quantified risk of disease flare).

STRASS is a 2-arm randomized controlled trial aiming to compare these 2 strategies (DMARD maintenance or progressive spacing of TNF-blocker injections) in terms of remission maintenance, relapse risk, safety issues and economic consequences during 18 months.

The inclusion period is 18 months, between September 2008 and February 2010.

Description:

Rationale:

Clinical remission is the therapeutic objective in rheumatoid arthritis, as recommended by professional practice guidelines. Once this objective is achieved with subcutaneous TNF-blockers, the maintenance of such treatments - highly efficacious but expensive and potentially toxic - is debated. To date, no reliable data are available to estimate the risk

• benefice ratio associated with either their maintenance or their tapering.

Objectives:

In RA patients in remission, the study aims:

1. To compare RA inflammatory activity based on repeated measures of the Disease Activity Score (DAS) depending on 2 therapeutic schemes: (M) maintenance of unchanged TNF-blockers or (S) tapering of TNF-blocker doses by progressive spacing of subcutaneous injections according to a predefined algorithm;

2. To estimate the cost - effectiveness ratio of TNF-blocker spacing as compared to TNF-blocker maintenance.

Inclusion criteria:

• Patients aged 18 or more, diagnosed with RA according to the 1987 ACR classification criteria;

• RA treated with subcutaneous TNF-blockers (etanercept or adalimumab) at stable and standard dosage for 1 year or more, as monotherapy or associated with stable conventional DMARD;

• RA in clinical remission, defined as a stable DAS28 ≤ 2.6 for 6 months or more, without any structural damage progression on X-rays (local reading by the treating rheumatologist);

Exclusion criteria:

• Treatment with steroids;

• progressing disease on X-rays during the year preceding the trial;

• surgery planed in the 18 coming months;

• pregnancy;

• on-going neoplastic disease;

• other auto-immune disorders different from RA;

• inability to speak or understand French;

• absence of signed informed consent;

• absence of medical insurance coverage.

Sample size calculation: 250 patients, 125 for each arm.

Centers: 22 inclusion centers in France.

Research duration: 3 years. Participation duration for each patient: 18 months. Inclusion period duration: 18 months (Sep 2008 - Feb 2010).

Methods:

Equivalence trial, prospective, randomized, controlled versus usual care, patients remaining blinded of the tested hypotheses.

Investigators assessing disease activity remain blind of the protocol arm. The statistical analysis will be based on a mixed linear model taking into account repeated data.

Randomization:

Computer-assisted randomization (CleanWeb software) by blocks of unequal size, stratified on inclusion centers and TNF-blocker molecule.

Primary endpoint:

RA inflammatory activity over 18 months estimated by DAS28 repeated measures.

Secondary endpoints:

• RA inflammatory activity over 18 months estimated by DAS44 repeated measures;

• Cost - Effectiveness ratio calculated as: (CostMaintenance - CostSpacing) / (EfficacyMaintenance - EfficacySpacing);

• Relapse rate over 18 months based on Kaplan Meier survival analysis;

• Functional impairment based on HAQ index;

• Health-related quality of life on SF-36;

• Utility based on EQ-5D instrument;

• Structural damage progression over 18 months assessed with the van der HEIJDE-modified Sharp score (SHS);

• Safety;

• Determinants of maintained remission or relapse after TNF-blocker injection spacing.

Research time sheet:

Clinical, biological and imaging follow-up is based on guidelines-recommended RA follow-up.

Biological work-ups specifically dedicated to the research represent 80 mL. The others are part of usual care and may be performed in non-hospital laboratories.

Expected results and perspectives:

The trial aims to test the feasibility and the risk - benefit ratio of a step-down strategy for TNF-blockers in the course of RA.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 250
• Est. completion date: September 2011
• Est. primary completion date: September 2011
• Accepts healthy volunteers: No
• Gender: Both
• Age group: 18 Years and older

Eligibility

Inclusion Criteria:

• Patients aged 18 or more, diagnosed with RA according to the 1987 ACR classification criteria;

• RA treated with subcutaneous TNF-blockers (étanercept or adalimumab) at stable and standard dosage for 1 year or more, as monotherapy or associated with stable conventional DMARD;

• RA in clinical remission, defined as a stable DAS28 = 2.6 for 6 months or more, without any structural damage progression on X-rays (local reading by the treating rheumatologist);

Exclusion Criteria:

• Treatment with steroids;

• progressing disease on X-rays during the year preceding the trial;

• surgery planed in the 18 coming months;

• pregnancy;

• on-going neoplastic disease;

• other auto-immune disorders different from RA;

• inability to speak or understand French;

• absence of signed informed consent;

• absence of medical insurance coverage.

Study Design

Allocation: Randomized, Endpoint Classification: Safety/Efficacy Study, Intervention Model: Parallel Assignment, Masking: Single Blind (Subject), Primary Purpose: Treatment

Related Conditions & MeSH terms

• Arthritis
• Arthritis, Rheumatoid
• Rheumatoid Arthritis

Intervention

Drug:
• progressive spacing of TNF-blocker injections
Experimental arm Progressive spacing of TNF-blocker injections according to the following algorithm : if DAS28 = 2.6 at trimestrial assessment: go for step N+1 if DAS28 > 2.6 and DAS28 change = 0.6: continue at step N if DAS28 > 2.6 and DAS28 change > 0.6 : return to step N-1 (relapse as defined by the European expert consensus). Step 0 (inclusion) : Adalimumab 40 mg / 14 days Etanercept 50 mg / 7 days Step 1 : Adalimumab 40 mg / 21 days Etanercept 50 mg / 10 days Step 2 : Adalimumab 40 mg / 28 days Etanercept 50 mg / 14 days Step 3 : Adalimumab 40 mg / 42 days Etanercept 50 mg / 21 days Step 4 : TNF-blocker stop
• DMARD maintenance
DMARD maintenance

Locations

Country	Name	City	State
France	Service de rhumatologie / Groupe hospitalier Pitié Salpêtrière	Paris

Sponsors (2)

Lead Sponsor	Collaborator
Assistance Publique - Hôpitaux de Paris	French Society of Rheumatology

Country where clinical trial is conducted

France, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	RA inflammatory activity over 18 months based on repeated DAS28 measures		over 18 months	No
Secondary	RA inflammatory activity over 18 months estimated by DAS44 repeated measures		over 18 months	No
Secondary	Cost - Effectiveness ratio calculated as: (CostMaintenance - CostSpacing) / (EfficacyMaintenance - EfficacySpacing);		during the study	No
Secondary	Relapse rate over 18 months based on Kaplan Meier survival analysis		over 18 months	No
Secondary	Functional impairment based on HAQ index		during the study	Yes
Secondary	Health-related quality of life on SF-36		during the study	Yes
Secondary	Utility based on EQ-5D instrument		during the study	Yes
Secondary	Structural damage progression over 18 months assessed with the van der HEIJDE-modified Sharp score (SHS)		over 18 months	Yes
Secondary	Determinants of maintained remission or relapse after TNF-blocker injection spacing		during teh study	No